Volume 2, Issue 2 - May 2010
Rabie E. Abdel-Halim, FRCS Ed
University of Al-Faisal, Riyadh, Saudi Arabia
Fig. 1: Title page of the 10th volume of Al-Razi book: Kitab Al-Hawi Fi Al-Tibb (The Continens)
Although lithotripsy1 is often looked on as a modern discovery, its roots may be traced back to antiquity. Yet there is little mention of lithotripsy in Greek medical writings, perhaps because of Hippocrates’s injunction to avoid cutting for the stone2 (Cumston, 1968). This silence lasted for several centuries (Dimopoulos, Gialas, Likourinas, Androutsos, & Kostakopoulus, 1980) and it was not until 50 A.D that Celsus described the technique of Ammonius3 (200 B.C) for
Fig. 2: The pincer used by Al-Razi to grasp and break off pieces of a large vesical stone (shown in the illustrated 30th section of Al Tasrif book of Al-Zahrawi).
splitting a large bladder stone through a perineal cystotomy by using a scoop, chisel and hammer (Celsus, 1938), now considered the earliest trial for crushing a stone.
Even though Celsus had long recommended the procedure (Celsus, 1938), it was not popularly employed because Charaka,4 Antyllus,5 and Susruta6 advised against breaking a bladder stone or even scratching it up till the fourth century (Charaka, 1961; Antyllus, 1961; Susruta, 1972). The idea was not even mentioned by Paulus Aegineta, the Byzantine physician who in the seventh century was thought to have summed up all medical knowledge of his time (Aegineta, 1846). Moreover, from the ninth to the fourteenth century the age of Greco-Roman medicine in Europe was coming to an end and there was no further progress in terms of lithotripsy (Cumston, 1968; Margotta, 1968; Bickers, 1969; Desnos, 1972).
In the East, however, the study of medicine and other branches of science were revived with the establishment of
Islam, which strengthened scientific inquiry7 (Cumston, 1968; Dickinson, 1975; Kirkup, 1981). In accordance with
Fig. 4: A manuscript page of the 30th section of Al-Tasrif book of Al-Zahrawi (the first ever illustrated operative surgical book) showing the instrument and technique he devised to crush an impacted urethral stone.
this, Al-Razi8 (Rhazes) (841-926 A.D.) described a new technique for breaking a large stone in the tenth volume of his twenty-three volume book, Al-Hawi Fi Al-Tibb (The Liber Continens), which represents his principal contribution to medicine (Fig. 1) (Al-Razi, 1961). He used a strong pincer (Fig.2) to hold firmly onto 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 was small enough to come out. This technique was an advance on classical procedures and a landmark in the process of stone crushing (Adams, 1846).
Fig. 3: Al-Zahrawi forceps (Al-Kalaleeb) for crushing large vesical stones through a perineal cystotomy.
Later Al-Zahrawi (Albucasis)9 (930-1013 A.D) carried Al-Razi's original idea further by designing a special forceps al-kalalib10 with which he could grasp the stone firmly through a perineal cystotomy and, with manual compression, break it into fragments (Fig. 3) (Albucasis, 1973). This has been described as the primitive lithotrite11 (Kirkup, 1981).
For managing an impacted urethral stone, Al-Zahrawi designed a fine drill (which he named al-mishaab12), which revolved gently upon the stone, perforating it until it was pierced through; the penis was then squeezed from outside by the other hand so that the broken remnants of the stone crumble and could be eliminated in the urine (Fig. 4). This device is generally viewed as representative of the foundation of true lithotripsy (Cumston, 1968; Spink & Lewis, 1973; El-Faquih & Wallace, 1978). Clearly, Al-Zahrawi was not just a mere compiler of ideas but rather a skillful surgeon who integrated surgery into scientific medicine (Cumston, 1968; Desnos, 1972; Spink & Lewis, 1973; Campbell, 1974; Ullmann, 1978; Montagnani, 1986); his thirty-volume book, Al-Tasrif, was translated to Latin and came to greatly influence the European schools of medicine from the medieval period well into the eighteenth century (Fig. 5).
Fig. 5: Two pages from an incunabulum of the 30th section of Al-Tasrif book of Abul-Qasim Al-Zahrawi (a.k.a. Abulcasis, Chirugia Abulcasum) as translated to Latin in the 12th century by Gerard of Cremona.
In Europe, the nineteenth century opened a period of ingenuity on the part of surgeons and surgical instrument
Fig. 6: A composite diagram from Spink & Lewis (1973), Ellis (1969) and Desnos (1972) showing how Al-Zahrawi's idea of drilling by Al-Mishaab evoluted in the 19th century to be applied on the bladder stone transurethrally.
makers (Ellis, 1969). Therefore, by the notion of getting at the stone while in the bladder, Al-Zahrawi's idea of drilling by al Mishaab which was introduced transurethrally to the bladder along a metal canula constituted the foundation of the Litholepte of Fournier de Lempdes13(1812), the instrument of Gruithuisen14 (1813), Civiale's15 trilabe (1818), Leroy d'Etoilles'16 curved trilabe (1827) and the Brise Coque of Rigal de Jaillac (1829) (Fig. 6). They differed only in their mode of stone fixation. Eventually, Al-Zahrawi's idea of drilling was modified by replacing al mishaab by a rotating burr, as in Leroy d'Etoilles’ Lithoprione (1822) and Civiale's Lithontripteur (1823).
Al-Zahrawi's model of lithotripsy was then taken further. The lithotrite, introduced by Andreas a Cruce in the early eighteenth century, was in fact a modification of Al-Zahrawi’ lithotrite, in which the manual compression on the handle was replaced by a screw action (Fig. 7) (a Cruce, 1785). In 1822, Amussat17 developed the idea further by applying it transurethrally instead of through a perineal cystotomy.
By 1832, the jointed serrated blades that Al-Zahrawi had devised to crush the stone were replaced by parallel blades, first advocated by Heurteloup18 in his percussion lithotrite. The percussion was then replaced by a successful screw action in 1834. Further efforts were aimed at identifying the most efficient evacuation of fragments, and by 1878, lithotripsy was recognized as a valuable and safe surgical operation. As Maximilien Littré19 pointed out, "There is nothing in the most advanced contemporary medicine whose embryo cannot be found in the medicine of the past" (Littré, 2001).
Fig. 7: Andreas a Cruce's modification (left) of Al-Zahrawi's lithrocite (right): a composite diagram from Spink & Lewis and Andreas a Cruce
This article was originally published as: Abdel-Halim, RE. Lithotripsy: A historical review, Matouschek E, editor: Endourology - Proceedings of the Third Congress of the International Society of Urologic Endoscopy, Karlsruhe; 1984 August 26-30. Baden-Baden: BuA-Verlag Werner Steinbruck; 1985. p. 474-476.
Adams, F. (1846). In the seven books of Paulus Aegineta, Trans. Adams, F., Vol 2, London: The Syndenham Society, pp. 356-363.
Albucasis (1973). Albucasis on surgery and instruments: A definitive edition of the Arabic text with English translation and commentary, Eds: Spink, M.S. and Lewis, I.L, London: Publications of the Wellcome Institute of the History of Medicine, pp. 414-417
Al-Razi (1961). Kitabul Hawi Fi Al-Tibb (Rhazes Liber Continens), Vol. 10, First Edition, Ed. The Bureau, Osmania Oriental Publications, Osmania University, Hyderabad, pp. 110-153.
Andreas a Cruce (1785). In: A system of surgery, by Alexander Bell, Second Edition, Edinburgh, C. Elliot publisher.
Antyllus, (1961). ln Kitabul Hawai Fi Al-Tibb (Rhazes Liber Continens), Vol.10, First Eortion, Ed. The Bureau, , Osmania Oriental Publications, Osmania University, Hyderabad, p. 114.
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. 1st ed (reprint). Amsterdam (NL): Philo Press, pp. XI-XV.
Celsus (1938). De Medicina, Trans. Spencer W.G., Vol. 3, London: William Heinmann, Cambridge and Massachusetts: Harvard University Press, pp. 425-445.
Charaka (1961). In Kitabul Hawi Fi Al-Tibb (Rhazes Liber Continens), Vol. 10, Ed. The Bureau, First Edition, Osmania Oriental Publications, Osmania University, Hyderabad, p. 131.
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, pp. 23-26, 185-212.
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, pp. 5-186.
Dickinson, E.H. (1975). The Medicine of the Ancients. Liverpool: Adam Holden.
Dimopoulos, C., Gialas, A., Likourinas, M., Androutsos, G., & Kostakopoulus, A.(1980). Hippocrates: Founder and Pioneer of Urology.
British Journal of Urology, 52: 73-74.
El-Faquih, S. & Wallace, D. M. (1978). Ultrasonic Lithotriptor for Urethral and Bladder Stones. British Journal of Urology, Vol. 50, 255-256.
Ellis, H. (1969). A History of Bladder Stone. Oxford and Edinburgh, Blackwell ScientifIC Publications, pp. 34-34.
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, Paul Hamlyn, p.109.
Littré, M. P. (2001). Quoted in: The New Healing Herbs: The Classic Guide to Nature's Best Medicines. Castleman M., 2nd edition, USA: Rodale Inc; p 1.
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Aegineta, P. (1846). The seven books of Paulus Aegineta, Trans. Adams F., Vol. 2, London: The Sydenham Society, pp. 354-362.
Spink, M. S. & 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, pp. VII-XV, 1-7, 280-283, 348-352, 410-423.
Susruta (1972). In The History of Urology, Ed. Murphy, LJT, , Springfield and Illinois: Charles, C. Thomas, p. 11.
Ullmann, M. (1978). Islamic Medicine, Islamic surveys series No. II, Edinburgh University Press, pp. 52-54.
RABIE E. ABDEL-HALIM, FRCS Ed is an emeritus professor of urology and formerly, visiting professor of the history of Islamic medicine and medical ethics at Al-Faisal University in Riyadh, Saudi Arabia. Urinary stone disease is his main urological research interest. His publications in this field include a book on “Urolithiasis in the Western Region of Saudi Arabia: A clinical, biochemical and epidemiological study” published in 1996 by King Abdulaziz City for Science and Technology.
Currently, Dr. Abdel-Halim is carrying out several primary source studies in the history of medicine, evaluating the contributions of Islamic medieval scholars to the field of science and medicine. In 2005, the Kuwait Foundation for the Advancement of Sciences awarded him the Kuwait Prize for his research activities and publications in this field. He was selected in May 2009 as an associate member of the Foundation for Science Technology and Civilization in Manchester, UK. Recently he was invited as a visiting professor to Al-Faisal University, Riyadh, where he authored and taught courses in the History of Islamic Science and Islamic Medical Ethics in addition to designing a course in Arabic Medical Poetry for future programs in the medical humanities. He is also a poet with several Arabic poetry publications. His website is www.rabieabdelhalim.com and he can be reached at email@example.com