Medical missionaries in China: John Glasgow Kerr (1824-1901) and cutting for the stone

With the introduction of Western medicine into China by Anglo-American medical missionaries in the early 19th century, Reverend Dr Peter Parker at the Canton Ophthalmic Hospital pioneered surgical operations in Chinese patients. The subsequent development of surgery for bladder stones at this institute by Parker's successor Dr John Kerr and colleagues is described.

Extraction of a bladder stone in a child as described by the renaissance physician Cristóbal Méndez

INTRODUCTION

in his Libro del exercicio y de sus provechos (Book of exercise and profits), the Spanish Renaissance physician Christopher Mendez (1500-1553) describes extracting a bulk stone from the bladder of a child younger than 5 years in the land of colonial Mexico. This is the first description of a surgical procedure in America.

MATERIAL AND METHODS

Biographical data were collected on Christopher Mendez. The electronic facsimile of the Book of exercise and profits was read. The historical aspects of perineal lithotomy and etiology of bladder stones were analyzed.

RESULTS

In chapter seven of the third treatise (page 120), Mendez speaks about the removal of a bladder stone in a boy named «Villaseñor». It uses the word «open» to describe the procedure, corresponding to a lithotomy more than a necropsy. It attributes the etiology of excess movements after ingestion and suggests a possible hereditary etiology.

DISCUSSION

Perineal lithotomy was a common practice in ancient times for children due to the high incidence of bladder stones. The technique was very invasive and was improved over the centuries.

CONCLUSIONS

The surgery described by Mendez for the child called Villaseñor most likely corresponds to a perineal lithotomy. A congenital cause could play a role in its etiology.

[Richard Strauß: a contribution on the occasion of his 150th birthday from an urological point of view]

Richard Strauß is one of the most important composers of the first half of the 20th century. In this article, his life is represented with special emphasis on the points of contact with urology and on the field of conflict of the time. We give a detailed description of the composer's urological illness, which finally lead to his death. The last works of the master, composed at the beginning and during his last illness, are appreciated as touching creations of his parting. Finally, we compare the treatment of the prominent patient with the contemporary level of urology.

[THE BLADDER STONE OF CARDINAL PIETRO BASADONNA (1617-1684) IN THE WORDS OF HIS PHYSICIAN ROMOLO SPEZIOLI (1642-1723)]

At the death of Cardinal Pietro Basadonna in 1684, his personal physician Romolo Spezioli wrote a report describing the disease, circumstances of death and autopsy findings of the illustrious prelate. This document, kept in the Biblioteca Civica at Jesi, is a significant attestation of the medical terminology and diagnostic and therapeutic procedures of the time. Even with the constraints that interpretation of a clinical account dating back over 300 years inevitably imposes, perusal of this report suggests that Cardinal Basadonna's demise could have been due to septic shock, consequent to a urinary infection caused by a bulky bladder stone.

Jacob Aall's illness and death

Jacob Aall (1773-1844) was one of Norway's most notable nation-builders at the beginning of the 19th century. He owned and operated a large ironworks, participated in political life and was an historian, writer and translator of sagas. In the last 15 years of his life, he suffered greatly from pain attacks. After his death, an autopsy was performed and the doctors found a stone the size of a hen's egg, which weighed more than 90 g. The stone was variously described as a kidney stone and a bladder stone. Aall had travelled to Copenhagen in 1837 and consulted the Danish doctor Ludvig Levin Jacobson (1783-1843), known for his instrument for crushing bladder stones, a new and revolutionary treatment method. But some disagreement appears to have arisen between them about the treatment. A year later Aall consulted Christen Heiberg (1799-1872), a professor of surgery in Christiania (now Oslo). Heiberg also examined Aall's bladder and found «no cause for alarm». Aall adhered to a strict diet, including drinking an Italian «spa water» daily which he obtained in bottles from Trieste. However, he showed no great improvement. To all appearances, it was kidney stones that afflicted him in his last years and which finally ended his life. This article gives a full portrayal of the course of his illness with an authentic description from an age when there were no treatment possibilities for kidney stones.

Cutting for stone: Roman lithotomy instruments in the Museo Nazionale Romano

Bladder stones, one of the scourges of the past, have been recorded as far back as 6,500 BC. Lithotomy was famously proscribed in the Hippocratic Oath, but it was certainly being undertaken in Hellenistic Alexandria by the 3rd century BC. However, the earliest surviving description of the operation is that of Celsus in the early 1st century AD, while identifiable instrumentation currently dates between the 2nd and early 5th century AD. Finds from Rimini, Marcianopolis, Ephesus and Cyrene illustrate how widespread the operation was at the time of the Roman Empire, but the majority of lithotomy instruments, of which those in the Museo Nazionale Romano are an important part, have been discovered in Rome itself doubtless a reflection of the size of the city's medical 'market'.

Avicenna's Canon of Medicine and modern urology: part II: bladder calculi

In the previous issue of the Urology Journal, a comparison of Avicenna's Canon of Medicine with modern urologic findings was done in part I of this article, addressing bladder anatomy and physiology and bladder calculi. In part II of this review, the remaining chapters of the Canon of Medicine on bladder calculi are reviewed. Avicenna points to perineal urethrostomy (perineostomy), which is today performed as the last therapeutic line or as a temporary remedy before surgical treatment. He also describes surgery via transperineal route and warns the surgeon of the proximity of vasa deferentia, prostate gland, and neurovascular bundle and their exposure in this position. Usage of grasping forceps for removal of bladder calculus and emphasis on removing all calculus fragments are the interesting points of this chapter. Avicenna explains a technique similar to the use of a Babcock forceps for prevention of calculus migration. Complications of bladder calculus surgery and cystostomy are also addressed with scientific precision in the Canon. It is noteworthy that 8 centuries before Fournier described necrotizing fasciitis in male genitalia, Avicenna had described Fournier gangrene in his book.

Benjamin Franklin's risk factors for gout and stones: from genes and diet to possible lead poisoning

Benjamin Franklin's medical history shows that he suffered from repeated attacks of gout and a large bladder stone. These conditions caused him considerable pain, markedly decreased his mobility, and likely contributed in indirect ways to his decline and eventual death from a pulmonary disorder. This article examines Franklin's risk factors for gout and stones, both as Franklin understood them and as we know them today. Significantly, both of these disorders are associated with high blood levels of uric acid, a metabolic by-product. Franklin's risk factors included his gender, genetics, diet, drinking, advanced age, psoriasis, and exposure to lead. Although it is impossible to assign a weight to each of these factors, it can be shown that a number of factors, each capable of raising uric acid levels, converged and conspired against him.

[Bladder stone surgery in antiquity]

Bladder stone with subsequent urinary retention was a common and challenging disease up to the 19 th century, and still is in tropical countries. Surgery has been used to remove stones (lithotomy) or to break them into small pieces (lithotripsy) since antiquity. If surgery was impossible, the urinary retention could be relieved with a catheter. The surgical technique for bladder stone remained unchanged up to the 16 th century, and some of its principles are still employed in urology. This article translates parts of Aulus Cornelius Celsus' treatise on bladder stone, found in his encyclopedia "De Medicina". The text is compared with archaeological findings from Pompeii.

[Bladder stones and lithotomy: a vanished ailment as the basis of urology]

Urinary bladder stones have played a role in medicine for ages. Many examples of this disease can be found in Dutch history. The need to cure this ailment led to the development of extremely painful interventions, for which self-appointed specialists very soon came forward and were then employed in this capacity in the cities. The various interventions were: perineal lithotomy using either the 'apparatus minor' or the 'apparatus major', lateral lithotomy, cutting for stone 'in two trips', suprapubic cystotomy, and ultimately lithotripsy. Bladder stones have largely disappeared from contemporary medicine and now represent only 5% of all urinary-tract stones, the main groups at risk being men with prostate hypertrophy, whether or not surgically treated, and women previously operated on for incontinence. Bladder stones are now seen mainly in developing countries. The dangerous operations via an extravesicular route have now been replaced by transurethral procedures in which the stone is disintegrated with the aid of an electric charge, shock waves or ultrasound. In an early stage, this ailment was the incentive for the development of a separate medical specialty: urology.

Samuel Pepys: A Patient Perspective of Lithotomy in 17th Century England

PURPOSE

Bladder stones have plagued mankind since ancient times with the oldest stone found in an Egyptian mummy dating from circa 4800 B.C. Lithotomy has also been practiced since antiquity with accounts describing the operation as risky and difficult. There are no contemporary details of the patient description of this ordeal. Samuel Pepys was a notable diarist of the 17th century who described his personal experience of having a bladder stone and subsequent undergoing lithotomy.

MATERIALS AND METHODS

A comprehensive review of the medical literature, the diaries of Pepys, biographies and historical texts was performed to compile this historical review.

RESULTS

The diaries of Samuel Pepys chronicle life in the 17th century in London. The diaries provide great insight into the contemporary political climate and London life. Stones afflicted Pepys from an early age and continued to trouble him, such that he finally decided to undergo lithotomy in 1658 for bladder stone. He provided a lucid account of his experiences in his diary.

CONCLUSIONS

Pepys survived through the skill of an early urologist or lithotomist, the prayers of his family and probably his own strong constitution. He then went on to write his diary during the next decade, giving perhaps unwittingly an insight into his world and times to later generations as well as the personal story of his lithotomy.

[Brief history of vesical lithiasis management]

Stones of the bladder are one of the oldest illness that we know. History of its treatment has been cause of discussion in different moments. Since first treatments in Egypt or India, until our extracorporeal shock waves lithotritia (ESWL), there have been many intermediate treatments. The objective of this work is to know a little about some of these advances and their authors, as well as the instruments that have made it possible.

[Guy Crescent Fagon (1638-1718), first doctor of Louis XIV cut for the stone by George Mareschal (1658-1736)]

In this paper we sketch the portrait of Professor Guy Crescent Fagon, first doctor of Louis XIV placing emphasis to his vesical stone and to his lithotomy by the first surgeon of the King, George Mareschal.

Sir William Osler's Perceptions of Urolithiasis and the Case of the Indigo Calculus

BACKGROUND

Sir William Osler published his textbook, The Principles and Practice of Medicine, in 1892. It became the definitive treatise on a wide variety of diseases. The section on nephrolithiasis clearly presents the etiology, pathology, symptoms, diagnosis, and treatments. What remains a mystery is the mention, under rare forms of human stones, of a type called "indigo."

MATERIALS AND METHODS

A search of Index Medicus starting from 1909 backward to its inception in 1879 was performed for key words "indigo," "calculus," "renal" or "bladder stones" and "indicanuria." Twelve textbooks of urology published before 1940 were scrutinized for references to indigo calculi.

RESULTS

Only two references to indigo were found, both related to its use for treating constipation (1887 and 1891). Of the 12 textbooks, only 4 make passing reference to "indigo stones." They all mention that such calculi are very rare, but direct references to cases are lacking. One textbook references a study of blue stones from Egyptian mummies.

CONCLUSION

It is unlikely that Osler's reference to an indigo calculus was taken lightly during his writing of The Principles and Practice of Medicine. The case of the indigo calculus is fascinating and perhaps enlightening if only for the source of Osler's intrigue.

Extraction of urinary bladder stone as described by Abul-Qasim Khalaf Ibn Abbas Alzahrawi (Albucasis) (325-404 H, 930-1013 AD). A translation of original text and a commentary

This is a detailed study of the technique of cystolithotomy as practiced by the Muslim surgeon Alzahrawi (Albucasis) in Cordova more than 1000 years ago. In addition to translating the relevant chapter in his book Al-Tasreef, his technique is critically evaluated comparing it with that of his predecessors and his successors. The study confirmed the originality of Alzahrawi who described operative steps and invented operative instruments not known in the Greco-Roman era. He was also the first to describe, in details, the operative technique in women and to recommend the 2-stage operation in complicated cases. His modifications and innovations greatly influenced surgery in Middle Ages Europe up to the 18th century which witnessed the beginnings of the modern method using the suprapubic, instead of the perineal, approach. Alzahrawi's influence is vividly seen in the practice of the Italian lithotomist "Marianus Sanctus" (16th century), the French "Jack De Beaulieu" (17th century) and the English "Shelsden" (18th century). Alzahrawi is the founder of lithotripsy. He introduced Al-Kalaleeb forceps to crush large bladder stones and Al-Mishaab to drill and fragment an impacted urethral stone. Andreas a Cruce (18th century) only added screw action to Al-Kalaleeb lithotrite but Amussat managed in 1822 to apply it transurethrally. Similarly, by the notion of transurethrally getting at the stone while within the bladder, Alzahrawi's idea of drilling by Al-Mishaab was the foundation of the litholepte of Fournier de Lempdes (1812), the instrument of Gruithusien (1813), Civiale's trilabe (1818) and the brise coque of Rigal De Galliac (1829).

Franz von Paula Gruithuisen (1774-1852): lithotrity pioneer and astronomer. On the 150th anniversary of his death

On the occasion of the 150th anniversary of the death of Franz von Paula Gruithuisen, the authors present his life and work. His most significant work in the fields of urology and lithotrity is examined, with special emphasis on the development of the latter field. He published his epoch-making historic study in 1813 in the Journal of Medicine and Surgery (Medicinisch-Chirurgische Zeitung). Franz von Paula Gruithuisen, the Bavarian physician and astronomer, led the way in the field of lithotrity. He developed crucial ideas on how to remove bladder stones transurethrally in a way that was safer and less likely to cause death. His instruments can be regarded as the model on which subsequent devices are based. Gruithuisen's influence on European medical scientists and, in particular, his rivalry with Jean Civiale are discussed.

[The prohibition of lithotomy within the Hippocratic Oath: historical and ethical considerations on the history of surgery]

A passage with one of the most contradictory interpretations of the so-called Hippocratic Oath, which was presumably created between 500 and 300 before Christ, is the prohibition of lithotomy. The oldest handwritten traditions of the Hippocratic Oath are dating back to the 11th-12th century. However the section of the prohibition of lithotomy is missing in the oldest preserved tradition (Codex Urbinas gr. 64), which led to some authors interpretation of being added later on. Beyond all doubt the analysis of the texture of the Hippocratic Oath leads to the conclusion that the prohibition of bladder stone lithotomy must have been an integrative part of the oath from the very first beginning. The author could have been inspired by the following reasons to have a non oath related doctor let done the medical operation: the removal of a bladder stone by an operation, which was outfitted with many complications, was one of the most difficult surgical interventions in the antique. Celsus (1st century A. D.) mentioned "severe fever, urine fistula and deadly inflammations" after lithotomy. Since the operation was done perineally, presumably a negative sexual potency was feared. No doctor engaged to help and not to harm his patients was allowed to make this kind of operation, which was often followed by many complications. Nevertheless sometimes patients were "tantalised to death by suffering dreadful pain" through those bladder stone diseases. Consequently "practising men" (the term "surgeon" was created at a later date), those who had been specialised in that operation and had not been linked to the oath, were allowed to make this kind of dangerous operation. Due to a greater experience of those specialists (named as "Lithotomos" by Celsus ih the 1st century A. D.) the danger of this kind of operation was reduced. The prohibition of lithotomy could be interpreted as a commitment to realize the limits of ones own medical actions.

[The Somovillas: a family of lithiasis surgeons from Rioja. Chronology of their trajectory in Arnedillo, 16th Century]

In the second middle of the XVI century lived in Arnedillo Juan and Francisco Somovilla, booths "maesse". The names of his wives were Anna Garcia and Iomar de Oña. The brothers of Juan and Anna were Mardia, Diego baptised on 20 of june of 1566, and Iñigo. Juan Somovilla passes away on 22 of December of 1574. His brother made the testament. We think that Juan was the surgeon that we contracted by Felipe II, instead of Francisco. Francisco Díaz talked about Arnedillo, as an important thermal baths in the treatment of the kidney diseases, in his text. If Arnedillo was a centre of treatment of urinary disease, the Somovilla family could learn here the surgery of bladder litiasis.

[History of surgical instruments. 9. Surgical instruments and development of surgical technique of lithotomy incision]

Lithotomy, i.e. the surgical method of cutting for stone in the bladder, belongs to the oldest and, due to the high risk, most notorious operating techniques. Records of stone-cuttings date as far back as Ancient Greece. The first detailed description of the procedure and instrumentation of lithotomy is to be found by Celsus (1. century AD). The patient in the lithotomy position, the neck of the bladder is approached by a median incision of the perineum. Celsus is also the first to mention special stone-hooking instruments ("uncus") to aid in extracting the bladder-stones. Medico-historical development lead to constant changes in the technique as well as in the instrumentation, since the lack of analgesia and anaesthesia necessitated quick operations of only a few minutes. A key step in the progress of operation was the introduction of so-called path-finders and directing probes in the 16th century. The opening of the bladder from the perineal incision was now accompanied by the simultaneous admission of a metal catheter into the bladder via urethra, thus providing the "Lithotomist", through manual control of the catheter, with an enhanced orientation towards the position of urethra and bladder. At that time, the dissection was conducted bluntly and without direct view of the situation, i.e. without an exact representation of the structures to be separated. Thanks to the improved instrumentation, the instruments could now be guided along a probe directly into the bladder, thus alleviating the tedious search for the opening after changing instruments, all the while with an agitated, pressing patient. Famous names in the development of the lithotomy with an perineal incision are the medical doctor Mariano Santo (around 1488-1564), the barber-surgeon Frère Jacques de Beaulieu (1651-1719) and later Johann Jakob Rau M.D. (1668-1719). Only later, to avoid injury to the perineum, the suprasymphyseal approach ("Sectio alta") was adopted (primarily by Pierre Franco 1556). Due to the construction of arrow-like probe by the barber-surgeon Frère Come (Jean Baseilhac [1703-1781]), which was pushed through the urethra into the bladder and up and above the symphysis, the danger of damaging or penetrating the peritoneum was greatly reduced. In the 19th century the upper lithotomy prevailed as the standard operating method over the perineal approach, known even by the ancient Greeks, but marked by its high complication rate. Since the end of the 19th century, however, the upper lithotomy in ist turn, has been nearly completely replaced by the cystoscopic transurethral lithotripsy.

[Surgery of bladder lithiasis in the 19th century]

In the nineteenth century, in France, the vesical lithiasis, that as almost vanished today, was frequent. In the middle of the century, the ancient methods of surgical exeresis, by perineotomy or abdominal cystotomy, left one place to a new technique, the removal of the calculus by the natural ways: the lithotrity.

[History of surgery in Preci better known as surgeons of Norcia]

This paper makes a small contribution to a more detailed knowledge of the history of Italian surgery. Few know that Italy can boast a category of surgeons who should be regarded as the world forebears of modern surgery. These skilled individuals are better known as "Norcini", a term which is often regarded as negative and contemptible. However, in practice, they came from Preci and were only called "Norcini" because their village formed part of the "contado" of Norcia. Preci still possesses a large collection of surgical instruments and other items which testify how the art of surgery developed from this small centre. Extensive research has led to the reconstruction of a general picture of this phenomenon and its influence in Italy and throughout the world. These surgeons were the only ones capable of operating gallstones, cataracts and inguinal hernia. They developed specific instruments and were the first to introduce cauterization and narcosis. The latter enabled them to overcome almost all the factors which limited surgery at the time, namely infection, pain and hemorrhage. This study attempts to explain how and why such skillful surgeons were to be found in such a small and isolated area of Umbria.

Frère Jacques Beaulieu: from rogue lithotomist to nursery rhyme character

PURPOSE

We discuss the history of Frère Jacques Beaulieu, a celebrated 17th century French lithotomist, and question the relationship of his name to a well-known nursery rhyme character.

MATERIALS AND METHODS

We reviewed historical reports about Beaulieu and his career as a lithotomist. Nursery rhyme interpretations were also reviewed.

RESULTS

Beaulieu was born in 1651 to a peasant family and learned the practice of lithotomy by apprenticeship. He was never formally ordained yet donned a monk habit and called himself Frère Jacques. He was the first person to use the lateral approach to perineal lithotomy and openly shared his surgical technique. His lithotomy procedure was observed by the high court in Paris on 3 separate occasions between 1697 and 1704. Unfortunately his patients had significant morbidity and mortality, and he was denied operating privileges. He performed approximately 5,000 lithotomies in 30 years and died in 1719 at age 68 years. The nursery rhyme "Frère Jacques" probably refers to a playful group of Jacobinic monks who often overslept. We found no direct association between Frere Jacques Beaulieu and the nursery rhyme character.

CONCLUSIONS

Beaulieu was an early urologist who was the first to describe the lateral approach to perineal lithotomy. Unlike other lithotomists of the 17th century, he openly shared his surgical techniques and stimulated others to refine the procedure. Regardless of the exact derivation of the nursery rhyme, the name Frere Jacques will always be remembered in song.

Autosurgery, 1816

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Hippocrates and urology: the first surgical subspecialty

Hippocrates, who is generally considered a focal point for the start of western medical tradition, left behind a corpus of medical writings that constituted the first recorded comprehensive health system. The pivotal point of the Hippocratic corpus was the Hippocratic Oath, which outlined the duties of healers of his school, but demarcated lithotomy as a practice that was off limits to his fellow physicians. Surgery for bladder stone, urology in essence, was thus the first specifically identified surgical subspecialty.

Sir Henry Thompson BT, the first English urologist

Sir Henry Thompson was a gifted Victorian. As a surgeon he achieved early recognition by successfully removing King Leopold of Belgium's bladder stone where two other eminent surgeons had failed. He was undoubtedly the most famous surgeon of his age, a position he was to occupy for some 30 years. As well as professional eminence he achieved success in an extraordinarily wide range of endeavours. He was an accomplished artist, exhibiting 12 times at the Royal Academy, a connoisseur and collector of china, a keen astronomer, an authority on diet and cooking and a pioneer advocate of cremation. He was interested in poultry-farming, market-gardening and photography. He published two novels sandwiched between a book on tumours of the bladder and another on the prevention of calculous disease, He was a celebrated host and his dinners--called 'Octaves'--at which he served eight courses to eight guests were legendary. To be invited meant one had 'arrived'. He was friendly with artists, scientists and men of letters--Huxley, Browning, Ray Lankester and Thackeray. At the age of 80 he bought himself a motor-car and 2 years later wrote a book on the anatomy of the motor-car engine. Sir Zachary Cope described him as a versatile Victorian, a fitting description of an extra-ordinarily gifted man. A commanding and slightly intimidating figure with little sense of humour, he achieved distinction in professional, artistic and social circles. Not only did he leave his mark on urology he left his mark on Victorian England.