Lithotripsy emerged in the early 19th century as an alternative to the morbid and frequently fatal perineal lithotomy practised for thousands of years to relieve sufferers of bladder stones. Lithotripsy developed in stages, first by learning how to pass a straight hollow sound, then drilling stones to break them up, later by crushing them, followed by means to evacuate the fragments, finally by integrating the lithotrite with the cystoscope, permitting surgery under direct vision.

INTRODUCTION Lithotrity or lithotripsy, that is, breaking up or crushing a stone in the bladder by means of an instrument passed through the urethra, was introduced into medical practice during the first part of the 19th century. The first instruments used were primarily for drilling holes in a stone, and later developed into present day lithotrites. By the middle of the century, lithotripsy had reached maturity and had almost replaced lithotomy except for large stones; by the end of the century, it had become the preferred method to relieve the body of almost all shapes, sizes and numbers of stones. The inevitable triumph of minimally invasive lithotripsy over the terrifyingly painful, highly morbid and frequently fatal open lithotomy can be appreciated by all urologists who are its beneficiaries practising in today’s rapidly advancing climate of minimally invasive urological surgery.

STONES AND LITHOTOMY Bladder stone was a common and morbid ailment that had plagued humanity for ages. They caused such unbearable suffering that people were willing to risk their lives to get relief. For thousands of years before the 19th century, ‘cutting for the stone’ or lithotomy through a perineal incision was the treatment of last resort, a gruesome procedure, done without anaesthesia, and associated with frightful morbidity and mortality [1]. It took patients up to 3 months or longer to recover, many were left with erectile dysfunction, incontinence or persistent draining sinuses, and at least one of every four or five died, usually from bleeding or sepsis. Understandably, the general inclination was to postpone any operation until the continued pain was worse than the operation itself. At the start of the modern European period, the climate seemed right to explore other ways.

BASIC PRINCIPLES With the growth and progress of the science of chemistry in the 18th century, much thought was given to dissolving bladder stones. Various medications, chemicals and noxious concoctions were tried and sold. None was successful, but it undoubtedly got people thinking about direct means to destroy stones within the bladder. The idea of intravesical destruction of bladder calculi was not entirely new. The Egyptians had dilated the urethra to facilitate the passage of small stones. It is possible some form of lithotripsy using a catheter dates back to the 9th century during the Byzantine era, but the secrets of surgical techniques were closely guarded by physicians and the information is derived from historical and not medical sources [2]. In 1626, Santorio proposed an instrument consisting of a hollow tube and a central rod ending in three prongs and a cup, used to catch and retrieve a stone aided by the flush of water from a full bladder. There was no record that it was ever used. However, about a century later, Haller mistook the cup for a drill and suggested that if a stone was too big to extract, it could be drilled. Although he never tried it nor is there any evidence that he passed his idea onto others, it appears that Haller (1708–1777), without realizing it, invented lithotresis, the drilling or boring holes in a calculus, and the first basic principle behind the first lithotrites [1]. The first persons who actually attempted to destroy bladder stones mechanically in situ were not surgeons but sufferers from the disease who practised on themselves. In 1824, Percy reported to the Academy of Sciences in Paris about the Monk of Citreaux, who broke up a stone in his own bladder. He passed a malleable metal catheter into the bladder and through this he inserted a long steel rod, bevelled at the end to form a fine chisel. He engaged the stone with the chisel, held it firm against the bladder wall, and tapped the rod with a hammer, chipping off small pieces, which were subsequently passed in the urine. It took the Monk almost a year to pass all the fragments. Many other examples of enterprising sufferers who sought relief from the stone by self‐performed operations can be cited [3]. In the process, a second basic principle, lithotrity, the breaking or bruising a stone in the bladder, was born.

GRUITHUISEN In the early 19th century, there was much discussion as to whether a straight sound could be passed through the male urethra. A Bavarian physician, Franz von Gruithuisen (1774–1852) settled the question by passing a straight tube into a bladder. He devised the first model of a workable lithotrite, outfitted with a wire loop to hold the stone and a drill. His original idea was to drill holes in bladder stones to facilitate their breaking up and subsequent passage. He introduced his ‘Steinbohrer’ (stone drill) in 1813, which became in principle the first lithotriptor of the following generations [4]. His idea was for these holes to increase the surface area of the stone for the action of dissolving chemicals, but no satisfactory solution could be found. Gruithuisen also suggested using an electric current to destroy stones. He tried it once in a dog, but never in a man. Dr Gruithusisen should receive credit for suggesting the basic idea of holding a stone in place at the end of a straight hollow tube and passing a drill through the tube to grind the stone. Only after many years of experimenting on animals, cadavers, and partly on himself, he decided to present his array of ingenious instruments and publish his results. This became the first scientific treatise on the transurethral destruction and extraction of bladder stones with no incision being made. However, he never tried his methods in people. The reason was that patients refused the new procedure and besides, the Napoleonic wars caused starvation, epidemic diseases, and an enormous number of wounded that became priorities for physicians. His German colleagues were not able to prove, try, or develop the new procedure. They accepted it, and used the introduction of straight catheter only. However, when peace returned, the idea suggested by Gruithuisen was taken up again, first of all in France.

CIVIALE AND LEROY In the history of the development of lithotripsy, the names of these two French surgeons stand out. Jean Civiale (1796–1867), while still a medical student in 1817, became interested in methods of removing stones from the bladder without submitting the patient to lithotomy. He first tried dissolving stones but like his predecessors was unsuccessful. He then considered drilling the stone. To accomplish this, he designed an instrument called a trilabe, consisting of two tubes, one within the other, the outer one to grasp the stone by means of hinged arms, and the inner one containing a drill or grinding tool. He later modified his trilabe to enhance the crushing ability and called it a lithotrite. His instruments suggested the influence of Gruithuisen’s work, but Civiale emphatically denied having known of him. Civiale did not have the funds to make his instruments, so he continued to study medicine and work on his ideas. He also tried passing a straight sound on himself and found after some practice that it could be done without causing much distress. Here, no doubt, is one of the reasons for his great success in later years as a lithotritist. Another was his habit of walking the streets of Paris with a lithotrite in his right hand, trying to pick up nuts in his coattail pocket to increase his dexterity with the instrument [5]. Leroy d’Etiolles (1798–1860) began designing lithotrites in the 1820s. He was a better mechanic than Civiale, but less interested in operating. Leroy designed an instrument for grasping the stone using three or four claw‐ended arms, an idea he found in the alphonsin of Alphonso Ferri, a Neapolitan surgeon of the 16th century, who used metal arms to seize and extract bullets from wounds. He invented a bridge to hold the drill and tube rigid and in line with each other. He introduced the bow and slack‐bow string used to rotate a drill instead of the fingers. Other inventions included files, and drills or ruffs, to hollow out a stone after the first hole was drilled. He also had tools to turn the stone within the arms and to re‐grasp it if it slipped out [6]. On 4 February 1824, before Drs Percy and Chaussier, representatives of the Paris Academy of Medicine, Civiale, using a lithotrite with grasping‐type arms and a drill, which he rotated by a bow‐string, drilled a bladder stone in a living subject for the first time (Fig. 1). The operation lasted a few minutes and required two subsequent sessions to remove the entire stone. The instrument used strongly resembled those of Leroy, but Civiale claimed them as his own design. By avoiding an incision, Civiale had initiated minimally invasive surgery [7]. Figure 1 Open in figure viewer PowerPoint The lithotrite used by Civiale in 1824 to perform the first successful lithotrity (lithotresis) on a patient. Heurteloup’s percuteur, to crush bladder stones, 1831 [7]. Lithotomy in the early 19th century was still a highly morbid and sometime fatal operation, suggesting the less morbid lithotripsy would be welcomed. It was not. Most surgeons were hostile and contested the good results, calling it a blind operation, which it was. Boyer complained, ‘I see well the handle of the pan, but I do not see what is fried in it’[1]. Civiale castigated his colleagues for adhering to their old ways, calling them ‘butchers’ and too clumsy to carry out his delicate procedure. Indeed, Civiale’s manual dexterity in passing instruments and grasping stones helped as much as any other factor in promoting its acceptance. He also used statistics to prove that his method was superior, citing a 2% mortality rate among 512 cases of lithotripsy in his hands compared with a 20% mortality in nearly 6000 cases after open lithotomy operated by some of Europe’s best surgeons. For that, Civiale is dubbed a pioneer in ‘evidence‐based medicine’[8].

HEURTELOUP Although the early lithotrites were primarily for drilling or grinding, the concept of crushing was not ignored. Like Gruithuisen and Civiale, Jean Amussat (1796–1852), after a careful study of the urethra, showed that straight sounds could be passed and in 1822 designed a stone crusher. This was a straight tube containing two metal rods with serrated jaws to hold the stone, which was crushed by withdrawing the rods into the tube. But like so many other inventions, Amussat’s did not prove practical or satisfactory, and he lost interest in devising instruments [6]. Baron Charles Louis Stanislas Heurteloup (1793–1864) was both a lithotrite inventor and an operator. He made many modifications of the instruments with experience. The first was an ingenious tool called the ‘brise‐coque’, or stone‐breaker, used to break up the shell after the stone was hollowed out to crush small stones. Manipulating two rods, strong claws, springs and gears, a stone could be grasped and crushed by a combination of chewing or grinding action and increased pressure. Also, it worked and was really the first satisfactory stone ‘crusher’, provided the stones were small or thin. Heurteloup then introduced the percuteur, or curved crusher with hammer in 1832, the prototype of the modern lithotrite (Fig. 1). It had parallel blades designed to hold the stone, which was crushed by blows from a hammer delivered at its proximal end; but the blows of the hammer jarred the patient and were uncomfortable. The hammer was later replaced by a split‐nut and screw. Crushing was accomplished by slow, steady pressure of the screw. By 1833, the basic principle for the operation of lithotrites had developed and was not changed until the first quarter of the 20th century [9]. A bitter argument erupted between Leroy and Civiale as to which one first conceived the idea of a lithotrite. Both spent a great deal of time claiming priority of invention and in defaming each other. It reached such proportions that the French Academy appointed a commission to investigate. In 1831 it decided against Civiale, but 2 years later reversed that decision. From the evidence now available, it seems that Gruithuisen first conceived the idea of intravesical destruction of calculi by drilling, Leroy made the first practical drilling instrument, Civiale did the first operation on a living subject and did the most to advance the method, and Heurteloup made the first practical stone‐crusher. More advanced lithotrites to follow all used the same basic ideas developed by these men: a straight hollow tube, sliding blades with arms to grasp the stone, a sectional nut to lock it in position, and pressure applied to the blades by a screw to crush the stone.

BIGELOW A nagging problem was retained stone pieces. Early lithotomists had been content to crush the stone and let the patient void the debris. It soon became apparent that not all fragments were expelled and they served as a nidus for new stones. Irrigating through a metal catheter with a syringe was insufficient. In the 1870s, Henry J. Bigelow of Boston introduced a new operation that consisted of crushing the stone and evacuating the fragments immediately through a separate large‐calibre catheter, using a rubber bulb but with a glass trap or reservoir under the bulb to catch fragments and keep them from washing back into the bladder (Fig. 2). He could operate for up to 2 h without ill effects and at the same time remove all of the stone, instead of working for a short time, requiring repeated sessions as was true of lithotripsy. Bigelow called his new operation, ‘litholapaxy’[10]. However, the secret of his success was probably the use of anaesthesia, discovered in 1846. Figure 2 Open in figure viewer PowerPoint Bigelow’s lithotrite and evacuator, showing method of removing stone fragments [10].

THE MODERN LITHOTRITE Max Nitze invented the first practical cystoscope in 1877, made better with Edison’s lamp in 1886, and for the first time, urologists could see what they were doing inside the bladder. Using Bigelow’s lithotrite as a model, Hugh H. Young of Baltimore introduced in 1908 a lithotrite in which the stone could be viewed as it was grasped, the first litho‐triptoscope [11]. Integrating the cystoscope with the lithotrite completed the final phase of development leading to the modern lithotrite. Urologists now could see, engage, crush or destroy stones completely and safely using mechanical or newer sources of energy. An example is electrohydraulic lithotripsy, a more sophisticated but not dissimilar percussion method as the hammer. The great advantage of the modern instruments is the ability to see the stone as it is being grasped, facilitating its destruction.

CONCLUSIONS Once or twice a year, I have the opportunity to pass a closed jaw‐angled lithotrite through the urethra past the prostate and into the bladder in the same manner one passes a Van Buren sound, open the jaws to see and engage a stone in its grooves aided by an attached video camera, and then repeatedly close the jaws on the stone using the levered handles, smashing it to bits. The sand and fragments of the crushed stone are washed out completely through a large cystoscope sheath, confirmed by direct vision. With skill and patience, large and hard stones can be removed safely using this method, and it is a tremendously satisfying procedure for both doctor and patient. Each manoeuvre used to accomplish this task, from passing a straight hollow tube to opening and closing sliding jaws to crush a stone by exerted pressure transmitted by the handles, all done under direct vision, was painstakingly made possible by the ingenuity and skill of our urological forebears.

ACKNOWLEDGEMENTS The author thanks Dr Martin Jeremias, a retired urologist residing in Hamilton, Ontario, who kindly allowed me to visit his magnificent urological library and to peruse original papers by Civiale, Leroy, Heurteloup and Bigelow describing their contributions to the development of lithotripsy.

CONFLICT OF INTEREST None declared.