The Glass and the Stone
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From the film's subtitles

Transcript

The narration and the quoted voices, line by line. Each timestamp opens the film at that line. Quoted voices speak documented words; their sources are on each chapter page.

Prologue: A Stone in a Jar

0:01 In a glass jar, in a museum in London, there once sat a stone.

0:09 It was larger than a hen's egg. It had grown, slowly, inside the bladder of a boy. And that boy had been buried in the desert of Upper Egypt, before the first pharaoh, more than five thousand years ago.

0:31 The man who found it, at the start of the twentieth century, had come to the cemetery of El Amrah to look at ancient brains. He wrote:

0:43 Elliot Smith: In the first Egyptian grave that I looked into, I saw the skeleton of an Egyptian boy, in whose pelvis there was a large vesical calculus.

0:56 It was long held to be the oldest bladder stone ever found. It is not in that jar today. I shall tell you why, before we part.

1:11 This is the history of two obsessions. The first is the stone: how to get it out, and at what cost. The second is the glass: the long, stubborn wish to see inside a living body, and to know what is happening there.

1:32 For most of that history, physicians were certain of things that were not so. Keep one lesson close: a thing repeated is not a thing proven. A few were brave enough to doubt, and to go and look. Listen for them. Some of what we repeat today will not survive the looking; finding out which is the work still ahead.

I. The River

2:19 Egypt has left us some of the oldest written medicine in the world: long rolls of papyrus, copied and recopied by scribes. Among their prescriptions are remedies for urine that will not come, and for urine that comes with blood.

2:41 Blood in the urine has long been common along the Nile. In 1851, in Cairo, Theodor Bilharz found the cause: a blood fluke that lives in the veins around the bladder. Then, in 1910, the pathologist Marc Armand Ruffer took the dried kidneys of two mummies of the Twentieth Dynasty, soaked them in a solution until they were soft enough to cut thin, and put them under his microscope.

3:14 He found the fluke's eggs, calcified. The parasite had been there three thousand years before. Whether it explains the bloody urine of the papyri we cannot be certain, but it is the likeliest culprit.

3:36 On the wall of a tomb at Saqqara, carved about 2300 B.C., a kneeling man works with a small blade upon a youth whose arms are held from behind. It is usually read as the oldest picture of circumcision. At least one Egyptologist has asked whether it shows an emergency operation instead. The stone does not say.

4:04 You will often read that the Egyptians drew off urine through hollow reeds. Perhaps they did. But no papyrus we have clearly describes it, and no such instrument has been securely identified. Let that be our first lesson. A thing repeated is not a thing proven.

II. The King's Permission

4:34 In India, a great Sanskrit book of surgery bears the name of Sushruta. It was compiled over many centuries; its core may be two thousand years old, and tradition places it earlier still. Among a great many operations, it describes, with remarkable candour, how to cut for the stone.

5:02 The book sorts stones by what was thought to make them: three kinds by the humours of the body, and one from semen. A stone of phlegm, it says, is white and glossy, and may grow to the size of a hen's egg. Medicines come first. Only when they fail does the book consider the knife. And then it gives a warning.

5:31 Sushruta: The death of the patient is almost certain without a surgical operation, and the result to be derived from it is also uncertain.

5:47 Sushruta: A skilled surgeon should perform such operations only with the permission of the king.

5:58 Consent, you see, was to be sought from the crown, because the operation might kill. The method itself is exact. Two fingers of the surgeon's left hand, passed into the rectum, push the stone forward. A fist presses on the belly to hold it there. The cut is made beside the midline seam, on the left, at the distance of a barley-corn.

6:26 And the text records a disagreement. Several authorities, it says, prefer to cut on the right. Even then, surgeons argued over which side to cut.

6:39 Through the cut, the stone was drawn out. In a grown man, a wound carried down to the bladder at that point must have passed through the prostate, though the text never names the gland. Then the patient was set in a cauldron of warm water, given a treacle drink to clear the passage, and the wound was dressed with honey and clarified butter. How many lived, the text does not say. It promises only that without the knife, death was almost certain.

7:17 For a narrowed outlet of the urine, Sushruta advises tubes of iron, wood, or shellac, open at both ends, smeared with clarified butter, passed gently, and changed for thicker ones every third day. Elsewhere the text describes the condition as a tight foreskin; its translator called it a stricture of the urethra; scholars read it both ways. Either way, it is the principle of the graduated dilator, still in use today.

III. The Oath and the Ligature

8:01 The physicians who wrote under the name of Hippocrates, four or five centuries before Christ, watched the urine closely, and some of what they saw was true.

8:15 Hippocratic: When bubbles settle on the surface of the urine, they indicate disease of the kidneys, and that the complaint will be protracted.

8:30 Froth on the urine. We would now say protein, leaking through a damaged kidney. They noticed it two thousand years before anyone knew what protein was. They noticed too that women suffer the stone less often than men, because, they explained, a woman's urethra is short and wide.

8:57 And then there is the Oath. Every young doctor knows it, in some form. Few notice its strangest line.

9:08 Hippocratic: I will not cut persons labouring under the stone, but will leave this to be done by men who are practitioners of this work.

9:23 Why should a physician swear never to cut for the stone? Some say it was a division of labour: leave the operation to the specialists. Some say it was prudence: the operation killed so often that it ruined reputations. A translation of 1923 reads it more sweepingly: I will not use the knife, not even, verily, on sufferers from stone. And one scholar argued that the Oath came from the followers of Pythagoras, and renounced the knife altogether. The Greek will bear more than one reading. The argument has never been settled.

10:06 Whatever it meant, for much of the next two thousand years, in Europe at least, cutting for the stone was left largely to a separate trade: the travelling stone-cutters.

10:21 In Alexandria, perhaps two centuries before Christ, a surgeon named Ammonius met a stone too large to draw out. He held it with a hook at the wound and split it with a blow. They called him Lithotomos, the stone-cutter. Keep him in mind. His idea, to break the stone rather than enlarge the wound, will come back.

10:53 The Roman writer Celsus, probably in the time of the Emperor Tiberius, set the operation down in full. Cut only in spring, he says, and only in a boy between nine and fourteen. A strong assistant on a high stool holds the child on his knees. The surgeon, his nails pared, finds the stone with two fingers in the rectum, presses it down, and makes a crescent-shaped cut over it.

11:27 One knife, one hook, and speed. This "lesser apparatus" remained the standard operation in Europe for fifteen hundred years. Celsus also describes bronze catheters: three lengths for men and two for women, "a little curved, but more so for men." Bronze catheters have been dug from the ashes of Pompeii.

11:55 Now an experiment, and a quarrel. Where does urine come from? Asclepiades, a celebrated physician of Rome some two centuries before Galen, had taught that what we drink passes into the bladder as a vapour, and condenses there. The kidneys, in his view, had nothing to do with it. He still had followers.

12:22 Galen of Pergamon thought this absurd. Vapours rise, he said, and the bladder lies below. Any butcher can see the tubes that run from the kidneys to the bladder. But Galen did not merely argue. He demonstrated.

12:42 Galen: One has to divide the peritoneum in front of the ureters, then secure these with ligatures, and next, having bandaged up the animal, let him go.

12:54 The animal stops passing water. Later, Galen loosens the bandages.

13:02 Galen: One loosens the external bandages, and shows the bladder empty, and the ureters quite full and distended, in fact almost on the point of rupturing.

13:12 Galen: On removing the ligature from them, one then plainly sees the bladder becoming filled with urine.

13:21 He went further. He tied the penis and squeezed the full bladder: nothing ran back up toward the kidneys. There is a valve. He tied one ureter and left the other free: only the free one filled the bladder. That is a control, in an experiment some eighteen centuries old. Then he cut the swollen ureter, and the urine spurted, he says, like blood from an opened vein.

13:54 Galen: Like slaves, then, caught in the act of stealing, these two are quite bewildered; and while the one says nothing, the other indulges in shameless lying.

14:08 That was his verdict on Asclepiades, and on the great anatomist Erasistratus, both long dead. Galen was right that the kidneys make the urine. But how? Not, he insisted, by straining the blood like a sieve. The kidney drew the watery part of the blood toward itself, as a lodestone draws iron. So great was Galen's authority that this answer stood for some fifteen hundred years.

IV. The Flask

14:51 For centuries, the emblem of the physician was not a knife, and not yet a stethoscope. It was this: a round glass flask, shaped like a bladder, called a matula. The doctor held it to the light and read the water.

15:11 In the seventh century, a Byzantine writer named Theophilus devoted a whole book to urine, and defined it, beautifully, as the filtrate of the blood. Remember that phrase. Medicine will take thirteen hundred years to find out how nearly right it was.

15:36 From Kairouan to Salerno to Paris, scholars built a whole science on the flask. Charts set out the colours of urine in a wheel, about twenty of them, from crystal clear, through straw and gold and wine red, to green, and livid, and black. Black, as a rule, meant death.

16:05 And the flask was a map of the body. The ring at the top of the liquid spoke of the head. The upper layer, of the chest. The middle, of the stomach and liver. The sediment, of the kidneys, the bladder, and the organs of generation. Often the physician never saw the patient at all. The water arrived in a basket, carried by a servant.

16:35 Meanwhile, in Córdoba, around the year one thousand, the surgeon al-Zahrawi, known in Europe as Albucasis, drew some two hundred surgical instruments for his great encyclopaedia. Among them: a fine drill, turned gently against a stone stuck in the urethra until it broke; a long silver catheter; and a syringe for washing out the bladder, with three tiny holes at its tip. Translated into Latin, his book taught European surgeons for centuries.

17:15 Not everyone trusted the flask. In the tenth century Isaac Israeli, author of a celebrated Book of Urine, warned against fools who prophesied from it without seeing the patient. By Shakespeare's day, it was a joke.

17:34 Falstaff: Sirrah, you giant, what says the doctor to my water?

17:41 Page: He said, sir, the water itself was a good healthy water; but, for the party that owed it, he might have more diseases than he knew for.

17:50 In 1637 an English physician, Thomas Brian, published a book called The Pisse-Prophet. His verdict:

18:01 Brian: There is no certaine knowledge of any Disease to be gathered from the Urine alone.

18:08 And elsewhere, borrowing a Latin tag:

18:14 Brian: The Urine is an Harlot, or a Lyer.

18:19 It was also a confession. Brian admitted that he had played the pisse-prophet himself, quizzing the messenger and then pretending to read the glass, and that one lady had praised him as the cunningest doctor in all the town, because he had told her, by her water, that she was with child.

18:45 Uroscopy ruled learned medicine for about a thousand years, and patients went on demanding it for two centuries more. And yet the flask was not wrong to be looked at. It had been looked at wrongly. What came next was to taste it, to boil it, and to take it apart.

V. What the Water Knew

19:16 Uroscopists had always sniffed the urine, and some had tasted it. In the 1670s the English physician Thomas Willis tasted it, and wrote down exactly what he found. Of a nobleman who passed nearly a gallon and a half of water in a day, he wrote that it was:

19:40 Willis: Wonderfully sweet, as though Honey were mixt in it.

19:45 A century later in Liverpool, Matthew Dobson evaporated such urine to a white cake that, he wrote, smelled like brown sugar. Then he tasted the patient's blood serum. It was sweetish too, though not so sweet as the urine. The sugar was in the blood before it ever reached the kidney.

20:12 Diabetes, from the Greek for a siphon, had long meant only a great flow of water. Willis's taste picked out the sweet kind, and later in that century the Scottish physician William Cullen gave it a second name: diabetes mellitus, honeyed, to set it apart from a rarer kind whose urine was tasteless.

20:41 Others had seen urine curdle with heat. In 1827, at Guy's Hospital in London, Richard Bright warmed a spoonful of a patient's urine over a candle, and watched it cloud before it boiled. Then he followed his patients to the post-mortem table: patients with dropsy, the old name for a body swollen with water, in the legs, the belly and the face.

21:12 Bright: I have never yet examined the body of a patient dying with dropsy, attended with coagulable urine, in whom some obvious derangement was not discovered in the kidneys.

21:26 For a century afterwards, kidney disease with dropsy and protein in the urine was simply called Bright's disease. The Hippocratic bubbles had found their explanation.

21:42 The stone, too, was put to the test. Physicians had long thought it earthy, a kind of gravel. In 1776 the Swedish chemist Scheele found in a bladder stone a new acid, which we now call uric acid. In 1810 William Wollaston described another stone, yellowish and glistening; the first had come from a child of five in Norwich. He named its substance cystic oxide, after the bladder. We call it cystine: one of the very first amino acids ever found, and it was found in a stone.

22:29 In 1828, in Berlin, the young chemist Friedrich Wöhler made urea, the chief solid of urine, in a flask, from simple salts, with no kidney involved. He wrote to his old teacher in Stockholm, the great Berzelius:

22:51 Wohler: I cannot, so to speak, hold my chemical water, and must tell you that I can make urea without needing kidneys, or indeed any animal at all, be it man or dog.

23:04 The textbooks will tell you that this one experiment killed the old belief in a vital force. It did not. That belief lingered for decades. But a door had opened.

23:21 Which brings us back to Galen's question. How does the kidney make urine? In 1842 a young London anatomist, William Bowman, looked again at the tiny tufts of blood vessels that Malpighi had seen in the kidney, and showed that each sits in a cup that opens into a tube. The tuft, he thought, let out water; the living cells of the tube did the real work, secreting everything else.

23:55 The very next year, Carl Ludwig in Germany proposed something colder. The tuft was a filter, driven by the pressure of the blood, and the tubes simply concentrated what came through. Filtration, or secretion. Physics, or living labour. Dyes injected into animals seemed to favour secretion; arguments from physics favoured filtration. The quarrel ran for eighty years. In 1917 Arthur Cushny argued for filtration and reabsorption, in a book he titled, of all things, The Secretion of the Urine. He called his account, rather boldly, "the modern view." But no one could prove it, because no one had ever sampled what came out of a single tuft.

24:53 Then, in Philadelphia, Joseph Wearn and Alfred Newton Richards tried. They anaesthetised a frog, laid open its kidney under a blazing light, and guided a fine glass pipette into the cup around a single tuft. They drew out a droplet of the fluid inside.

25:16 The droplet contained sugar, and it contained salt. The frog's bladder urine, taken at the same moment, contained neither. And the droplet held no protein. Here, it seemed, was the blood's fluid, filtered, with its proteins held back. Somewhere along the tubes, the sugar and salt were being taken back again.

25:43 When they first reported it, in 1921, someone objected at once that a frog is not a mammal. Richards's reply, I am told, won an ovation. Their own colleague wrote that the result suggested, though it did not prove, filtration. The mammals came later, and agreed. Theophilus had called urine the filtrate of the blood thirteen hundred years before. Here it was, very nearly, in a glass pipette. And Bowman, I should add, was not entirely wrong: the tubes secrete as well. The best quarrels in science often end with both sides half right.

VI. The Stone-Cutters

26:39 Now back to the stone, and to those who cut for it. You must understand how common it once was. In parts of Europe, bladder stone was above all a disease of poor children, probably from a diet of little but bread and gruel. The hospital at Norwich operated on some fifteen hundred patients for stone between 1772 and 1909, and kept every stone, labelled, with the patient's name and age. The collection ends in 1909. Nobody closed it. The disease had simply disappeared, and we are still not entirely sure why.

27:26 A good method for the stone could feed a family for generations, and it was guarded as a trade secret. In France, the Colot family were stone-cutters for some eight generations. In Italy, around 1520, a surgeon called de Romanis devised a new approach, described by his pupil Mariano Santo: a grooved metal staff, passed down the urethra into the bladder, to guide the knife. It used so many instruments that it was called the "greater apparatus."

28:07 In the middle of the sixteenth century, Pierre Franco, a barber-surgeon who worked in Switzerland, could not get a large stone out of a two-year-old child from below. The parents begged him to try something. So he did what the Hippocratic rule said was fatal: he cut into the bladder from above. The child lived. Franco put it down to luck, and wrote that he would not advise anyone to do the like. The "high operation" lay almost forgotten for a hundred and sixty years.

28:47 In 1697 a strange figure arrived in Paris: Jacques Beaulieu, a stone-cutter dressed in a monk's habit of his own design, who called himself Frère Jacques. He cut at the side of the perineum, into the neck of the bladder. Paris let him operate in its hospitals. Of about sixty patients, about twenty-five died. The figures vary, but they were dreadful. Witnesses said there was no part of the region that he had not cut at one time or another.

29:25 You may be hearing a tune. It is often said that the nursery round "Frère Jacques" was written about him. Historians have looked. They found no connection. The melody first appears decades after his death, under another name. A thing repeated, as I said, is not a thing proven.

29:48 But Jacques learned. He studied anatomy, adopted a grooved staff, and his later results were far better. In Amsterdam, a surgeon named Rau, who had watched him, perfected the side approach, and is said to have hidden his method from onlookers by keeping his thumb in the wound.

30:14 In London, William Cheselden of St Thomas's Hospital made the side operation his own. Remember: there was no anaesthetic. Speed was mercy. One eyewitness reported an operation of his lasting fifty-four seconds.

30:36 But what marks Cheselden out is not his speed. He counted. He published his results at St Thomas's: two hundred and thirteen patients, twenty deaths, and he set them out by age. Of a hundred and five children aged ten or under, three died. In Paris, by his reckoning, the old method was losing nearly two patients in five. His tables are among the earliest records of surgical results ever broken down by age. He also left us this:

31:15 Cheselden: No one ever endured more anxiety and sickness before an operation, yet from the time I began to operate, all uneasiness ceased; and if I have had better success than some others, I do not impute it to more knowledge, but to the happiness of a mind that was never ruffled or disconcerted, and a hand that never trembled during any operation.

31:53 The patients have left us their voices too. Samuel Pepys, the diarist, was cut for the stone on the twenty-sixth of March, 1658, at his cousin's house in London. He survived, and kept the anniversary as a feast.

32:12 Pepys: This day it is two years since it pleased God that I was cut of the stone at Mrs. Turner's in Salisbury Court. And did resolve while I live to keep it a festival.

32:23 He had a case made for the stone. It cost him twenty-four shillings, which, he noted, was a great deal of money, but it was well done and pleased him. When he died, many years later, seven more stones were found in his left kidney.

32:44 Across the Atlantic, in 1752, Benjamin Franklin's brother John was suffering from the stone. Franklin wrote to him:

32:57 Franklin: Reflecting yesterday on your Desire to have a flexible Catheter, a Thought struck into my Mind how one might possibly be made.

33:07 He went straight to a silversmith, and sat by until it was finished, so that it might catch the post. It was a tube of silver wire wound in a tight spiral, supple enough to follow the turns of the passage. Franklin is often said to have invented the flexible catheter. He did not; an Italian had made one much like it some thirty years before. But I like to picture him in that shop, waiting.

VII. Breaking the Stone

33:47 Remember Ammonius, who split the stone in the wound? In January 1824, in Paris, Jean Civiale went one better. He passed a straight steel instrument up the urethra of a living patient, opened three claws inside the bladder, seized the stone, and drilled it to pieces. No cut at all. Rivals crowded round him, among them Baron Heurteloup, whose instrument gripped the stone and was then struck with a little hammer.

34:27 Then Civiale did something remarkable. He gathered the results of thousands of cutting operations reported across Europe, set them against his own crushings, and laid the numbers before the Academy of Sciences. After cutting, about one patient in five had died. After crushing, about one in forty.

34:53 In 1835 the Academy appointed four men to judge: a chemist, a military surgeon, a physician, and the great mathematician Siméon-Denis Poisson. Large numbers, they agreed, were valuable. But these numbers had been gathered from many surgeons, chosen who knows how, and judged who knows how. They could not prove what Civiale claimed.

35:24 And the physician among them, Double, objected to counting patients at all. To use statistics, he complained, one must first forget that a man is an individual, and treat him as a mere fraction of the species. Certainty of that kind, he said, belongs to astronomy, not to medicine. Poisson disagreed. It is a quarrel between the average and the individual, and I assure you it is not over.

35:59 Crushing had its own dogma. The bladder, Civiale taught, could not bear instruments for long. A sitting should last a few minutes; the fragments were left to pass on their own, and a large stone might need dozens of painful sessions. Even emperors submitted. In January 1873 the exiled Napoleon the Third was twice operated upon in England, under chloroform. He died, of his failing kidneys, an hour and a quarter before the third sitting was due to begin.

36:40 The man who broke that rule was a Boston surgeon, Henry Jacob Bigelow. In 1846 he had published the first report of operations performed under ether. Thirty-two years later he reasoned that a bladder under anaesthesia need not be hurried.

37:01 Bigelow: My own conviction is that it is better to protract the operation indefinitely in point of time, if thus the whole stone can be removed without serious injury to the bladder.

37:14 He crushed the whole stone at one sitting, and washed every fragment out with a rubber bulb and a glass trap. His longest operation lasted three hours and three quarters. A rule half a century old fell in a single book.

37:36 Anaesthesia, and soon Lister's antisepsis, opened the body to the surgeon. In Heidelberg in 1869 Gustav Simon faced a woman of forty-six, Margaretha Kleb, whose ureter had been injured in an earlier operation, so that urine leaked from her constantly. He had failed three times to repair it. The only cure was to remove the kidney. But can a person live with one?

38:10 Simon first removed a kidney from each of thirty dogs, and saw the remaining kidney grow larger to take up the work. Then, on the second of August, 1869, he removed Margaretha Kleb's kidney in forty minutes. She was out of bed in four weeks. One kidney is enough.

VIII. Light

38:41 For most of history the inside of the living body stayed dark. Physicians guessed at it from symptoms, from the flask, and from the click of a metal sound against a stone. In the first years of the nineteenth century, a young doctor in Frankfurt, Philipp Bozzini, asked a simple question. Why not look?

39:07 His "light conductor" was a vase about the height of a wine bottle. Inside it burned a wax candle, held by springs so the flame stayed in place as it burned down. A concave mirror sent the light down one channel; the doctor's eye looked back up another, so that the glare would not blind him.

39:31 Bozzini: The usefulness of the light conductor is so general that it must have, directly or indirectly, the most significant influence on every part of medicine.

39:43 Too poor to travel, he sent it to Vienna. At the army's medical academy they tried it on a cadaver, declared that it met every expectation, and built an improved model within two months. At the University faculty, their rivals, the verdict was different. As it was later recovered from the Viennese files:

40:10 Vienna faculty: It will always remain a mere toy.

40:16 A biographer, writing long afterwards, says they mocked it as a magic lantern in the human body. It was not the light that killed him. In 1809 typhus swept Frankfurt, and Bozzini served as an epidemic physician. There was no cure, only nursing; forty-two of his patients are recorded as recovering. Then he caught the fever himself, and died. He was thirty-five.

40:51 In Paris in 1826, Pierre Ségalas showed the Academy a lighted speculum for the urethra; and, as he later told the story, the physicist Fresnel, on his way out, advised him to put the light at the side and reflect it down the tube with a tilted mirror. In 1853 Antonin Desormeaux did exactly that. He burned alcohol and turpentine in a tall brass lamp, coined the word "endoscope," and looked into the urethra and bladder of the living. His colleagues were not all convinced.

41:32 Desormeaux: When, in its infancy, it was shown to some of my colleagues, one of whom remarked: We can see well with your instrument; but what is the use of seeing?

41:46 Desormeaux considered the new electric light, and rejected it. Too cumbersome, he wrote; it would need an assistant, and double the price.

42:02 The decisive step came from a young doctor in Dresden, Maximilian Nitze. The story goes that, cleaning a dusty microscope eyepiece, he saw through it a tiny upside-down image of the church across the street, and understood that a telescope could carry a picture out of a hollow organ. He put the light inside the bladder itself: a platinum wire, made white-hot by a current, cooled by a stream of iced water, at the tip of a slender tube full of lenses.

42:40 Built with the Viennese instrument-maker Josef Leiter, it was shown on a living patient in Vienna on the ninth of May, 1879. The two soon quarrelled bitterly over the credit; history, diplomatically, gives the instrument both their names. Six months after that demonstration, Thomas Edison filed his patent for the electric lamp. By 1887 tiny bulbs glowed at the tips of cystoscopes in Vienna and in Berlin, and one American wrote that a tumour of the bladder could be seen as plainly as a section under the microscope.

43:24 Now the urologist could steer. In Paris, around 1897, Joaquín Albarrán fitted a tiny hinged lever at the tip of the cystoscope, to lift a fine catheter into the opening of a ureter, and so draw the urine of each kidney separately. And in 1912, at Johns Hopkins, Hugh Hampton Young slid a child's cystoscope up a ureter enormously widened by a blockage below. It is usually counted as the first look up a ureter, though he did not report it for seventeen years.

44:06 Then came a different kind of light. In November 1895 Wilhelm Röntgen discovered rays that pass through flesh. Within months John Macintyre in Glasgow had photographed a stone inside a living kidney. The great kidney surgeon Henry Morris welcomed the rays, but added a warning. If they could show only whether a stone was there, and not the other diseases that mimic it, then:

44:41 Morris: It will, I fear, be the means of putting back renal surgery, by deterring many patients from submitting to surgical explorations who can be cured by no other treatment than an operation.

44:59 Morris had made his name by opening the kidney itself: in 1880 he cut a stone from a kidney otherwise healthy, the first operation of its kind. To such a surgeon, the knife and the finger were still the surest diagnosis, and a clear plate a dangerous comfort.

45:23 In 1906, surgeons learned to fill the kidney with a silver solution through a ureteric catheter and photograph its shape. But that meant a cystoscopy every time. The answer came in 1929, in Hamburg and Berlin, from a young American, Moses Swick. Testing compounds of iodine that chemists had made for quite another purpose, he found one that the kidneys passed out quickly. Injected into a vein, it drew the kidneys, the ureters and the bladder in white upon the plate.

46:05 The professor in whose clinic he worked presented the discovery to the world.

46:13 And with the light of the cystoscope and the X-ray came a flourishing of modern urology: a field that already looks far more like the one we know today than like anything that came before.

46:30 Young Swick's part, though, was overlooked for decades; he received a medal for it only in 1966. And that the professor who presented his work was himself, a few years later, driven from his posts in Germany because of his Jewish ancestry. History rarely arranges its heroes and villains so neatly.

46:57 In 1954 the British physicist Harold Hopkins, with a young research student, Narinder Kapany, showed that an ordered bundle of glass fibres could carry an image round a bend. And then he turned the telescope inside out. The old cystoscope was a tube of air with a few thin lenses held in rings. Hopkins filled the tube with long rods of glass, and let thin gaps of air serve as the lenses. More light could pass, more cleanly, through a narrower tube: as much as eighty times more, by one account.

47:42 British makers declined to build it. A German firm in Tuttlingen, Karl Storz, did. From 1967 the rod-lens cystoscope, lit through glass fibres from a lamp outside the body, became the eye of modern urology. After eighty years inside the bladder, the light had gone back outside, where Bozzini had put his candle.

IX. The Gland That Stands Before

48:21 Below the bladder, wrapped around the urethra, lies a gland whose name comes from a Greek word meaning "one who stands before." The Greeks are often given the credit, but the anatomists of Alexandria seem to have used a different word, and the name was fixed much later. The gland was first plainly described in Venice in 1536, and drawn by Vesalius two years later.

48:51 Anatomists have always compared it to food: a pair of kernels, a walnut, a small grape, and, when enlarged, a pear. Later surgeons spoke of chestnuts, oranges, even coconuts. For in older men the prostate grows, and as it grows it can close the passage. For centuries, the remedy was the catheter, often for life.

49:24 In 1893 the Philadelphia surgeon J. William White reasoned that if removing the ovaries could shrink growths of the womb, removing the testes might shrink the prostate. In castrated dogs it did. Surgeons took up the idea, and by 1895 White could report on a hundred and eleven castrated men. In most, the prostate shrank. Nearly one in five died, many of them already gravely ill. The fashion was soon abandoned. Remember it anyway. White was right about the biology, and that will matter in a moment.

50:12 The surgeons turned to removing the gland itself. In Leeds in 1887, Arthur McGill was operating for a bladder stone when he noticed a lump at the neck of the bladder and twisted it free. It came away, it is said, in his hand. Two years later he showed a meeting of doctors his patients, each holding his own prostate in a jar. Eugene Fuller of New York described shelling out the enlarged gland through the opened bladder in 1895. Peter Freyer of London performed the same operation in 1900, called it total removal of the prostate, published it as his own, performed it more than a thousand times, and caused a great deal of anger in New York and in Leeds.

51:08 Surgeons had already tried to reach the gland through the urethra: blind, with an electrically heated blade, in Pavia in 1874, and with Hugh Young's punch in 1909. The method that lasted needed three things. In 1926 Maximilian Stern of New York made a wire loop that cut with high-frequency current. Theodore Davis, an electrical engineer before he was a doctor, helped build a generator that could cut with one current and seal bleeding vessels with another, at the press of a foot pedal. And in 1931 Joseph McCarthy put loop, current, and a good lens together in an insulated sheath. Three keys, one lock. The transurethral resection of the prostate remained the standard operation for an enlarged gland for the rest of the century.

52:08 In Chicago, Charles Huggins was collecting drops. He had found a way to isolate the prostate of a dog, so that its secretion could be gathered alone and measured, day after day, for months. Remove the testes, and the secretion stopped and the gland shrank. Give the male hormone, and it returned. Give the female hormone, and it stopped again. White's biology, measured at last.

52:42 Then a stroke of fortune. Some of the old dogs had tumours of the prostate. The dog, Huggins said later, is the only laboratory animal in which such tumours occur. So he asked a bold question. If the gland depends on male hormone, might its cancer depend on it too?

53:08 He needed a number to measure it by, and in New York, Alexander and Ethel Gutman had just supplied one: an enzyme, acid phosphatase, that rose in the blood when prostate cancer spread to the bones. In 1941 Huggins and Clarence Hodges castrated men with advanced, painful prostate cancer, or gave them oestrogen. The enzyme fell. The pain eased. When male hormone was given instead, it rose.

53:44 A spreading cancer, it turned out, need not be master of its own growth. Of the first twenty-one men treated by castration, four were alive more than twelve years later. Huggins shared the Nobel Prize in 1966.

54:04 From that work also grew a further fear: that giving testosterone to any man might feed a hidden cancer. For some sixty years doctors were reluctant to prescribe it. Some now argue that the evidence for that particular fear came down, in the end, to a single untreated man given testosterone for eighteen days. The argument goes on.

54:35 Removing the whole prostate for cancer was, in those years, a brutal operation. It bled terribly, and almost every man was left impotent. Surgeons believed that the nerves of erection ran through the gland itself, so nothing could be done. Then, in 1977, a patient of Patrick Walsh at Johns Hopkins mentioned that, after the operation, his potency had returned. Walsh began to wonder.

55:11 In February 1981, in Leiden, he sat with a retired Dutch urologist, Pieter Donker, who was tracing the nerves of the bladder under a microscope, in the body of a stillborn infant, where such fine nerves are easier to follow. Walsh asked him where the nerves to the penis ran.

55:38 Donker: I've never looked.

55:41 Three hours later they had found them, running not through the prostate, but alongside it, outside it. On the twenty-sixth of April, 1982, Walsh performed the first operation designed to spare them.

55:59 Back at Johns Hopkins, Walsh's resident, Herbert Lepor, traced the same nerves through the adult pelvis, and in 1985 they published a precise map of their course beside the prostate. Surgeons still operate by it.

56:20 Then came a blood test. Prostate-specific antigen, a protein made by the gland, was proposed in 1987, in a landmark paper, as a marker for cancer. Read that paper carefully. It found the protein rose with the size of the cancer, and vanished after the gland was removed. But it also found the protein raised in most men with simple enlargement, and concluded, in its authors' words, that "neither marker is specific": neither the new antigen, nor the old acid phosphatase.

57:02 Screening spread anyway. In 2009, two great trials reported side by side. A European one found that screening saved lives. An American one found that it did not, though so many of its unscreened men had been tested anyway that it was comparing screening with less screening. American advisers recommended against the test in 2012, and then, in 2018, for men of fifty-five to sixty-nine, for a conversation between a man and his doctor. That conversation is still going on.

X. Without the Knife

57:49 Some revolutions are small. Around 1930 an American urologist, Frederic Foley, designed a soft rubber catheter with a little balloon near its tip, inflated inside the bladder, at first to stop bleeding after prostate surgery, and to keep the catheter where it is put. It may be the most used urological device on earth, and it bears his name. The patent, after a dispute, went to someone else: Paul Raiche, of the Davol Rubber Company. Foley won it on appeal, Raiche won it back in court, and the name on the catheter stayed Foley's.

58:33 On the twenty-third of December, 1954, in Boston, Richard Herrick was dying of kidney failure. His identical twin, Ronald, offered him a kidney. The surgeons first proved the twins identical by grafting a patch of skin from each onto the other. The urologist Hartwell Harrison removed Ronald's healthy kidney, and Joseph Murray placed it in Richard. It worked at once, and it went on working for years: the first transplant of an organ to succeed for years rather than weeks. It also meant putting a healthy man under the knife for his brother's sake, and before they agreed, the surgeons consulted physicians and clergy. Murray later received the Nobel Prize.

59:28 And the stone? It met its strangest enemy of all. Engineers at the German aircraft firm Dornier were studying how raindrops pit the skin of an aircraft flying near the speed of sound: each drop drives a shock wave into the metal. An engineer who touched a target as a shock wave struck it felt something like an electric shock, yet his skin was unharmed. The wave had passed straight through him.

1:00:03 Now, here is the beautiful part. Take an ellipse. A wave that starts at one focus, and reflects from the curved wall, gathers again at the other. Put an underwater spark at the first focus. Put the patient's kidney stone at the second. Doctors and engineers in Munich tested the idea on human stones placed in the kidneys of dogs. On the seventh of February, 1980, they treated their first patient, lying in a bath of water, with crossed X-ray beams to take aim. The stone broke apart. No knife at all.

1:00:55 In the same years, surgeons were learning to reach stones through a small puncture in the back, or with fine telescopes passed up the ureter, and soon to break them with pulses of laser light. Ammonius would have understood perfectly.

1:01:15 The abdomen, too, was opened less and less. In 1990, in St Louis, Ralph Clayman removed the whole kidney of an eighty-five-year-old woman through small punctures, bagging it and breaking it up inside her so that it could be drawn out through an opening about a centimetre wide. The first such removals of the prostate took more than nine hours on average, and their own surgeons concluded the method had no advantage over open surgery. Then came the robot. In the year 2000, in Frankfurt, surgeons removed a prostate using a robotic system: the surgeon at a console, the instruments held by mechanical arms. Soon afterwards, at the Henry Ford Hospital in Detroit, the city of the assembly line, Mani Menon built a program around the robot, and his team refined the operation over thousands of cases. Their method carried it around the world.

1:02:21 Robotic surgery spread faster than good evidence could follow it, and few surgical instruments have since been studied so closely. Head-to-head trials have not shown that it cures more men, or restores more function, than a skilled open surgeon. But it bleeds far less, and it lets surgeons attempt operations few had envisioned. In many countries a bloody open operation became a robotic one. In 2018 a single-port robot, working through one small opening, was cleared for urological surgery in America. The wound that once ran the length of the belly can now be the width of a thumb.

Epilogue: Look Again

1:03:19 Let me end where we began, with the flask. For most of the twentieth century, students were taught that healthy urine, inside the bladder, is sterile. It was never quite proven. In the 1950s Edward Kass set a threshold, a hundred thousand bacteria in each millilitre, to tell infection from mere contamination. Ordinary cultures, in ordinary air, for a day, grew nothing from most healthy bladders, and nothing was taken to mean nothing there.

1:03:56 In 2012 and 2014, investigators near Chicago looked again. They took urine straight from the bladder, by catheter and by needle; they searched it for bacterial genes; and they cultured a hundred times more of it, in many atmospheres, for longer. Bacteria grew from four samples in every five, taken from women with and without bladder symptoms, and nearly all of those had been reported, by the routine method, as "no growth". The bladder has its own inhabitants. We are only beginning to learn what they do.

1:04:43 And the stone in the jar? It sat in the museum of the Royal College of Surgeons in London for forty years. In May 1941, in the Blitz, bombs struck the College, and more than half of its specimens were destroyed. The stone once called the oldest in the world, which had lain more than five thousand years in the desert, was, in the words of a later surgeon, crushed and completely dispersed.

1:05:23 We still do not fully know why stones form. At least half of those who pass one will form another within ten years. We do not fully know why the prostate begins to grow in middle age, or which of its cancers will matter and which will sleep.

1:05:42 Every age in this story believed it saw clearly: the uroscopist with his wheel of colours, the surgeon who would not cut above the pubis, the faculty that called the light a toy. Somewhere, in what we are sure of today, there is another flask, waiting to be looked at again.

1:06:07 So look again.