Lithotomy

‘It is universally allowed, that amongst all the Diseases with which Mankind are afflicted, there is none more terrible than the Stone in the Bladder; and amongst all the Chirurgical Operations now in Use, there are none so painful, dangerous, and uncertain, as the common Operations which are made in order to cure it’.

John Douglas, Lithotomia Douglassiana: or, a New Method of Cutting for the Stone
(London, 1723), p. 1.

Ambroise Paré, Les oeuures d’Ambroise Paré … (Lyons, 1685), p. 390.

Despite the ancient Greek physician Hippocrates’ reservations about the dangers of ‘cutting for stone’, the operation has a long history: Riches points to ancient Hindu and Egyptian accounts and, over the centuries, many approaches were taken: the lesser operation, the greater operation, the lateral operation, and the high operation.

In his De re Medicina the ancient writer Celsus (25BC-50AD) described what was known as the ‘lesser operation’ (which continued to be used until the early sixteenth-century):

‘A strong and intelligent person being seated on a high stool, lays hold of the patient in a supine posture, with his back towards him, and his hips being placed on his knees, with his legs drawn backwards he orders the patient to seize his own hams with his hands, and to draw them towards his body with all his power, and at the same time he secures them in that position.

Then the physician, having carefully pared his nails, introduces his index and middle fingers of the left hand, first the one gently, afterwards the other one into the anus, and places the finger of his right hand lightly on the lower part of the abdomen … First of all the stone must be sought for about the neck of the bladder … and when it had been brought into that position … a lunated incision must be made through the integuments immediately over and extending to the neck of the bladders near the anus, with the horns a little inclined towards the Ischia; then a second incision is to be made in the transverse form in the convex part of the wound so as to open the neck of the bladder’.[1]

Hieronymus Fabricius ab Aquapendente, Opera chirurgica … (Padua, 1647), p. 79.

The early sixteenth century witnessed the rise of the ‘greater operation’ which was also known as the ‘Marian’ operation because it was first brought to prominence by Marianus Scotus Barolitanus in 1522. This involved using a dilator to dilate the urethra and was adopted by Ambroise Paré (c. 1510-90). The method continued to be used until the end of the seventeenth century. However, by the very end of the seventeenth century it was being challenged by a new method: the lateral operation. Jacques Beaulieu (1651-1714, known as Frère Jacques) did much to popularize the method in France and elsewhere although the survival rate of his patients using his first version of the lateral operation was un-impressive. His lateral method was, however, perfected by the English surgeon, William Cheselden.

John Greenfield, A compleat treatise of the stone and gravel (London, 1712), plate facing p. 177.

The high point of lithotomy came in the early eighteenth century with the work of surgeons such as William Cheselden (1688-1752) and John Douglas (d. 1743). It is therefore unsurprising that the operation forms such a dominant sub-section in Worth’s surgical library. Apart from the works examined here, Worth owned copies of the following: Nicolaus Franchimont à Franckenfeld, Lithotomia medica, seu tractatus lithontripticus, de calculo renum & vesicae (Prague, 1683); Tomasso Alghisi, Lithomia (Florence, 1707); John Greenfield, A compleat treatise of the stone and gravel (London, 1712) and Henri François Le Dran, Parallele des differentes manieres de tirer la pierre hors de la Vessie (Paris, 1730).

John Douglas, Lithotomia Douglassiana; or, A new method of cutting for the stone … to which is added, what has been written by … Rossetus, and … Pietreus, on the same subject … (London, 1723), plate IV.

John Douglas (d. 1743), is credited with providing one of the first descriptions of the ‘high operation’ (also called the supra-pubic operation), in 1719. As he himself noted, it had been practised by Francis Rosset in the 1590s, but it was Douglas who brought it to prominence. Douglas provides a useful examination of previous and contemporary methods but his focus was on the ‘high operation’. A brother of the famous Scottish anatomist James Douglas (1675-1742), he emphasised the importance of understanding the anatomy of the bladder prior to any operation. The operation itself required (1) a table and the instruments illustrated above:

‘The Catheter and Stillet, Tab. 4. Fig. 1, 2.

The flexible Tube with its Heads, Fig. 4, 5, 6. one of which is screwed into the Head of the Catheter, and the other is slip’d upon the Nose of the Syringe.

N.B. The Tube is made of an Ox’s Ureter, and was first contrived by Mr. Cheselden.

The Syringe, Fig. 7. which ought to hold Water enough to fill the Bladder at once, or twice at most?

The Catheter Key, Fig. 8.

The first Incision Knife, Fig. 9.

The second Incision Knife, Fig. 10.

The new Instrument, Fig. 11. It is about the thickness of a common Case Knife, has not Edge but from x to x, which is as sharp as a Razor.

The Forceps, Fig. 12’.

Portrait of William Cheselden. Line engraving by Cook after J. Richardson. Credit: Wellcome Collection. CC BY

In the above passage, Douglas refers to William Cheselden. Cheselden had likewise described the high operation in his A treatise on the high operation for the stone with XVII. Copperplate (London, 1723), a text which Worth duly bought. The publication of Cheselden’s treatise led to a medical debate over who was the inventor of the ‘high’ method. It was a debate in which Worth clearly had an interest for he also collected Robert Houstoun’s Lithotomus Castratus; or, Mr. Cheselden’s Treatise on the High Operation for the Stone; Thoroughly Examin’d, and plainly found to be Lithotomia Douglassiana, &c. … (London, 1723). The debate was so vociferous that it put Cheselden off using the high method (in which he had, in any case, already identified some weaknesses), and he turned back to improving the lateral perineal procedure – which became the standard operational procedure until the nineteenth century.

A surgeon based in Chelsea recorded the after-care given to patients who had under-gone Cheselden’s lateral method for cutting for the stone as follows:

‘Mr Simpson, of Little Ormond-Street, aged Seventy-five, after having been afflicted with the Stone above five Years, and taking Mrs Stevens’s Medicines about a Year before for seven Months successively, without receiving any Benefit, was cut by Mr. Cheselden, March 13, 1741-42, at which time he had a Fit of the Stone upon him, which had continued for ten Days; and when, consequently, the Bladder and urinary Parts were very much inflamed, this, together with his great Age, made the Success very doubtful. However, at his own earnest Request, after Consultation, the Operation was perform’d, and a large flattish round Stone was extracted, weighing very near four Ounces.

The Wound bleeding plentifully from the small Vessels, only a Piece of thin wet Spronge was introduc’d, that it might bleed for a while through; intending (if there should be Occasion) to tie any Vessel afterward, that should require it. But, contrary to Expectation, this prov’d the means of stopping the Effusion of Blood; and, from Experience, in many Cases since, it has been observed, that nothing is so useful as this Method (thus accidentally discover’d).

About six Hours after the Operation, the Patient having lost but little Blood, it was though proper to take twelve Ounces of Blood from his Arm. The Urine flow’d freely through the Wound in about two Hours after his being cut, and also thro’ the Penis; and continued do so, though with great Pain from the Heat and Sharpness of it; which excoriated the Parts about, notwithstanding his being drest every two or three Hours, and the Parts being anointed with a cooling Ointment.

On the fourth Day, not having had a Stool since the Operation, an emollient Clyster was order’d; which purged him twice, gave him a great deal of Ease, and abated some slight feverish Symptoms that were observ’d. This was repeated once in a Day or two for about three Weeks, he being naturally costive.

About a Week after the Operation he complain’d of a Pain in his Sides, had little convulsive Motions in his Bowels, with Faintings, and the Abdomen swell’d: But, on bleeding him eight Ounces, his Pain was removed, and the other Symptoms went off on taking the Confect. Raleigh. in Aq. Paeon. Comp. every Night for a Week.

During this Time the Wound began to digest, a large Slough cast off, and in it came away several very small Bits of Stone, which had crumbled off in extracting the Stone with the Forceps. These, by obstructing the free Passage of the Urine, had given him sometimes great Pain, but which was removed by frequently injecting Oil and warm Barley thro’ the Penis and Wound.

At the Beginning we made use of a Fomentation made of Absinth. Roman. & Flor. Chamaemil. but it proving too sharp for the excoriated Parts, it was left off, and the Parts bath’d with warm Milk, and sometimes Barley-water. His Diet, the first three Weeks, was nothing but Spoon-Meats and light Pudding, afterward a boil’d Chicken, &c. and, in a Fortnight after the Operation, Asses-Milk Night and Morning, from which he receiv’d great Benefit, being very thin, and having a Cough, which had afflicted him many Years, and being of a hectic Disposition.

At the End of three Weeks, the Wound was above half heal’d, the Uringe began to come chiefly through the Penis, daily lessening thro’ the Wound; and when that was near cicatrized, it all came the natural Way, and had lost its Heat and Sharpness; then his Mouth blister’d within, from the Saltness of the Saliva. For which, during the whole Course of the Cure, he drank plentifully of cooling Emulsions with Gum-Arabick, &c. In five Weeks he was perfectly cured, and continues to this Day without any Reason of his Distemper’.[2]

A treatise on the high operation for the stone with XVII. copper-plates. By William Cheselden Surgeon to St. Thomas’s Hospital in Southwark, and F. R. S. (London, 1723), plate VII.

Worth appears to have favoured Cheselden’s account of the high operation in one respect: while his copies of Douglas and Houston are in paper covers (i.e. were never bound), his copy of Cheselden’s treatise was given a gold-tooled binding. In the above image, from Worth’s copy, we see his illustration of the injecting syringe:

A: ‘Part of the injecting syringe which holds ten ounces.

B: The end of the syringe fitted into the pipe C.

C: the injecting pipe.

D: An ox’s ureter tied at one end upon the injecting pipe, and at the other end of the catheter.

E: the catheter’.[3]

Sources

Cheselden, William, A treatise on the high operation for the stone with XVII. Copperplate (London, 1723).

Cheselden, William, and Mr. Reid, ‘A Remarkable Case of a Person Cut for the Stone in the New Way, Commonly Called the Lateral: by William Cheselden, Esq: Surgeon to Her Late Majesty: Communicated to Martin Folkes, ESq: by Mr. Reid, Surgeon at Chelsea. Who Attended the Cure’, Philosophical Transactions (1683-1775), vol. 44 (1746-47), pp 33-35.

Douglas, John, Lithotomia Douglassiana: or, a New Method of Cutting for the Stone (London, 1723).

Herr, Harry W., ‘’Cutting for the stone’: the ancient art of lithotomy’, British Journal of Urology, vol. 101, issue 10 (2008), 1214-16.

Houston, Robert. Lithotomus Castratus; or, Mr. Cheselden’s Treatise on the High Operation for the Stone; Thoroughly Examin’d, and plainly found to be Lithotomia Douglassiana, &c. … (London, 1723).

Morgan, Sir Clifford Naunton, ‘Surgery and Surgeons in 18^th-Century London’, pp 1-37.

Riches, Eric, ‘The History of Lithotomy and Lithotrity’ (1967), 185-99.

Walker, Katherine A., ‘Pain and Surgery in England, circa 1620-circa 1740’, Medical History, vol. 59, no. 2 (2015), 255-74.

Text: Dr Elizabethanne Boran, Librarian, The Edward Worth Library, Dublin.

[1] Riches, Eric, ‘The History of Lithotomy and Lithotrity’ (1967), 187 (quoting Celsus).

[2] Cheselden, William, and Mr. Reid, ‘A Remarkable Case of a Person Cut for the Stone in the New Way, Commonly Called the Lateral: by William Cheselden, Esq: Surgeon to Her Late Majesty: Communicated to Martin Folkes, Esq: by Mr. Reid, Surgeon at Chelsea. Who Attended the Cure’, Philosophical Transactions (1683-1775), vol. 44 (1746-47), pp 33-35.

[3] Cheselden, William, A treatise on the high operation for the stone with XVII. Copperplate (London, 1723), p. 28.