Cutting for the stone in seventeenth-century Bruges

cutting for the stone in seventeenth-century bruges

Johan J. Mattelaer

bladder stones and lithotomists The presence of stones in the bladder is associated with a wide range of complaints, causing patients acute pain and severe difficulty in urinating (Fig. 20). Bladder stones are especially prevalent in times of poverty and malnutrition, with a diet low in protein – especially meat or fish – as was the case in the seventeenth century. There is evidence in Flanders from as early as the tenth century of barber-surgeons operating to remove bladder stones. We know that Count Arnold the Elder (919–964) suffered from a bladder stone and consulted a number of lithotomists, but that fear ultimately prevented him from going through with the procedure.

Many ‘cutters for the stone’ travelled from town to town: only later did larger cities appoint their own ‘sworn lithotomists’. These travelling surgeons sometimes gave themselves elaborate titles: many were simultaneously steensnijder ende oculist (cutter for the stone and optician) or threw in obstetrics too (steensnijder, oculist ende woutmeester) or even steen ende houtsnijder, oculist en woutmeester (cutter for the stone and wood, optician and obstetrician). In response, surgeons’ guilds and civic authorities in Flanders began to supervise and regulate the activities of itinerant lithotomists. Numerous bylaws were announced in this regard from the seventeenth century onwards.

The surgical method for removing a bladder stone changed little between the Roman era and the late sixteenth century. Two assistants gripped the patient’s legs as he sat on a table (known in Flemish hospitals to this day as the steensnedeligging or ‘stone-cutting position’). The surgeon inserted his left index finger into the patient’s anus in order to feel the stone and to press it downward against the perineum (Fig. 21). A probe held by a third assistant was inserted into the patient’s ureter. The surgeon made an incision in the perineum below the anus until he made contact with the stone. The incision was then dilated and the stone removed by forceps. The procedure was performed with no anaesthesia other than a little alcohol and a sponge impregnated with mandrake solution. The most common postoperative complications were bleeding and infection, and also fistula formation, where the wound did not close and the patient continued to lose urine through the opening.

cutting for the stone in bruges The earliest known lithotomy in Bruges was performed in 1270 by Pierre dou Leene, li maistre le tailla (‘master cutter’) on a certain Jan vander Beurse. The lithotomist was assisted by his son, by Maistre Simons, le mire de Bruges, and

20 Bladder stones. Personal collection

21 The Celsian method (named after the Roman surgeon Celsus) for removing bladder stones according to Tollet and Frère Jacques de Beaulieu: the left index finger inserted into the patient’s anus presses the stone downward against the perineum, where the right hand is ready to cut it out.

22 ‘The undersigned hereby consents to the cutting of the stone from my son Joosep de Pan, Bruges, 8 September 1686 – Joos de Pan’ A father’s consent for a lithotomy procedure for his child. Stadsarchief Brugge 118 Resolutieboek 1683-1685, p.109.

Maistre Watiers d’Ipre, physician. The Bruges municipal archives record the modest sum that master Jan Arras was obliged to pay as early as 1340–41 in return for citizenship of the town and the right ‘to cut for the stone’.

In 1595, the lithotomist Jan van den Vyvere, ‘Bruges born’, removed a bladder stone from Clayken Vinchon, ‘aged three years and three months, [who] had long been afflicted by a stone in his bladder, such that when the child made or passed water, he suffered very great pain and distress, this to the great sorrow of the deponents and all other persons who witnessed it ... [Van den Vyvere] cut a remarkable stone from his bladder and did so in such a short time that little blood was lost, to the wonder of many people there present; and he laboured further with good medicines such that he consolidated, closed and treated the wound, so that the child no longer suffers any pain from the stone; but now on the contrary is strong, fresh and healthy in body, and can make and pass water as if he had never been tormented by a stone.’

bruges in the seventeenth century In 1634, the Bruges surgeon and lithotomist Jan Rullens was paid 16 pounds for cutting for the stone in three children and dealing with hernias in five others. The talented surgeon later moved to Utrecht, but Bruges was able to lure him back with the promise of a two-pound fee for every lithotomy or herniotomy he performed on the city’s behalf. A similar sum was paid in 1645 to Rullens’s son Laurent, who presumably learned how cut for the stone from his father, preserving the secrets of the trade, as was customary. The Bruges municipal accounts for 1666 record the payment to the city’s official lithotomist, Master Descamps, of 50 guilders for one lithotomy and over 24 pounds for similar procedures performed on poor children. The were performed on males and 87% on patients under the age of 12 – no less than 40%, indeed, on children under five. The number of lithotomies performed in Bruges peaked in the latter part of the century, when a multitude of people consulted Thomas Montanus. We concluded from our study that bladder stones were much more prevalent then they are today and that the principal sufferers were children.

A permit had to be obtained from the civic authorities before the procedure could be perfor

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present author, together with Robert Pannier (1927–1995), carried out a study of the city’s Resolutieboek in the seventeenth century. We learned that at least 611 lithotomies were performed in Bruges between 1600 and 1700 – an average of over six a year. This is a minimum figure, as similar procedures performed in the homes of wealthier citizens were not paid for by the civic authorities and so their number was not recorded. Of these 611 lithotomies, 94% med. Parental consent was required if the patient was a child, that of the patient himself or the next of kin if he was an adult (Fig. 22). These permissions are invariably documented as consent snijden or consent snijden steen (‘consent cutting (stone)’). We noted that from 1696 the permit also began to include the phrase met het versoeck en de wens dat het goed en wel vergaen mag (‘with the request and the wish that it go well’). The system can be viewed as an early

23 Theodoor van Loonen (1620-1701), Frère Jacques de Beaulieu (1651- 1714), inv. P00791, Rijksmuseum voor de Geschiedenis van de natuurwetenschappen en van de geneeskunde ‘Museum Boerhaave’, Leiden He holds in his right hand the catheter that was needed to identify the location of the stone in the bladder via the ureter. On the table to his right we see the scalpel, two spoons to remove the stone and forceps.

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example of what we nowadays call ‘informed consent’. Prominent citizens or other surgeons were sometimes called on to verify lithotomy requests. We found no references in the seventeenth century to the alms-giving or charity that used to feature in previous years.

Between 1650 and 1700, half of the operations were funded by the city because the patient or his or her parents were too poor to pay. All poor children, soldier’s children and orphans were operated on at the city’s expense. Foundlings, poor and neglected children, and orphans were treated at Sint-Juliaanshospitaal, the master of which generally paid the doctors’, surgeons’ and pharmacists’ fees. The names of physicians and surgeons from Sint-Janshospitaal are therefore found in the accounts for Sint-Juliaan. Study of the Resolutieboek also enabled us to draw up a list of the twelve lithotomists and four surgeons who cut for the stone in seventeenthcentury Bruges.

frère jacques de beaulieu in bruges A new surgical technique began to spread throughout Europe in the late seventeenth century: lateral lithotomy or la taille latérale, in which the incision in the perineum is no longer made in the midline but to one side (mostly the left). The best known itinerant lithotomist working in the Low Countries around 1700 was the French monk, Frère Jacques Beaulieu (1651–1714) (Fig. 23). He developed the lateral lithotomy technique that made his name throughout Europe. He also worked in Bruges, as we see from the municipal accounts for 1699: ‘To Cornelius Kelderman and Pieter Lambiot, master surgeons of this city, for their services. Assistance and expenses undergone at the time that Brother Jacques Beaulieu, hermit of Burgundy, practitioner of bladder stone and hernia surgery and experienced in the aforesaid operations, which he has performed here for both the wealthy and the poor out of pure charity, without wishing remuneration or recompense, by order nine pounds and 14 guilders.’ A passage in the accounts for 1705 alludes to the same monk. In this instance, the sum of 12 pounds was paid to the Bruges Capuchins for bringing to the city a hermit from Burgundy who was highly skilled in ‘cutting for the stone and hernias’ and who did not wish to accept any reward from the citizens.