28. Lithotomy through the ages: Big stones, small stones and all the ways to cut them out

The first known specimen of urological interest was a vesicle calculi dated to 5000 BC, found by Elliot Smith in 1901, in an ancient tomb in Egypt. Since these ancient times, urolithiasis has been a condition which fascinated and frustrated the medical world, both in understanding of its etiology and in how to treat patients afflicted with such stones. Medical management of urinary calculi has a complex and suspect past; when such therapies failed, as their mystical and unscientific approaches often did, patients sometimes resorted to more drastic and dramatic means such as lithotomy. Lithotomy was known since early times in India and Persia; when it was introduced to Europe is unclear. Writings by Susruta in India describe early forms of the procedure, and techniques were improved by Celsus of Rome (1st Century AD), remaining in use, largely unchanged until the eighteenth Century. Marianus Sanctus (1490-1550) described a technique, the “grand appareil” which superseded the Celsus method, and other approaches by Franco (1500-1570), Jacques de Beaulieu (1651-1714), Johann Rau (1658-1709) and William Cheselden (1688-1752) gained and lost dominance over the centuries. Perhaps most interesting about lithotomy was the development of the tools used in its practice. From the beginning, the various knives, forceps, dilators and sounds became ever more complicated, intricate and gruesome looking, resembling more the armamentarium of a torture master than the curative tools of a physician. As endoscopic techniques began and evolved, the necessity to make large incisions for stone removal decreased. Nonetheless, the approaches and instrumentation used to treat bladder stones helped shape the practice of urology and contributed to the continuing goal of minimizing invasion of the patient while still providing effective treatment of stone disease and other genitourinary problems. Murphy LJT. The History of Urology. Springfield, Ill.: Charles C. Thomas, 1972. Chevalier RL. Kidney and urologic disorders in the age of enlightenment. Am J Nephrol 1994; 14(4-6):461-6. Herman, JR. Urology; a view through the retrospectroscope. Hagerstown, Md.: Harper & Row, 1973