IRELAND IN UROLOGICAL HISTORY

By ANTHONY WALSH, F.R.C.S.I. Urological Surgeon, Jer ,.is Street Hospital, Duhlin.

THE President suggested that on the occasion of the first visit of the Association to this country it might be of some interest to you if I were to sketch briefly the history of urology in Ireland. I must at the outset pay tribute to the very generous help given to me by Dr Widdess, the Librarian of the Royal College of Surgeons in Ireland.

The first name I would mention is that of William Dease the elder, the founder of our Royal College of Surgeons in Ireland, who practised in the latter half of the eighteenth century and who, in addition to his extensive writings on hydrocele, was a great exponent of lithotomy- his work being on a par with that of Cheselden in England. Dease's published records show a remarkably low mortality for that period, with four deaths i n eighty-eight cases of perineal lithotomy. At a time when the practice of surgery was traditionally confined to the Pentateuch of wounds, fractures, luxations, tumours, and ulcers, the influence and example of Dease inspired a great interest in the art of urology so that, for example, at the beginning of the nineteenth century the Richmond Surgical Hospital in Dublin had set aside thirty beds for male patients with diseases of the bladder and urethra. That interest was not confined solely to Dublin, for in 1822 we find Byron, a practitioner in the small town of Kells, describing a method of treating clot retention by introducing a large silver catheter and adapting to it a brass syringe for the evacuation of the clot.

You will recall that in 1825 Civiale introduced the operation of lithotrity in which he used a three-branched instrument to grasp the stone and a central drill to break the stone into fragments. If Civiale is rightly regarded as the father of lithotrity we must give credit to the Baron Heurteloup of London for the basic design of the operation as we know it to-day, for it was he who first, in the year 183 1, used a two-branched instrument to grasp and crush the stone. In his instrument the crushing force was supplied by a hammer. Sir Philip Crampton introduced this operation to Dublin, performing his first lithotrity in March 1834. He immediately perceived the importance of preventing the accumulation of debris between the jaws of the instrument, and set out to remedy this defect with Oldham, a Dublin instrument manufacturer. Together they produced a fully fenestrated lithotrite, essentially the same as those we use to-day-though after Crampton the fully fenestrated female blade was mostly discarded until reintroduced fifty years later by Freyer (1908).

The next great advance was the replacement of the hammer as a crushing force by a screw. There has been some doubt as to who first applied the screw principle to lithotrity, but the opinion of Civiale is probably correct when he suggests that the idea was due to several independent workers about the same time-among whom was Francis L'Estrange, a Dublin dentist who had been present when Crampton performed his first lithotrity, and within a few weeks produced what was perhaps the first screw lithotrite. L'Estrange also invented an ingenious and very delicate sound for finding small stones in the bladder, which was adapted to a wooden sounding board held against the ear. This instrument was wonderfully delicate in its appreciation of any contact with a small solid object. The stone having been found, it could then be measured by grasping it and observing the reading on a scale engraved on the shaft.

One of Crampton's greatest services to lithotrity was to establish firmly its position. One must remember that at that time the lithotomists and lithotritists were in sharply divided camps-

Read at the Tenth Annual Meeting of the British Association of Urological Surgeons at Dub[," on 24th June 1954.

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the statistics of the operations being like statistics of battles, each side diminishing the number of their own killed and wounded and exaggerating the killed and wounded of the enemy. Crampton was one of the first who practised both lithotomy and lithotrity and who recorded with exact care the results of each operation in his hands, and who showed their relative merits and the indications for the choice of one or the other. In addition he was acutely aware of the necessity of trying to remove all the fragments from the bladder, and Rigelow, who gave us the modern operation of lithalopaxy in 1878, gives full credit to Crampton for his idea of evacuating the fragments. To this end Crampton devised a glass suction bottle. The air was exhausted by a syringe and the vessel then applied to a wide-eyed steel evacuating catheter in an effort to suck out all the fragments. This we may fairly call the first step from lithotrity to lithalopaxy.

The first practical cystoscope was used by Fisher of Boston in 1827, but was neglected until I853 when Desormeaux revived interest i n the subject. Desormeaux’s cystoscope suffered from the grave defect of very poor illumination and his cystoscope was not adopted generally. Sir Francis Cruise of the Mater Hospital in Dublin set himself to devise means to remedy the poor illumination which cramped the use of Desormeaux’s instrument. After much hard work he found that the brightest illumination at that time was given by the thin edge of the flat flame of a paraffin lamp. The steadiness and intensity of the light were increased by using a tall draught chimney and by dissolving camphor i n the paraffin. The lamp was enclosed i n a mahogany case to protect the operator’s hands from the heat, and the light led by a very exact adjusting apparatus to a perforated mirror set obliquely just beyond the eye-piece and so reflected down the interior of the endoscope. The endoscopic tubes included direct and right-angled vision. The instrument was exhibited at the Dublin meeting of the British Medical Association in 1867. but already Christopher Heath had used it at the London Lock Hospital and from there its use had spread widely in England. “ The American History of Urology ” says that Cruise’s endoscope was the means of keeping cystoscopy alive until Nitze’s production of the first modern cystoscope with distal lighting in 1877. Cruise assiduously observed disease of the urethra and bladder and gave the first accurate description of the upward spread of the pathological process in gonorrhea.

These men-Dease, Crampton, L‘Estrange, and Cruise-were but a few of those who built up a urological tradition in this country, a tradition which was carried on by such as Freyer. Keegan, and Swift Joly-Irish master urologists too familiar to need further mention.

Many of the instruments referred to in this article including Crampton’s evacuating bottle, L’Estrange’s screw Iithotrite, Byron’s clot-evacuating catheter and syringe. and Cruise’s original cystoscope are preserved in the Royal College of Surgeons in Ireland, and by courtesy of Dr Widdess they were shown at the meeting in illustration of the paper.

REFERENCES

B I C ~ ~ L O W , J . H. ( 1878). Amer. J . nied. Sci., 75, I 17. BYRON, L. (1822). ’. The Dublin Hospital Reports and Cornniunicationz in

CRAMPTON. Sir PHILIP ( I 846). Dublin Quart. J . mecl. Sci.. I , I . CRUISE, Sir FRANCIS ( 1865). h b h Quart. J . me(/. sci., May. FREYER, P. (1908). ‘‘ Surgical Diseases of the Urinary Organs,“ p. 273. VESTRANGE, F. ( I 83Y ).

Medicine and Surgery,” vol. 3, p. 241.

Duhlrn med. Pr., 2, 91.