ABSTRACTS OF CONTRIBUTION OF ISLAMIC MEDICINE TO UROLOGY

Dr. A.M. Dajani
JORDAN

The aim of this paper is twofold; to review the most important contribution to urology by Arabian and Muslim Physicians and to refute the frequent denials by many scholars of their role in this field.

Picturing Muslim Physicians simply as transcriptors of Greek, Roman and Indian medicine has been refuted by many scholars. To the contrary, they had enriched medicine by their experience and deligence and became the discoverers and exporters of knowledge, which lit the way to modern European civilization.

Al Razi, Ibn Sina and Al Zahrawi top the list of these physicians, and of equal importance, though less renowned, we find that Ibn al Quff, Thabet Ibn Ourrah, Al Magousy, Al Tabary and others had also made great contributions witnessed in their works.

ANATOMY:
Al Magousy, Ibn Sinas and Ibn Hubal gave a detailed account of the anatomy of the bladder and of the intramural part of the ureter, which is no different of what we know now. They also drew the attention to the importance of such an arrangement in the prevention of vesico-ureteric reflux. It is interesting to note that nearly a thousand years later this same observation was made by another renowned scholar of Arab descendence viz. E. Tanagho. Both Ibn Hubal and Ibn Sina stressed the importance of the muscle 'at the mouth of the bladder' which on voluntary relaxation allows urine to flow out during micturitions.

Ibn al Quff described the value of the cremasteric muscles in keeping up the two testicles and preventing their dangling.

Al Magousy is said to be the first to describe such anomalies like hypospadias, epispadias and hermaphroditism. He also described the arteries to the penis and their role in erection.

The description by Ibn Sina that 'the-bladder contracts in every direction and squeezes out urine while the muscle at its mouth relaxes' does not differ from what we know now about the principles of the act of micturition.

RENAL STONES:
Muslim Physicians had devoted a lot of their attention to this subject. They tried to explain the way of their formation and described their signs and symptoms. They also described, for the first time, operations to remove such stones or to break them; and advised certain medications to treat stone patients and to prevent formation of such stones.

STONE FORMATION:
In trying to explain that Ibn Ourrah attributed it to the narrow opening of the kidney or of the bladder, and that the nidus on top of which further deposition might occur was viscid material found in urine as a result of ingestion of heavy food. Ibn Sina mentioned that inflammation of the kidney might end in stone formation. Al Razi on the other hand believed that calcification of pus resulting from ulceration of the kidney might initiate the process; and that stones might be formed either in the kidney substance, in the pelvis of the kidney, or in both. According to Ibn Ourrah, stones start as small bodies and enlarge by time.

This is what we actually know nowadays of the presence of a nidus albeit pus, blood etc., on which salts are deposited. We are also aware of the importance of obstruction and infection in the aetiology of stone formation.

Both Ibn Sinas and Al Zahrawi had agreed that bladder stones are common in children and that kidney stones occurred in the elderly. This is similar to what we know nowadays of the prevalence of stones in children of many of the Third World Countries.

The two physicians also agreed that bladder stones were less in women as their bladder passages are less tortuous, shorter and wider.

SIGNS AND SYMPTOMS OF STONES:
According to both Ibn Sina and Al Razi, pain is worse when stones are formed or during their passage down to the bladder, otherwise patients "feel heaviness in the flanks". This is very similar to how we describe pain due to the stones.

Ibn Sina made a very clear differentiation between kidney and bladder stones, which did not differ either with that of Al Razi, or of Al Zahrawi (Table 1).

Muslim physicians had mastered differentiation between many diseases and Ibn Sina as well as Al Razi before him, though in more detail, gave us a perfect description of differential diagnosis between colonic and renal pain (Table 2) which we believe is no different from what we teach now.

TREATMENT OF STONES:
Al Razi advised giving sedatives during the attack of colic and later drugs, which help to move the stones once the pain had subsided.

Ibn al Quff believed that treatment of large stones was easier for the following three reasons:

1. The large ones stop at the beginning of the urethra and in fact remain in the bladder.
2. It is easier to palpate the large one.
3. Surgery is more tolerated in-patients with the large one as they had got used to the pain.

Al Razi quoting Al Tabbary, Abu Khaled Al Faresy and Bukhtaishoua mentioned the following substances as useful for breaking stones; juice of radish leaves: caper: Prunus mahaleb: water of soaked chick peas: bitter almonds etc., lbn Qurrah and al Antaki added the Jewish Stone and Rubus Sanctus, etc., to the list. In addition in the margin of Tathkaret Daoud (p.92) the following were said to be useful -Alkekenge, Rubus friticosus, diuretics and honey.

SURGERY:
According to Springle, Al Zahrawi was the first to remove a bladder stone transvaginally, and the Lithotomy operation was devised by him. S. Hamarneh remarked about the latter that it was a great step in surgery. (Fig. 1 ).

Both Al Razi and Al Zahrawi gave a detailed description of the operation for the removal of bladder stones and stressed that the internal wound should be smaller than the external one to prevent leakage of urine and that no force should be used.

Al Razi even advised extracting the stone by means of "a forceps" or breaking it to pieces before removal.

Both Al Razi and Al Zahrawi had pointed out the difficulty of operating on women and Ibn Al Quff gave five reasons for that:

1. She may be a virgin and one cannot introduce the finger in the vagina in search of the stone.
2. A woman would rarely accept surgery and her tolerance of pain is less.
3. Women are usually shy.
4. The incision is more difficult and dangerous as the site of the stone is farther.
5. She may be pregnant and surgery will harm the foetus.

Commenting on the advice by Maysosen to use forceps for extracting the stone after incision, Al Razi believed that method was better as it would cause less laceration.

Ibn Sina on the other hand did not advise surgery because "it is very dangerous" This is in agreement with Ibn al Quff's opinion who added that wounds after kidney operations would not heal because of the continued passage of urine.

URETHRAL STONES:
Al Razi's advice to pull the skin of the penis forwards before direct incision on the stone to prevent fistula formation is similar to that of Al Zahrawi's. Both advised tying a thread behind the stone thus preventing it from slipping back into the bladder. To avoid laceration to the external meatus if the stone is near the tip Al Razi advised meatotomy, the procedure that is followed today.

In case of retention of urine due to a stone stuck in the urethra Al Zahrawi devised the following (Fig. 2) and method by which he had avoided surgery on many occasions.

"Take a steel probe with a sharp and pointed triangular end and with a long handle. Tie a thread behind the stone... introduce the probe gently till you reach the stone and try to penetrate it bit by bit... until you make a hole through it. Urine comes out immediately. Press on the stone from outside to crush it... The patient is thus cured... If you do not succeed then operate".

Commenting on that Spink and Lewis said -"This device of Albucasis does seem to have been in a manner a true lithotripsy many centuries earlier than our modern era and completely lost sight of and not even mentioned by the great middle-age surgeons Franco and Parei, nor by Frere Come the doyen of genitourinary surgery".

PREVENTION OF STONE FORMATION:
Ibn Qurrah advised avoiding heavy food and drinks, taking things which would clear the passage and cause diurese.g. seeds of melon, squirting cucumber, raddish seeds, cumin, bitter almonds; and many others.

This advice was also given by Al Razi.

This is what we nowadays advise for stone patients regarding diet, hydration and diuresis.

CIRCUMCISION:
We believe that the four methods of circumcision described by Ibn al Quff are the basis of what we practice at the present time. His description of (a round object of the size of the prepuce to be put below it in order to stretch it and push the glans to inside) can be considered the original genuine prototype of the present day Gumko. Also (...to tie the prepuce with a fine thread so that the glans can be pushed to inside...) can be considered the principle of the plastic capstan used for circumcision. Al Zahrawi prefers using the scissors for cutting (... because cutting will be proportionate and at the same level...)(Fig. 3).

HYPOSPADIAS AND IMPERFORATE EXTERNAL MEATUS:
Both Al Zahrawi and ibn al Quff had stressed the importance of these conditions (...Some children are born with no opening to the glans... if there is one there may be a downward curvature, 'chordee'... each is harmful. The first causes retention of urine while the latter affects fertility as sperms are emitted at an angle...).

Al Zahrawi described the anomaly as a very bad disfigurement and added (... the child cannot urinate forward until he lifts up the penis). This is a very clear picture of the anomaly and of its ill effects, as we know today. The benefit of repeated dilatation of the narrow external meatus was also stressed by Al Zahrawi. (Fig. 4) Regarding the surgical treatment of the anomaly, we do not believe that either physician was successful in introducing an acceptable procedure.

SURGERY AND SURGICAL INSTRUMENTS:
The famous surgeon E. Forge, praised Al Zahrawi for compiling all contemporary surgical knowledge in his great work Al Tasreef. Al Zahrawi described some operations for which he can be considered a leader in surgery. He also invented many instruments of his own. In addition to the previously described operations he must have the merit of being the first to recommend what we now know as the Trendelenburg's position which was adopted from him and named after by the German Surgeon.

He is mentioned as having described urinary diversion to the rectum in males and to the vagina in females.

Al Razi described operations on the bladder, urethra and the treatment of complications of such operations.

Before those two surgeons, Al Magousy, in addition to describing urethral anomalies and their treatment, is said to be the first who described perineal cystolithotomy.

However no advancement was made in the treatment of varicocele and hydrocele.

Regarding surgical instruments, Kirkup said that the first application of the modification of the handle of an instrument was the dental forceps made by Al Zahrawi. Commenting on the use of Al Zahrawi of the scissors for circumcision, Spink and Lewis said (...it may, therefore, be attributed to the Arabs; that is the application if not the actual invention...). The Methkab devised by Al Zahrawi can also be considered an instrument for lithotripsy.

CATHETERS:
Tucker denied that any improvement on catheters had been made before the beginning of the eighteenth century, and that the anatomy of the urethra was not taken into consideration. This is clearly refuted by the Muslim Physician's description of the catheter regarding its size, shape and malleability, together with the material of which it was made.(Fig. 5)

Again while J. Herman had denied that any improvement was made in the field of catheters we find that Ibn Sina had advised that more than one hole should be made for irrigation and drainage and that it should be of a round head.

In addition our Muslim Physicians had described very beautifully what could be considered irrigation syringes with negative pressure effect. (Fig. 6). We also find that Ibn Sina had advised caution and gentleness during catheterisation to avoid urethral injuries, not as Tucker had described that the patient was at the mercy of the size of the catheter.

Commenting on the irrigation of the bladder, Spink and Lewis wrote -(This chapter on irrigation of the bladder is both more comprehensive than any classical description and of the utmost original value. Celsus and Paulus merely give a few lines or a paragraph, but Albucasis devotes a whole chapter with splendid illustrations. (Fig. 7)

DILATORS:
The importance of urethral dilatation and the indication that the Arabs were the first to use the dilators and to stress their importance are well documented.

URINE:
As modern techniques for chemical, microscopical and bacteriological examination of urine were not available to them, Muslim Physicians had to rely upon the physical characteristics of urine and were able to draw very important conclusions. Thus Al Razi considered that urine reflected the circulation in the urinary system. Muslim Physicians laid down strict rules for the collection of urine, which do not differ, from what we advise today.

Al Razi advised examining urine for colour, consistency, deposit, taste, clarity, touch etc., and he divided each into different subdivisions and then specified the cause and the meaning of each. Haematuria with epithelial debris and foul smelling urine denoted cystitis, which might be associated with pain in the suprapubic region. In case of arthritis there might be discharge with burning along the shaft during micturition.

Both Al Razi and Ibn Sina described different types of frequency and polyuria including diabetes, the later stressed the importance of a pelvic mass pressing on the bladder causing such a disturbance.

Both physicians attributed nocternal enuresis to the laxity of the bladder neck muscles and the sphincter together with deep sleep. They advised for treatment limitation of fluid intake and light food at bed as many advise nowadays. Ibn al Quff added that involuntary urination can be due to spinal injury (neuropathic bladder).

Urinary retention could be due to obstruction at the bladder neck due to blood clot, a stone or a new growth. Both Al Tabary and Al Razi differentiated very clearly between the different types of anuria whether of kidney origin due to ureteric obstruction or bladder neck obstruction; they also stressed the importance of the presence or absence of a round globular mass (bladder) in the suprapubic region. In addition Al Razi described azotaemia, gangrene of the scrotum and haemoglobinuria.

TREATMENT BY HERBS:
Muslim Physicians had copied many prescriptions from ancient medicine and added very many of their own as seen in (Table 3).

SUMMARY
This review demonstrates how Muslim Physicians had contributed to and improved on the progress of medicine in the field of urology.

ACKNOWLEDGEMENTS
I am grateful to Dean A. AL-Badry and Prof. A. Daher for their comments. I am also thankful to Miss M.O. Mabrouk, Miss S. Abdullat of the Faculty of Agriculture and to Miss I. Rida our Librarian for helping in getting the references.

Mr. E. Bataineh and the Photographic Section of the University Library were kind to take photographs and make slides out of the microfilm.

Prof. B. Abu Rumaileh of the Faculty of Agriculture was very helpful in producing the scientific names of the herbs and plants.

Table 1
Differentiation between Kidney Stone and Bladder Stones

	Kidney Stone	Bladder Stone
Description	Softer, smaller, reddish	Harder, larger, grey-greyish white coarse. May be as small particles and more than one.
Patient	Obese, elderly	Usually thin (boys) Infancy - adolescence.
Pain	Worse during formation or movement to bladder. Radiation to groin means movement, stops when stone in bladder.	Less except if causing retention. Itching and pain along penis and its base. Pain in hypogastrium. The patient plays with his penis.
Urine	Turbid then clears, or remains turbid with deposit.	Lighter in colour but with deposit, may contain gravel. Mixed with blood if stone is big or coarse. Dysuria with small one (aneck), Frequency.
Associated complaint	Parasthesia over ipsilateral thigh.	May have prolapse of rectum.

Table 2
Differentiation between Colonic Pain and Renal Pain

	Colonic	Renal
Severity	Severe	Little, like thorns
Site	Begins below on the right, extends up to the left; more in front and in hypogastrium.	Begins high in the back, with dysuria, extends slightly downwards, more in the back. Pain in ipsilateral testicle.
Time	Sudden, eases on defecation, worse on eating	Gradual, severe at end, may be worse on defecation.
Radiation	To any part of abdomen.	Steady in place.
Chills	Not present	Frequent
Agreeable & Unagreeable	Wind and stools ease the pain.	Do not ease pain.
Medications to break the stone	No effect	Ease it.
Stools	Hard scybala, or like dunge of cows.	May be no constipation.
Accompanying symptomis: Pain in lower limbs & back Anorexia, biliary vomit, severity of pain, Drowsiness Relief by vomiting	Less More More	More Less Less
Causes & indications: Overeating, Bad food, colic, Borborygmi, Constipation Turbid urine, Burning	Precede	Precede

Table 3
Herbs and Plants used by Muslim Physicians

Diuretics	Disintegration of Stones	Dribbling of Urine	Dysuria	To increase Sperms
Artemesia absenthium Ammoniacum resina Cucumis melo var. Flexuosus (seeds) Cucumis sativus (seeds) Ficus carica Opopanax Eruca sativa Mill Ceratonia siliqua Punica granatum Crocus sp. Andropogon nardus Sagapenum Fumaria officinalis Alkekenge Struthium Malva sylvestris Apium graveolens Cuminum cyminum	Solidago virgaurea Cucumis melo Anethum Graveolens Raddish (leaves) Water of chick Peas Prunus amygdalus Prunus mahaleb Capparis Alkekenge Rubus sanctus	Juglans regia	Matricaria chamomilla	Phoenix dactylifera

REFERENCES

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