LITHOTRIPSY -A HISTORICAL REVIEW
Urology Unit, King Abdul.Aziz University Hospital, Jeddah / Saudi Arabia
The Third Congress of The International Society of Urologic Endoscopy together with World Health Organization (W.H.O.) Collaborating Centre For Urinary Bladder And Prostatic Cancer and with European Organization Of Research On The Treatment Of Cancer (E. O. R. T. C.) Genito-Urinary Tract Cancer Cooperative Group.
August 26- 30,1984
Centre Of Physics , University Of Karlsruhe
Federal Republic Of Germany
President E. Matouscheck, Karlsruhe
W.H.O. Director F. Edsmyr , Stockholm
E. 0. R. T. C. /GU-Group Chairman
L. Denis, Antwerpen
Local Secretary R.-D. Huber, Karlsruhe
Scientific Program E. Matouscheck, Karlsruhe
M. A. Reuter, Karlsurhe
Publisher Baden Baden, bua-Verlag,
Werner Steinbruck (1985), pp 474-476
Lithotripsy is looked upon as one of the modern discoveries. However, in this paper we will trace the idea back to its roots and review its progress with the subsequent modification of the intstruments used until it attained its modern shape.
The idea of Lithotripsy lives too exclusively in the contemplation of the so-called modern discoveries. Therefore, in this paper we will try to follow the idea back to its roots.
Cumston (1968) attributes the silence of all Greek medical literature as to the technique of Lithotomy to Hippocrate's teaching of avoiding cystotomy. This doctrine according to Dimopolous et al (1980) lasted several centuries after his death.
Therefore, though the technique of Ammonius (200 B.C) for splitting a large stone through a perineal cystotomy by using a scoop, chisel and hammer was described only by Celsus (50A.D,), it may be considered as the earliest trial for crushing a stone.
Celsus recommended it. However, it seems that the idea was not popular as Charaka, Antyllus and Susruta up till the fourth century advised against breaking a stone or even scratching it and Paulus in the seventh century who is looked upon as summed up all medical knowledge accumulated up to his time, did not mention a word about splitting a large stone.
From the ninth to the fourteenth century according to Cumston (1968), Margotta (1968), Bickers (1969) and Desnos (1972), in Europe the Graeco-Roman medicine came to an end and no progress was made in medical science. However, in the East, Dickinson (1875), Cumson (1968) and Kirkup (1981) stated that with the firm establishment of the Muslem supremacy, the study of medicine along with other branches of science revived and acquired a scientific nature.
In accordance with this, AI Razi who lived between 841-926 A.D. described in full details a new technique for breaking a large stone, in the tenth volume of his twenty three volumes book, "The Continens”, which represents his principal contribution to medicine. He used a strong pincer to hold firmly on a part of the stone made to protrude through a perineal cystotomy and break it away. The process was repeated at different angles until the stone is small enough to come out.
AI Razi's technique was not only an advance on classical procedures as shown by Adams (1846) in his chronological review of lithotomy, but also a landmark in the process of crushing a stone.
Afterwards, Albucasis, who lived between 930-1013 A.D. carried Al Razi's originality further by designing a special forceps, AI Kalalib, by which he could grasp firmly on a stone through a perineal cystotomy and with manual compression break it into fragments. Therefore, Kirkup (1981) described Albucasis forceps as the primitive lithotrite.
On the other hand, unlike Celsus, Paulus and AI Razi, in the case of impacted urethral stone, Albucasis designed a fine drill AI Mishaab.. He revolves it gently upon the stone, perforating it until piercing it through to the other side, then by
the other hand outside the penis, squeeze the remnants which will be washed out by the urine.
Cumston (1981), Spink and Lewis (1973) and El- Faquih and Wallace (1978) admitted that Albucasis' device represents the foundation of true Lithotripsy.
In fact, Cumston (1968), Desnos (1972), Spink and Lewis (1973), Campbell (1974), Ullmann (1978) and Montagnani (1983), stated that Albucasis was not a mere compiler but rather a skillful surgeon who completely integrated surgery into scientific medicine and his thirty volumes book AI Tasrif was translated to Latin and greatly influenced the European medieval schools of medicine well into the eighteenth century.
However, in Europe, the nineteenth century as Ellis ( 1969) and Desnos (1972) stated, opened a period of ingenuity on the part of surgeons and surgical instrument makers.
Therefore, by the notion of getting at the stone while actually within the bladder, Albucasis' idea of drilling by AI Mishaab which was introduced to the bladder along a metal canula was the foundation of the Litholepte of Fournier de Lempdes (1812), the instrument of Gruithuisen (1813), Civiale's trilabe (1818), Leroy d'Etoilles' curved trilabe (1827) and the Brise Coque of Rigal de Jaillac (1829) (Fig. 1). They differed only in their mode of stone fixation.
Then the final modification to Albucasis' idea of drilling was in the replacement of AI Mishaab with a rotating burr as in Leroy d'Etoilles Lithoprione (1822) and Civiale's Lithontripteur (1823).
On the other hand. AIbucasis' idea of Lithotrity was taken further. The Lithotrite introduced by Andreas a Cruce, in the early eighteenth century, was in fact, a modification of AIbucasis lithotrite in which the manual compression on the handle was replaced by a screw action (Fig. 2).
In 1822, Amussat took the idea further by applying it transurethrally instead of through a perineal cystotomy.
By 1832 Albucasis' principle of a pair of jointed serrated blades to crush was replaced by the modem principle of parallel blades, first advocated by Heurteloup in his percussion lithotrite. Then the percussion was replaced by a sucessful screw action by 1834. Then further efforts were directed towards the most efficient evacuation of fragments and by 1878, according to Desnos (1972), Lithotripsy was recognized as a valuable and safe surgical operation.
In conclusion, as Littre pointed out, "There is nothing in the most advanced contemporary medicine whose embryo cannot be found in the medicine of the past".
Adams, F. (1846). In the seven books of Paulus Aegineta, Trans. Adams, F., Vol. 2, London: The Syndenham Society.
AIbucasis (1973). AIbucasis on surgery and instruments: A definitive edition of the Arabic text with English translation and Commentary, by Spink, M.S. and Lewis, I.L, London: Publications of the Wellcome Institute of the History of Medicine.
AI-Razi (1961). Kitabul Hawi Fi T -Tibb (Rhazes Liber Continens), Vol. 10,Ed. The Bureau, First Edition, Osrnania Oriental Publications, Osmania University, Hyderabad, 7.
Antyllus, (1961).ln Kitabul Hawai FiT-Tibb (Rhazes Liber Continens), Vol.10, p 114, Ed. The Bureau, First Eortion, Osmania Oriental Publications, Osmania University, Hyderabad, 7.
Andreas a Cruce (1785). In: A system of surgery, by Alexander Bell, Second Edition, Edinburgh, C. Elliot publisher.
Bickers, W. (1969). Adventures in Arabian Medicine, Journal of the Royal College of Surgeons of Ireland, 5: 5-14.
Campbell, D.C. (1974). Arabian Medicine and its influence on the Middle Ages, First Edition (reprint), Amsterdam: Philo Press.
Celsus (1938). De Medicina, Trans. Spencer W.G., Vol. 3, London: William Heinmann, Cambridge and Massachusetts: Harvard University Press.
Charaka (1961). In Kitabul Hawi Fi T-Tibb (Rhazes Liber Continens), Vol. 10, p 131, Ed. The Bureau, First Edition, Osmania Oriental Publications, Osmania University, Hyderabad, 7.
Cumston, C.G. (1968). An Introduction to the History of Medicine from the Time of Pharaohs to the End of the XVII Century. London: Dawsons of Pall Mall.
Desnos, E.C. (1972). The History of Urology up to the latter half of the Nineteenth Century, In the History of Urology, Ed. Murphy, LJT, Springfield & Illinois: Charles, C. Thomas.
Dickinson, E.H. (1975). The Medicine of the Ancients. Liverpool: Adam Holden.
Dimopoulos,A. Gialas, M. Likourinas, G. Androutsos and A. Kostakopoulus (1980). Hippocrates: Founder and Pioneer of Urology. British Journal of Urology, 52: 73-74.
Ellis, H. (1969). A History of Bladder Stone. Oxford and Edinburgh, Blackwell ScientifIC Publications.
El Faquih, S. and Wallace, D.M. (1978). Ultrasonic Lithotriptor for Urethral and Bladder Stones. British Journal of Urology, Vol. 50, 255-256.
Kirkup, J.R. (1981). The history and evolution of surgical instruments. I. Introduction. Annals Royal College of Surgeons of England, 63: 279.285.
Margotta, R. (1968). An illustrated history of medicine. Ed. Paul Lewis, p. 109, Paul Hamlyn.
Montagnani, C.A. (1983). Paediatric Surgery in Islamic Medicine from Middle Age to Renaissance. Greek Association of Paediatric Surgeons, 8th Annual International Meeting, Chios.
Paulus Aegineta (1846). The seven books of Paulus Aegineta, Trans. Adams F., Vol. 2, London: The Sydenham Society.
Spink, M.5. and Lewis, J.L (1973). In Albucasis on Surgery and Instruments (A definitive edition of the Arabic text with English translation and commentary). London: Publications of the Wellcome Institute of the History of Medicine.
Susruta (1972). In the History of Urology, Ed. Murphy, LJT, p. 11, Springfield and Illinois: Charles, C. Thomas.
Ullmann, M. (1978). Islamic Medicine, Islamic surveys series No. II, Edinburgh University Press.