Kidney stones can be extraordinarily painful and have always demanded the attention of patients and physicians alike. Artists became interested in the anatomy of the kidney well before normal function was understood and before therapy of stones was available (1-3). The removal of stones, or lithotomy, was looked down on by the medical profession and was left to traveling barber-surgeons who also did other minor surgical procedures including dental extractions, bloodletting, abscess drainage, and fracture repair. A Frenchman named Guy de Chauliac (1300-1367) is given credit to have removed the first bladder stone.

Instrumentation for Stone Removal

Bladder stones apparently were more common prior to the 20th century and their treatment generated the production of a number of instruments designed to locate (4-6) and treat this painful condition. Some early instruments were designed to drill stones after they reached the bladder (7-10), while other instruments crushed them for easier removal (11-15).

Of Bladder Stones and Nursery Rhymes

One of the early lithotomists was a traveling clergyman named Brother John, who operated in the early 18th century. He is well remembered in nursery rhymes since he is the famous Frere Jacques for whom the nursery rhyme was written: "Frere Jacques, Frere Jacques, dormez vous, dormez vous?Ö." He developed a new method for stone removal (16,17), though was unsuccessful since 25 of his first 60 patients died. Brother John was temporarily restricted from operating though was reinstated after modifying his procedure. In 1703, it so happened that the very wealthy Marechal de Lorges found himself suffering from this painful condition and solicited Brother John's help. In order to be certain that the new technique was safe, the Marechal invited 22 patients with a similar problem to his mansion to have their stones removed. Brother John performed the surgery successfully on all so the Marechal allowed the procedure on himself. Unfortunately, as you might expect, it did not go well and the aristocrat died.

The removal of stones was accomplished at the risk of bowel perforation, bleeding, infection, and nonhealing wounds, that is, if the patient survived. According to one 16th century author:

The cure itself is something horrible, grave and perilous. The mind recoiled at the thought of so frightful a remedy, but what remedy seems frightful when it carries hope to people in peril of death?

Brother John's method was further modified by William Cheseldon and has met with success since.

Relief!

Obstructive uropathy, or blockage of urine in the bladder, was fairly common at a time when antibiotics were not available to treat syphilis and other venereal diseases which caused this problem (18). The first urinary catheter is reported to have been passed by John of Gaddesden (1300-1367) and catheterization was illustrated in some of the earliest texts (19,20). When a tube could not easily be passed into the bladder to relieve the obstruction, other procedures to enter the bladder were devised, some quite novel, though all probably as painful and dangerous as the condition itself (21-24). Remember that these instruments were often used prior to the discovery of anesthesia and aseptic technique!

Early Urinals - In Church

Of course urinary retention is not always mechanical and one of the earliest urinals became popular in early French churches. A Jesuit priest named Louis Bordeloue (1632-1704) gave a most beautiful and lengthy sermon, so lengthy in fact that young ladies passed around a female urinal, now called a "bordeloue" (25), in order not to miss his oratory.

1-3) Artistic Representations of the Urinary Tract

Leonardo da Vinci's sketch of the urinary tract, ca 1517, is a fairly accurate representation. It was based on human dissection and was intended primarily to instruct other artists. Bourgery's 11-volume compendium of anatomy and surgical technique, "Traite Complet de L'Anatomie de L'Homme" (1866-1871), marks a high point in medical illustration and is a must for any collector of medical art or illustration. A wonderful 18th century wax model of the kidneys can now be found at IL Museo della Specola in Florence, Italy.

4-6) Urinary Sounds, Bougies, and Catheters by Williams, Baltimore

This is a full set of urinary sounds by Williams, which were used to dilate the tube leading to the bladder (urethra), as well as to help find bladder stones. Note the very fine mahogany box and the accompanying set of round tipped bougies for the same purpose. Another unmarked set of round tipped bougies is included.

7-10) Bow Civiale Lithotrite, ca 1829

This is one of the first instruments designed for lithotripsy, or bladder stone removal, and is beautifully illustrated in Bourgery's text. Note that two operators were required for the procedure. This particular set was made by Samson in Paris and is one of the earliest and finest cased sets of instruments for stone removal ever made. Note the carved brass dragonhead and the two sized baskets for large and small stones. Once within the basket, the stone was drilled to be broken up and then withdrawn.

11-15) Instruments for Stone Removal

Bourgery here illustrates some of the instruments that were used for stone removal in the first part of the 19th century (a preanesthetic era!). Seen is an interesting array of lithotrites, catheters, and a wonderful bow Civiale lithotrite on the right. Bladder stones were often too large to be withdrawn without breaking them up. A lithotrite like the one shown by Robert et Collin, ca 1880, was placed in the bladder in a closed position. The stone was found, crushed, and then removed. George Tiemann produced this pictured early complete surgical set (ca 1840) manufactured for the removal of stones, bladder catheterization, and the performance of other minor urologic procedures. It contains a number of catheters, lithotrites, scalpels, and gorgets, (which are directors seen at the top of the set).

16-17) Depuytren's Double Bistoury Cache, ca 1880

This is a very early nickel-plated instrument for the direct removal of bladder stones. It has a finely crafted, checkered ivory handle and was used for urologic surgery and stone removal. When the handle is compressed, two blades with sharp outer edges extend to make a double cut. The diagram is by Bourgery.

18) Glass Urethral Syringes

These male and female syringes were used to inject medications into the urethra of patients with obstruction, a common complication of venereal disease prior to the antibiotic era.

19-20) Bladder Catheterization

Wandering barber-surgeons catheterized grateful patients to relieve obstruction caused by bladder stones, as illustrated by Kullmaurer and Meher in "Short-Robed Surgeon Catheterizes a Patient" (1510). Urology did not become a surgical speciality until the end of the 19th century when sterling silver catheter sets became available like the one pictured. The dilating urethrotome was inserted into the tube leading to the bladder (urethra) and a wheel was turned which enlarged the instrument in hopes of improving urinary output.

21-24) More Aggressive Intervention

When the urinary tract could not be opened up by dilatation for stone removal, more drastic measures had to be undertaken. Another type of urethrotome was made by Otis and had a small cutting blade that slid down the shaft to help expand the urethra before the instrument was expanded. Another path could be taken by Cock's trocar (ca 1870), which is a sharp trocar that bypassed the prostate and entered the bladder directly through the rectum. The accompanying silver catheter could then be strapped to the patient to maintain a urinary stream until a more definitive procedure could be performed. A gruesome device, indeed.

25) Bordeloue (Early 19th Century)

This is a fine hand painted porcelain female urinal that got its early use during prolonged church sermons.

 

3) Urinary Tract, la Specola

5) Urinary Sounds and Bougies

9) Bow Civiale Lithotrite Set

15) Lithotrite Set, Tiemann

17) Double Bistoury Cachet

18) Urethral Syringes

19) 16th Century Catheterization

23) Cock's Trocar, Bourgery

25) Bordeloue