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Title: Lithotomists: the first nephro-urological specialists
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Lithotomists: the first nephro-urological specialists

A sound has been passed from the penis into the bladder. With the genitalia held out of the way, and the patient strapped firmly to the table and held down by strong men, the surgeon cuts down onto the sound through an incision in the perineum. The incision is then widened a little, and the stone grasped in special forceps and removed intact if possible.  The illustration also explains the origin of the ‘lithotomy position’.  (From Litotomia, by Tommaso Alghisi, Florence 1707.  Wellcome Images, Creative Commons.)

This terrifying operation to remove bladder stones was first described by Celsus in Roman times, but is mentioned in Ancient Greek literature and a bladder stone was found in a 16 year old  boy buried in Egypt in 4800 BC. Even the ancient Hippocratic Oath required physicians to leave the business of urinary stones to specialists.  

Bladder stones caused pain, urinary symptoms including typically ‘strangury’ when you feel a strong urge to pass urine but can’t, infections, and much suffering, often in children and young adults.  This ‘primary’ type of bladder stone has almost disappeared from the developed world, for incompletely explained reasons. When bladder stones occur they are now usually found in older patients with catheters, outflow obstruction, or other anatomical abnormalities.  

Samuel Pepys (1633-1703) vividly described his symptoms and (retrospectively) experience of 'stone cutting' when Thomas Hollyer (1609-70) removed a tennis-ball sized stone from his bladder when Sam was 25.  He first had symptoms five years earlier. Some of his symptoms were clearly ureteric colic though, and a left staghorn calculus was described at his autopsy.  The operation was successful, so much so that his diaries describe how he celebrated his delivery from the symptoms and survival from the operation annually on its anniversary. However it sounds as if a perineal fistula may have opened up later. 

The risks of the operation were substantial in this pre-anaesthetic, pre-antibiotic era in which the importance of asepsis in surgery was also not appreciated.  Skilled lithotomists were famous and sought after, though even then the risk of death and poor outcomes were substantial.   

The techniques were developed slowly from the 'Celsus method'.  Al-Razi (841-926 AD) described new tools and techniques for fragmenting stones.  It is suggested that ‘Frere Jacques’ of the French nursery rhyme was renowned lithotomist Jacques Baulot, though this has been questioned.  He developed a lateral perineal approach which was safer, avoiding the prostate gland and base of bladder.  

Shortly after Samuel Pepys’ operation the French composer Marin Marais (1656-1728) wrote a wonderful short dramatic, narrated musical enactment of a lithotomy operation - listen at youtu.be/Xlw0dKOPkkE (by Early Music Alberta with commentary in English)  

Further Reading

Ellis HE 1979.  A history of bladder stone. J Roy Soc Med 72:248-51 (Good read with graphic description of the techniques)

Riches E 1977.  Samuel Pepys and his stones. Proc Roy Soc Med 59:11-16

Franklin JL 2012.  Marin Marais’ Tableau de l’operation de la taille.  Hektoen international 4 (2)

http://bit.ly/1BstUB2

Abdel-Halim RE 2010.  Lithotripsy:  a historical review.  Hektoen International 2 (2)

http://bit.ly/1CcbohE

Ganem JP, Carson CC  1999.  Frere Jacques Beaulieu: from rogue lithotomist to nursery rhyme character.  J Urol 161: 1067-9 (behind paywall)

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