Paediatric Urology 1000 Years Ago
By Rabie E. Abdel-Halim*
Note of the editor
This article was originally published as: Professor Rabie E. Abdel-Halim, "Paediatric Urology 1000 Years Ago", Progress in Pediatric Surgery, edited by P.P. Rickham, Berlin Heidelberg: Springer-Verlag 1986, Vol. 20, pp 256-264. © Springer-Verlag. To visit the original article (HTML version), click on any one of the following links: link 1, link 2, link 3. We are grateful to Professor Rabie E. Abdel-Halim for allowing republishing.
* * * Summary
In this paper we present a commentary on four books from the paediatric urology point of view: al-Hawi fi al-tibb (The Continens), fi siyasat as-sibian wa-tadbirihim, at-Tasrif li-man 'ajiza 'an at-ta'lif and al-Qanun fi al-tibb by the Muslim scholars al-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 of 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 al-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 Sina who pointed out the psychological role in some cases of nocturnal enuresis. Though al-Razi 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 thirteenth 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 CE, and greatly influenced the European mediaeval schools of medicine up to the eighteenth century.
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   .
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   . Between the ninth and the sixteenth centuries, the study of medicine and other branches of science revived and acquired a scientific basis  .
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 al-Razi, Ibn al-Jazzar, al Zahrawi and Ibn Sina, who lived between the ninth and the eleventh centuries.
AI-Hawi fi al-tibb
Al-Razi lived in Baghdad between 841 and 926 CE  . In addition to his treatise Liber de Variolis et Morbillis on eruptive fevers      , which was considered a masterpiece of clinical medicine , the 23-volume work al-Hawi (Continens), an encyclopaedia of medicine and surgery, is another major contribution by al-Razi to medicine    .
Al-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  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, al-Razi followed the original scheme of methodically classifying diseases according to the organs affected . 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  .
Al-Razi was a keen observer, differentiating with great precision among various conditions that produce similar complaints and accurately describing signs 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:
"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" (, part 10, p.120).
Though Rufus of Ephesus had differentiated between vesical and renal haematuria , al-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" (, part 10, p.10).
He also differentiated between renal haematuria due to a ruptured vessel and that due to congestion with increased permeability (, 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 CE), both of whom referred only to urinary retention. Al-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" (, part 10, pp.167-168).
In a similar fashion, he discussed clinical observations concerning retention (, part 10, p.168).
According to Husain and al-Okbey , al-Razi differentiated with great precision between renal or vesical pain and pain due to colitis (, part 10, pp. 80-81, 105). He also excelled in differentiating between dormant stones and moving ones, describing the precise location of the latter (, part 10, p. 92). Radbill  states that al-Razi was the first to describe spina bifida and its relation to incontinence.
From the surgical point of view, al-Razi's procedures for lithotomy were similar to those of Paul of Aegina. However, al-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 (, part 10, pp. 113, 114).
Figure 1: Pincers devised by al-Razi to grasp vesical stones (see below reference  for the source).
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" (, part 10, p.166).
Risala fi siyasat as-sibian wa-tadbirihim
Ibn al-Jazzar, or al Gizar, lived in Qairawan between 895 and 980 CE . His book Siyasat as-sibian wa-tadbirihim, comprising 22 chapters, is considered a continuation of al-Razi'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 li-man 'ajiza 'an al-ta'lif
Al Zahrawi, also known as Albucasis, Abulcasis, Bucasis or al Zahravius  , lived in Cordoba (al Andalus) between 930 and 1013 CE .His book Kitab at-Tasrif li-man 'ajiza 'an at-ta'lif (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    .
Al-Zahrawi summed up all the surgical knowledge of his time in the 30th volume of this large medical encyclopaedia . 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        .
According to Cumston , Spink and Lewis  and El Faquih and Wallace , 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:
Figure 2: Steel drill used by al-Zahrawi to pierce urethral stones (see below reference 31 for the source).
"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 , 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:
Figure 3: Forceps designed by al-Zahrawi to crush vesical stones (see below reference 31 for the source).
"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 extract it piecemeal" (cited by , 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 .
Figure 4: Scissors invented by al-Zahrawi to perform circumcision by dissection technique (see below reference 31 for the source).
His chapter on bladder irrigation with its numerous illustrations of syringes and other instruments is of utmost originality . 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  . 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         .
Al-Qanun fi al-tibb
Ibn Sina, or Avicenna , lived in Hamadan and Jurjan from 980 to 1037 CE , and acquired great fame in mediaeval European medicine     .
In al-Qanun, Ibn Sina basically followed the methodical, analytical line originated by al-Razi. AI-Qanun was, however, more broadly conceived than Al-Hawi (the Continens)  and included all branches of medical science   .
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  . 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 (, 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 (, vol. 2, p. 526).
Both Ibn Sina and al-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 (, vol. 2, p. 522).
The al-Hawi, at-Tasrif and al-Qanun were translated into Latin as early as 1150 CE by Gerard of Cremona  and greatly influenced the European Mediaeval schools of medicine well into the eighteenth century          .
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* Emeritus professor of urology. Formerly, Professor of Urology at King Saud University, College of Medicine, and King Khalid University Hospital, Riyadh, Kingdom of Saudi Arabia.
by: Professor Rabie E. Abdel-Halim, Wed 13 May, 2009