Urology Unit, King Abdulaziz University
Hospital, Jeddah, Saudi Arabia
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Progress in Pediatric Surgery , Vol. 20, pp 256-264
Ed. by P.P.Rickham
© Springer-Verlag Berlin Heidelberg 1986
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It is noticeable that, in any contemporary article on medicine, the more than 1000 years between Graeco-Roman times and the modern era are commonly over-looked, giving the appearance that during this period nothing worthy of mention happened in medicine. In Europe, this period is usually referred to as the Dark Ages, in which the great era of the Graeco-Roman medicine came to an end and no progress in medical science was made until the Renaissance [7, 11, 12].
However, in the East,
the firm establishment of the Moslem supremacy, coincided with the development
of botany, pharmacy and chemistry, branches of science that the Moslem world is
given credit for having established [11, 13, 24]. Between the ninth and the
sixteenth centuries, the study of medicine and other branches of science
revived and acquired a scientific basis [11, 13].
Historical Review of Literature on Paediatric Urology
In this study, we present a brief commentary on four books having to do
with urology, with a special view toward aspects of paediatric urology. The
books were written by the Moslem scholars ar-Razi, Ibn al-Jazzar, al Zahrawi
and Ibn Sina, who lived between the ninth and the eleventh centuries.
Ar-Razi lived in Baghdad between 841 and 926 A.D. [4, 18]. In addition
to his treatise Liber de Variolis et Morbillis on eruptive fevers [9,
11, 15, 24, 28, 32], which was considered a masterpiece of clinical medicine
[8], the 23-volume work al-Hawi (Continens), an encyclopaedia of
medicine and surgery, is another major contribution by ar-Razi to medicine [9,
11,24,28].
Ar-Razi critically evaluated the views of the
ancients in light of his own experience and practice, a mode of analysis that
constitutes basic scientific research. Cumston [11] has stated that the
Islamic physician has the merit of having carefully analysed the scattered
insights of Greek medicine, extracting from them the most important material
and leaving aside everything that was superfluous. According to Husain and
al-Okbey, unlike his predecessors, ar-Razi followed the original scheme of
methodically classifying diseases according to the organs affected [17]. In
this, he showed his supreme abilities as a clinician by presenting various
pathological conditions, usually starting with the complaint, then analysing
its origin and finally describing the signs necessary for diagnosis [9,25].
Ar-Razi was a keen
observer, differentiating with great precision among various conditions that
produce similar complaints and accurately describing sign necessary for
diagnosis. Given the symptom of heaviness in the loin, for example here is his
precise differentiation of renal stones and renal obstruction or swelling:
"... and the
differentiation between them is that; with inflammation, [there are] mixed fevers,
rigors and polyuria with frequency; with obstruction, [there is] oliguria and
the urine is clear and with stones, the urine is either clear or not and with
sandy sedimentation" [5, part 10, p.120].
Though Rufus of
Ephesus had differentiated between vesical and renal haematuria [12], ar-Razi also
gave the underlying physio-anatomical reasons for this difference:
...Sudden haematuria is due to a ruptured renal
vessel as this cannot be the case in the bladder because it cannot be for a
vesical vessel to rupture due to plenty of blood coming to it as it happens in
the kidney. And this is because blood is not filtered in the vessels of the
bladder as it does in the vessels of the kidney. But the amount of blood that
comes to the bladder is only enough for its nutrition, while in the kidney
because blood is filtered in it and then, large blood vessels and plenty of
blood comes to it, far more than its need for nutrition. Also the vessels in
the bladder are not close to the interior and unsupported as the vessels which
enter deep into the kidney. ...[5, part 10, p.10].
He also
differentiated between renal haematuria due to a ruptured vessel and that due
to congestion with increased permeability [5, part 10, p.10].
His chapter "The
Stoppage of Urine" differs from the views of his predecessors Celsus,
writing at the start of the Christian era, and Paul of Aegina (625-690 A.D.),
both of whom referred only to urinary retention. Ar-Razi differentiated between
retention and anuria:
The urine stops either because the kidney lacks it and the sign of this is the stoppage of urine and no heavy pains in the back and not in the loin, ureter and bladder, any discomfort and not at the bladder neck, any cause of obstruction as we will show and together with this, the abdomen is lax and in the body there is swelling and dropsy or profuse sweating.
Or urine is within the kidney which is obstructed
and in it the lesion which is swelling or stone or clots of blood or pus.
Common to all of them is the pain in the lumbar region with emptiness of the
bladder. But if it be a stone, the signs of the stone would appear before that.
And if it be a hot swelling, with the pain there is some throbbing. And if it
be diseases in the kidney then it
is only heaviness. And if it be a
solid swelling, the urine does not stop suddenly but gradually and with
heaviness only. And if it be clots of blood or pus, then it would be preceded
by ulcer .
And if the urine is stopped because of the urinary
passages from the kidney the bladder will be empty and the pain in the ureter
along its course with pricking and stitching as the ureteric pain is continuous
and pricking, after this, use the previous criteria as in the kidney [5, part 10,
pp.167-168].
In a similar fashion,
he discussed clinical observations concerning retention [5, part 10, p.168].
According to Husain and al-Okbey [17], ar-Riazi
differentiated with great precision between renal or vesical pain and pain due
to colitis [5, part 10, pp. 80-81, 105]. He also excelled in differentiating
between dormant stones and moving ones, describing the precise location of the
latter [5, part 10, p. 92]. Radbill [28] states that ar-Razi was the first to
describe spina bifida and its relation to incontinence.
From the surgical point of view, ar-Razi's
procedures for lithotomy were similar to those of Paul of Aegina. However,
ar-Razi was the first to use enemas as a preparation for surgery and to
describe the sign of crepitus on rectal examination in the case of multiple
vesical stones. He was also the first to break a large stone by using strong
pincers (Fig.
1) to hold the stone firmly and to make it protrude through a perineal
cystotomy in order to break it, repeating this procedure at different angles
until the stone became small enough to be extracted [5, part 10, pp. 113, 114].
Meatotomy was also
first conceived of and practised by ar-Razi:
"If a stone is impacted in the tip of the urethra be aware not to force it out by pushing as this causes laceration and subsequent severe pains and infections, but incise the end of the penis and remove the stone" [5, part 10, p.166].
Ibn al-Jazzar, or al Gizar, lived in Qairawan between 895 and 980 A.D.
[3]. His book Siytlsat as-sibyan Wa Tadbirihim, comprising 22 chapters,
is considered a continuation of ar-Razl's tradition of distinguishing
pediatrics from other diseases. As far as urological disorders are concerned,
he devoted a whole chapter to a discussion of bladder stones, including their
aetiology, sex incidence, symptoms and signs. Ibn al-Jazzar's book sums up most
of the knowledge of his predecessors.
At-Tasrif
Al Zahrawi, also known as Albucasis, Abulcasis, Bucasis or al Zahravius
[2, 9], lived in Cordoba (al Andalus) between 930 and 1013 A.D. [32].
His book at-Tasrif, Kitab at-Tasrif li-man ajiza
aan at-taalif (The disposal of medical knowledge to he who is not able to
compile it by himself) constitutes his largest work on medicine. Consisting of
30 volumes it is an encyclopaedia of medicine and surgery [2,9, 11, 18].
Al-Zahrawi summed up
all the surgical knowledge of his time in the 30th volume of this large medical encyclopaedia
[31]. A number of historians have described this volume as giving the first
rational and complete illustrated treatment of its subject, and the many
surgical procedures and instruments described in it do not appear in any other
work of the time [2,9, 11, 15,26,30-32].
According to Cumston
[11], Spink and Lewis [31] and El Faquih and Wallace [14], al-Zahrawi's device
of drilling a hole in an impacted urethral stone by a special drill called al
Michaab, made of the finest steel, may be considered as the foundation of true
lithotripsy:
...Now if the calculus be small and be impacted in the opening of the urinary passage, preventing the exit of the urine treat it with the means I am about to describe before you go on to make your incision, for often I have found this treatment sufficient without incision; I have experience of this. You take a drill of the finest steel of this shape. It should be triangular at the point and sharp with a wooden handle. Then take a thread and with it bind the penis beneath the calculus to prevent the stone from returning to the bladder. Then introduce the iron of the drill gently into the meatus until the drill reaches the stone itself and then very, very gently revolve the drill upon the stone with your hand, and try to perforate it, till you pierce it through to the other side. Then the urine will at once be released. Then, with your hand outside the penis, squeeze the remains of the stone and they will crumble and be washed out by the urine and the patient will be cured (Fig. 2) (cited by [31, pp. 416- 417]).
Al-Zahrawi also
designed a special forceps he called Kalalib (Fig. 3),
which he used for crushing a large vesical stone through a perineal cystotomy.
It was in fact a primitive lithotrite:
". ..But if
the stone be very large, it is foolish to make a great incision down upon it,
for the result is that the patient either dies or has a chronic urinary fistula
because the place will not heal at all. Try rather to manipulate it so that it protrudes, or else
attempt to break it up with the forceps so that you can ex- tract it
piecemeal" (cited by [31, pp. 414-415]).
Circumcision was not
described by either Celsus or Paul of Aegina. The latter described only the
excision of blackened prepuce in gangrenous infections. Therefore, as related
by Spink and Lewis, al-Zahrawi was the first to describe the dissection
technique of circumcision performed with scissors (Fig. 4), an
instrument he was the first to make use of in surgery [31].
His chapter on bladder irrigation with its numerous
illustrations of syringes and other instruments is of utmost originality [31].
In contrast to the Greek S- shaped catheter, al-Zahrawi used catheters of his
own design, which resembled modern ones in that they were straight [24, 31]. For
operating on children, he stressed that small versions of the instruments
designed specially for this purpose should be used.
From the observations made by al-Zahrawi with
regard to his personal experience and the care with which he warns the reader
of the dangers of injury that can be incurred during surgery, he was not a mere
compiler, but also a very skilful surgeon [9, 11, 12, 15,24,26,30-32].
Al-Qanun (The Canon of Medicine)
Ibn Sina, or Avicenna [2] lived in Hamadan and Jurjan from 980 to 1037
A.D. [l8] and acquired great fame in mediaeval European medicine
[11,16,21,28,29].
In al-Qanun, Ibn Sina basically followed the
methodical, analytical line originated by ar-Razi. AI-Qanun was,
however, more broadly conceived than the Continens [11] and included all branches of medical science
[11,16,21].
According to Desnos, most of the disesaes of the
kidneys and bladder can be recognized in the systemic classification of renal
diseases and the accounts of bladder diseases given by Ibn Sina in al-Qanun [12,
20]. He was also the first to point out the fact that haematuria may be due to
causes outside the urinary system, for example, blood diseases [20, vol. 2, p.
529].
Apart from the methodical classification and
precise descriptions of aetiological factors and signs in his chapter on
urinary disturbances, Ibn Sina pointed out the role of psychological factors in
the treatment of certain cases of nocturnal nuresis [20, vol. 2, p. 526].
Both Ibn Sina and
ar-Razi warned against catheterization in the presence of inflammation, as it
increases the swelling and pain. To ensure gentle catheterisation, Ibn Sina
designed catheters with rounded, firm tips and many side holes from the skin of
certain marine and other animals [20, vol. 2, p. 522].
The al-Hawi, at- Tasrif and al-Qanun were
translated into Latin as early s 1150 A.D. by Gerard of Cremona [32] and
greatly influenced the European Mediaeval schools of medicine well into the
eighteenth century [9, 11, 12, 15, 16, 4,26,28,29,32].
In this paper we present a commentary on four books from the paediatric
urology point of view; al-Hdwi (Continens), fiSiyasat as-Sibyan wa
tadbirihim, at- Tasrif and al-Qanun by the Moslem scholars ar-Razi,
Ibn al-Jazzar, al Zahrawi and Ibn Sina who lived within the period of the ninth
to the eleventh centuries.
In these books the
supreme abilities of the authors as clinicians and their role in the creation
of clinical medicine are shown by: the presentation of the various pathological
conditions usually starting with the complaint then describing the origin of
the disease and enumerating the accurate signs necessary for diagnosis.
Differential diagnosis between various conditions which produce similar
complaints is precisely described. For example, retention of urine and
different types If anuria, types of renal haematuria, dormant and moving renal
stones and their precise localisation, renal or vesical pain and pain due to
colitis. Finally the methodical classification of the diseases according to the
organs affected is discussed.
The description of the pathology and the knowledge
of new diseases was an important advance made by these scholars. From the
urological point of view, spina bifida and its relation to incontinence was
first described by ar-Razi and most of the diseases of the kidney and bladder
can be recognized in the systemic classification of the diseases of these
organs given by Ibn Slna who pointed out the psychological role in some cases
of nocturnal enuresis. Though ar-Razl was the first to think of and practice
meatotomy, introduce enema in the pre-operative preparation for lithotomy and
break large vesical stones piecemeal in the bladder , the merit of having
integrated surgery into scientific medicine must go to al-Zahrawi. The many
operative procedures and instruments described in the thirtieth volume of his
encyclopaedia of medicine and surgery (at-Tasrif), such as the Kalalib
"a primitive lithotrite", the Michaab to drill a hole in an impacted
urethral stone forming the foundation of true lithotripsy, the scissors used in
the dissection technique of circumcision, straight catheters and the numerous
instruments and techniques for bladder irrigation, do not appear in any other
classical writing.
These books were
translated into Latin as early as 1150 A.D. and greatly influenced the European
mediaeval schools of medicine up to the eighteenth century.
Rėsumė
Ce chapitre traite de 4 manuels du point de vue de l'urologie infantile,
ėcrits par les
savants musulmans ar-Razi, Ibn al-Gazzar, al-Zahrawl et Ibn Sina qui vivaient
entre le IXe et le Xle siecle.
Ces ouvrages tėmoignent de l'extraordinaire compėtence des auteurs et de l'importance de leur rōle lors de la naissance de la mėdecine clinique. Ils dėcrivent d'abord les symptomes presentes par le patient, indiquent la cause de la maladie et les signes qui conduisent au diagnostic. IIs connaissent aussi le diagnostic differentiel, par exemple pour les rėtentions d'urine dans les cas d'anurie, d'hėmaturie, de calculs vėsicaux, de nėphrites ou de colites. IIs discutent aussi des merites d'une classification methodique des affections d'aprės les organes touchės.
Ces savants ont aussi fait progresser les
connaissances en pathologie et dans le domaine des maladies nouvelles. Dans le
domaine de l'urologie par exemple, ar-Razi dėcrit pour la premiėre fois le spina bifida dans le contexte de
l'incontinence. Ibn Sina ėnumere la plupart des affections rėnales et vėsicales. II mentionne aussi l'aspect psychologique
de l'ėnurėsie. Ar-Razi effectua la premiėre mėatotomie, utilisait des clystėres comme preparation
ā une
lithotomie et broyait de gros calculs vėsicaux mais c'est al-Zahrawl qui fit vraiment
entrer la chirurgie dans le domaine de la mėdecine scientifique. Les diverses mėthodes operatoires et
les instruments qu'il dėcrit dans le volume 30 de son encyclopėdie de la medecine et de la chirurgie (at-Tasrif)
tels que le "Kalalib" un broyeur de calculs primitifs, le
"mischab" avec lequel il perc,ait un trou dans un calcul
bloquė dans l'urėtre (le dėbut de la lithotritie), les ciseaux pour la circoncision, le cathėter et les nombreux
autres instruments pour le lavage vesical ne sont mentionnės dans aucun autre
ouvrage classique.
Ces ouvrages ont ėtė traduits en latin dės 1150 et ont eu une grande influence sur la mėdecine europeenne au
Moyen-Age et jusqu'au XVIIIe
siėcle.
Zusammenfassung
( German Summary)
References
1. Abdel-Halim RE, Mohammad Y (1983) Kinderheilkunde vor 100 Jahren: Blick in die arabisch-islamische Medizin. Kinderarzt 14:61-63.
2. Abouleish E (1979) Contributions of Islam to
medicine. J Islamic Med Assoc (US) 28: 45.
3. AI-Haila, Muhammad al-Habib (ed) (1968) Risiila
fi siyasat as~sibyian wa tadbirihim (Ibn al-Jazzar). AI-Dar at-tunisiya
lin-nashr. Tunis (About management and direction of the youth).
4. AI-Nadim (1970) The fihrist of al-Nadim, a tenth
century survey of muslim culture. Columbia University Press, New York, vol2.
5. Ar-Razi (1955-1969) Kitab al-Hawi fi al-Tibb (The book of the
collector of medicine) (Rhazes, Liber Continens), 1st edn. Osmania Oriental
Publications, Osmania University, Hyderabad, vol 10.
6. Deleted in production.
7. Bickers W (1969) Adventures in Arabian medicine.
J R Coll Surg Irel 5 : 5-14.
8. Browne EO (1962) Arabian medicine. Cambridge
University Press, New York.
9. Campbell DC (1974) Arabian medicine and its
influence on the middle ages, 1st edn (re- print). Philo Press, Amsterdam.
10. Celcus (1938) De Medicina. Heinmann, London; Harvard University
Press, Cambridge, vols 1-3.
11. Cumston CO (1978) An introduction to the
history of medicine from the time of the pharoahs to the end of the XVIII
century .Dawsons of Pall Mall, London.
12. Desnos E (1972) The history of urology up to the latter half of the
nineteenth century .In: Murphy UT (ed) The history of urology. Thomas,
Springfield.
13. Dickinson EH (1875) The medicine of the ancients. Holden, Liverpool.
14. El Faquih S, Wallace DM (1978) Ultrasonic
lithotriptor for urethral and bladder stones. Br J Urol 50:255-256.
15. Freind J (1727) Histoire de la medecine, depuis
Galien, jusqu'au commencement du seizieme siecle, part 3. Langerak, Leyden.
16. Gruner OC (1930) A treatise on the Canon of
Medicine of Avicenna incorporating a translation of the first book. Luzac,
London.
17. Husain MK, al-Okbey MA (1977) Tibb ar-Razi,
Dirasa wa tahlil li kitab al-Hawi. Dar al- Shoruq, Cairo (The medicine of
ar-Razi, Studies and researches in al-Hawi).
18. Ibn Abi Usaybiaa (1965) Uyunul-Anbaa' fi tabaqat al-atibba. Dar
maktabat al-Hayat, Beirut (The sources of the knowledge of classes of doctors).
19. Ibn al-Jazzar (1968) Risala fi Siyasat as-sibyan wa tadbirihim.
Ad-Dar at-tunisiya lin-nashr, Tunis.
20. Ibn Sina (1877) Kitab al-Qanun fi t-tibb. Dar
Sadir, Beirut (The canon of medicine).
21. Iskandar AZ (1967) A catalogue of Arabic manuscripts on medicine and
science in the Wellcome Historical Medical Library. Wellcome Historical Medical
Library, London.
22. Jan MY , Abdel-Halim RES (1983) Ibn AI Gazzar
und sein Werk: die Fuhrung von Kindern und ihre Betreuung. Kinderarzt 14:
643-646.
23.
24. Margotta R (1968) In: Lewis P (ed) An illustrated history of
medicine. Hamlyn, Feltham.
25. Meyerhof M (1935) Thirty-three clinical
observations by Rhazes (circa 900 AD). Isis 23 : 321-393.
26. Montagnani CA (1983) Paediatric surgery in
Islamic medicine from Middle Age to Renaissance. Greek Association of
Paediatric Surgeons, 8th annual international meeting, Chios.
27. Paulus Aegineta (1844-1847) The seven books of Paulus Aegineta,
translated by F Adams. Sydenham Society, London, vols 1-3.
28. Radbill SX (1971) The first treatise on paediatrics. Am J Dis Child
122: 369-376.
29. Shah MH (1966) The general principles of Avicenna's Canon of
medicine. Naveed Clinic, Karachi.
30. Sprengel K (1815) Histoire de la medecine,
depuis son origine jusqu'au dix-neuvieme siecle, vol 2. Deterville Libreure,
Paris.
31. Spink MS, Lewis IL (1973) Albucasis on surgery and
instruments (a definitive edition of the Arabic text with English translation
and commentary). Wellcome Institute of the History of Medicine, London.
32. Ullmann M (1978) Islamic medicine. Islamic surveys series no 11.
Edinburgh University Press, Edinburgh.
