Urolithiasis management in the early 1900s: Howard A. Kelly and the wax-tipped ureteral catheter
Timothy K. O'Rourke, Jr., M.D.1, Marc A. Lavine, M.D.2, Anthony A. Caldamone, M.D.1.
1Brown University/Rhode Island Hospital, Providence, RI, USA, 2Jefferson Health, Philadelphia, PA, USA.
BACKGROUND: Diagnosis of ureteral and renal calculi was revolutionized with medical implementation of X-ray in the early decades of the 1900s. Diagnosis of urolithiases prior to X-ray was largely based on history and physical exam. Given the invasive nature of “cutting for stone” at that time, innovations aimed at improving diagnostic precision were needed. Dr. Howard Atwood Kelly, a gynecologist and member of the “Big Four” founders of the Johns Hopkins Hospital in Baltimore, Maryland along with William Halsted, William Welch, and William Osler is known for many contributions to surgery. Among some of his perhaps lesser known contributions include aerocystoscopy and ureteral catheterization utilizing wax-tipped catheters to improve the diagnosis of ureteral and renal stones in the late 19th century. His innovation in ureteral catheterization revolutionized the diagnosis of nephrolithiasis.
METHODS: Historical textbooks and manuscripts were reviewed in an effort to characterize methods of diagnosing ureteral and renal calculi in the late 1800s and early 1900s with specific interest in Howard A. Kelly and the wax-tip catheter utilized for such purposes.
RESULTS: Multiple references including those from Hugh Hampton Young, Guy LeRoy Hunner, Howard A. Kelly, and others were identified and reviewed to characterize early practice in wax-tip ureteral catheterization. The technique involved the creation of a “wax tip” associated with a silk renal catheter or rubber bougie, used to catheterize a ureter. Various methodologies were utilized to create the wax mixture. Dr. Young utilized “ordinary embedding paraffin,” while Dr. Hunner, a colleague at Hopkins, utilized beeswax. Dr. Kelly reportedly utilized a mixture including dental wax and olive oil. The bladder, instilled with air, was inspected cystoscopically with direct visualization of the ureteral orifices. The wax-tipped catheters were passed proximally, twirled, removed, and closely inspected for scratch marks or defects suggestive of contact with a hard surface, that is, a stone. Occasionally stone fragments would become embedded in the wax—thus the procedure could potentially serve therapeutic purposes.
CONCLUSIONS: Although diagnosis of urolithiasis has been revolutionized by advanced imaging techniques including X-ray, computed tomography, and ultrasound, early innovations utilizing a wax-tip catheter were a significant advancement in management of nephrolithiasis in the 1890s and early 1900s. In 1926 Dr. Hugh H. Young commented on the importance of this innovation stating that with the diagnostic combination of X-ray and wax-tip ureteral catheterization “exploratory operations for kidney stone have become almost curiosities if not disgraceful.” Urologists have been known for decades to be on the forefront of surgical technology and innovation. Important discoveries such as the wax-tip catheter are not only of historical interest but inspirational to those walking in the footsteps of the giants that came before.
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