Historical Review

Early twentieth century surgical urology: the 1909 - 1939 experience of Henry Wade

D.L. Gardner
Department of Pathology, University of Edinburgh Medical School, Teviot Place, Edinburgh, EH8 9AG, U.K.

Correspondence to: D.L. Gardner, Department of Pathology, University of Edinburgh Medical School, Teviot Place, Edinburgh, EH8 9AG, U.K. Email: d.l.gardner@ed.ac.uk 

Introduction Diagnosis Surgery of the kidney Surgery of the ureter Surgery of the urinary bladder

Surgery of the prostate gland Acknowledgements Footnotes References

Keywords: Anatomy, biography, Henry Wade, history, pathology, surgery, urological surgery Surg J R Coll Surg Edinb Irel., 1 June 2003, 166-176

This historical review uses the experience of Henry Wade (1876-1955) to examine the state of surgical urology in the early decades of the twentieth century. For 50 years, Wade was a central figure in the life of the Royal College of Surgeons of Edinburgh. His work epitomises Scottish surgery in the years between 1909 and 1939. Wade adopted every available technique to arrive at the precise diagnosis of urinary tract disease. An exact clinical history and examination were followed by the testing of the urine, the analysis of the blood, radiography and cystoscopy. During his time, urological surgery was revolutionised by the advent of excretion pyelography. Soon afterwards, blood transfusion and the first antibacterial agents began to transform prognosis. Nevertheless, the urological scene was still dominated by the hazards of prostatectomy, the high frequency of renal tuberculosis, and the challenges of bladder and renal cancer. The virtual impossibility of eradicating malignant prostatic tumours, much less common in a population where the mean expectation of life for males was 20 to 30 years less than now, relegated this insidious disorder to a small place in his practice. In 30 years of active consultant life, Wade brought to surgical urology the skills, integrity, knowledge and determination that had already led him to prominence in the fields of cancer research and in orthopaedic and military surgery

Figure 1: Signed portrait of Henry Wade. The drawing is thought to have been done in 1935. The artist has not been identified

INTRODUCTION
During the past 100 years, few aspects of surgery have advanced more rapidly or changed more radically than the management of diseases of the urinary tract. The techniques of diagnosis, the benefits of operation and the nature of the results have altered so greatly that it is difficult for contemporary clinicians to grasp the immensity of the challenges that confronted surgeons before 1939.

Henry Wade (1876-1955) (Figure 1), was a pioneer of early twentieth century surgical urology. ^1-3 He aquired an understanding of surgery during two years engagement in the South African War before returning to Edinburgh to undertake cancer research of outstanding quality. He became Assistant Surgeon at Leith Hospital and to the Royal Infirmary of Edinburgh (RIE) in 1909 but his career was interrupted by the outbreak of the First World War. Exemplary service in Gallipoli, Palestine and Syria led to the award of the DSO, the CMG and the Order of the White Eagle of Serbia.

Following the war, Wade was responsible for the development of surgical oncology in Edinburgh. He was the Scottish pioneer of this speciality. With advancing experience and success, Wade’s reputation grew and he was elected President of the Royal College of Surgeons of Edinburgh. In 1937, he became President of the Section of Urology of the Royal Society of Medicine.

DIAGNOSIS OF DISEASE
It was axiomatic that precise diagnosis preceded exact surgical treatment. Henry Wade, demanding, meticulous and skilled, used every method available (Table 1) in the years of a consultant practice that extended from 1909 to 1939.^4,5 He was constantly aware of the problems of systemic illness and metabolic dysfunction. The challenge of diagnosing urinary disease, he believed, should be understood by general practitioners.⁶ Urinary obstruction could upset the ‘renal equilibrium’ invoking incipient uraemia.⁷ With Dick (1933-34), he reviewed the problems of pre-renal, renal and post-renal anuria.8 Renal secretion ceased when the blood pressure fell to 50mm of mercury. The intravascular injection of a soluble salt could be a diuretic but water was dangerous and sodium chloride ineffective. However, hydrated sodium sulphate (Glauber’s salt) was restorative.⁸

After recording a full history, Wade made a complete urological examination. The sequence was first, the macroscopic, microscopic and bacteriological analysis of the urine; second, the analysis of the blood; and third, preliminary radiography. Cystoscopy might be followed by retrograde pyelography.⁹ Wade valued laboratory techniques highly when confronting diagnostic problems such as haematuria, pyuria, suspicious radiographic shadows, unexplained renal hypertrophy, abdominal swelling and loin discomfort. ^4,10-12 However, he wrote “I have never found any value in the nature of the cells present as a means of localising the site of a lesion of the genito-urinary tract”.⁴ To stress the significance of radiographs, Wade quoted two cases where cystitis had persisted undiagnosed for several years in spite of cystoscopy. When, at last, radiographs were obtained, renal tuberculosis was revealed in both patients.

As instrument design improved, the use of cystoscopy significantly assisted the diagnostic process. In 1922, Wade reported that he had carried out over 1,000 investigations by ureteral catheterisation without complication.⁴ The procedure was difficult with rigid, prominent strictures of the urethra, with severe prostatic hypertrophy, when an ureteral orifice was due to an opening into a diverticulum, with ureterovaginal fistula, if a visible ureteral orifice could not be catheterised, or in the presence of inflammation. In 1920, the simplest and safest way of demonstrating that both kidneys were ‘functionating’ [sic] was chromocystoscopy (cystochromoscopy). Where a calculus was the cause of partial ureteric obstruction, ‘the pigmented urine escaped like smoke from a slow-burning fire’.

When retrograde (infusion) pyelography was employed, the principal renal diseases recognised were: infection, tuberculosis, calculi and tumours.ⁱ Congenital abnormalities included a single functionating [sic] kidney, horse-shoe kidney, cystic disease, pelvic kidney, and unilateral fused kidney. Wade emphasised the importance of a proper understanding of the anatomy of the renal pelvis.  ¹⁵ Minor variations included two ureters opening independently, close to each other, or the presence of three major calyces. He employed ‘infusion’ urography without harm in over 4,000 patients. ¹⁹

Figure 2: Chemical apparatus employed in 1910 to measure blood urea. The use of the apparatus was described by Weiss (1910) ⁶⁷

Intravenous (descending or excretion) pyelography was introduced in 1929.^16,17 The entire kidney could be outlined (Figure 3). Wade and Band (1929) and Wade (1933) wrote warmly of the technique. ^19,20 ‘Excretion’ urography proved useful for determining the function of a remaining kidney when unilateral nephrectomy was being considered. Interpretation of the appearances could only be by ‘one well trained in recognising pyelographic appearances; the method should not be depended on as a routine means of demonstrating the cause of disease. Rather its province is more to demonstrate the effect of disease’. The procedure was painless but difficult in adults ‘of unstable mind’ (sic). It offered the first means of visualising the urinary tract in early childhood.

Finally, Wade accepted that laparotomy was sometimes essential to confirm the presence of a functionating [sic] contralateral organ. Nephrectomy without such an investigation was only justified if there was accidental rupture and haemorrhage, or if acute fulminating suppurative pyelonephritis endangered life.

SURGERY OF THE KIDNEY

Tuberculosis
Before the end of the Second World War, tuberculosis was rife in Scotland. The most frequent forms of systemic disease, other than infection of the lung and lymph nodes, were osteoarticular and urinary. ‘They could not be cured by sunlight alone’. Renal, urinary bladder and epididymal tuberculosis, therefore, were closely familiar to Wade. A substantial part of his practice concerned their surgical treatment.

Figure 3: Excretion urogram: It is Figure 3 from Wade and Band (1929) ¹⁹ The original legend reads: ‘Excretion urography. Tuberculous disease of the right kidney’. The work described in this article was undertaken within a year of the first report of the technique from von Lichtenberg’s Clinic

Figure 4: Tuberculous kidney: 20-year-old male with a 3-year history of urinary symptoms. Nephrectomy was performed on October 29th 1925. Subsequently, the patient developed tuberculous prostatitis, vesiculitis, and urethral and periurethral tuberculosis. He died three months later. Haematoxylin and eosin (HE) staining; approximately one half natural size

The symptoms centred on urinary frequency and discomfort. There was a diminished bladder capacity. Diagnosis did not rely on demonstrating mycobacteria in the urine although in 26 of his cases, the organism was found. After cystoscopy, bilateral ureteral catheterisation was undertaken. There was a risk of misdiagnosing bilateral disease if the selective examination of urine from both kidneys was not practiced. Rarely, suprapubic cystotomy might be required but Wade did not favour ‘this French practice’. A grid-iron incision in the loin could expose the ureter, allowing a characteristic, pipe-stem change to be seen; the ureter could then be incised. Tuberculous glands occasionally caused ureteric constriction. An ureteral orifice might be reddened, swollen and congested and have the appearances of a ‘golf-hole’ ureter. Many cases had tuberculous ulcers on the vesical wall. Ultimately, a whole, infected kidney would be destroyed by local re-infection.

Treatment of renal disease (Figure 4) could only be by nephrectomy; he had never seen a healed lesion. ²¹ Wade (1935) described his experiences retrospectively.⁵ He had performed nephrectomy in 200 cases. ²¹ Between August 2nd 1922 and June 5th 1928, he operated on 53 patients; they were aged 11 to 64 years. ²² Thirty-four cases healed by primary union. Twelve had a small residual sinus, 5 a larger sinus, but in only 1 did the wound break down completely. It was directly infected and required excision.

Nearly one third of those who were not operated upon died within 2 years. ²³ Even if the disease was not eradicated, removal of the tuberculous kidney reduced inflammation of the lower ureter and urinary bladder. A residual complication was bladder involvement with dilatation of the ureter and renal pelvis. In one case, a vesico-vaginal fistula developed. The uncured patient, he believed, should not be allowed back to duty too soon - ‘the surgical treatment was but a milestone in a long and weary journey’.

Figure 5: Renal carcinoma: the patient was operated upon by Wade on September 11th 1926. There was a recent history of painless haematuria. The histological diagnosis was recorded as ‘papillary carcinoma’. HE; approximately one half natural size

The average stay in hospital after nephrectomy was 21 days. Prolonged sanatorium care was necessary before and almost always after surgery. The immediate postnephrectomy mortality was less than 2%, the ultimate mortality, 6%. Postoperative deaths were attributable to persistent infection and a ‘decline’ of the patient due to generalised tuberculosis or renal insufficiency. Thirty-five of Wade’s 1922-1928 cases appeared cured but two died subsequently from disseminated tuberculosis, two from activity of unremoved tissue, and one from extensive disease detected before surgery. A sixth patient had an inoperable liver carcinoma. Wade’s results may be compared with the series collected by Thomson-Walker (1936). ²⁴

Of the 1,149 patients operated on by five surgeons during the period 1923 to 1927, an average of 23% were dead, 53% ultimately ‘entirely well’ and 20% were only ‘improved’.

Renal tumours
The cardinal symptoms and signs of a primary malignant renal tumour (Figure 5) were: painless, intermittent haematuria, loin discomfort, pencil-like urinary blood clots, renal enlargement and an altered pyelographic contour. ²⁵ Cystoscopy revealed the nature and origin of the bleeding. Infusion (retrograde) pyelography, Wade claimed, should not be used by itself but always with excretion (intravenous) urography. The former identified the tumour, the latter defined its effects on renal function. Excretion urography might enable an estimation of the degree of malignancy.

Biopsy was seldom practiced. The only possible cure was nephrectomy. ²⁵ When a tumour had invaded the renal vein, ‘the surgical skill of the operator was tested admirably’. In Wade’s hands, the operative mortality fell below the disastrous figures for 1885 (76%), 1888 (65%) and 1902 (22%), although haemorrhage, pulmonary embolism, anuria and cardiac failure remained threats to survival. ²⁴ Recurrence was likely in 70% of instances within one year.

SURGERY OF THE URETER

Calculus
Lithotomy is recognised as one of the very earliest forms of surgery but the safe, surgical removal of ureteric calculi open surgery demanded antisepsis. ‘Bouncing’ stones, or stones immobilised outside the bladder, at the lower end of the ureter, could offer difficulty. The size of the stone, its nature and the degree of obstruction were factors influencing a decision. High stones might slip back into the renal pelvis. When a kidney was destroyed, nephrectomy and ureterectomy might prove necessary.

Wade emphasised the problems encountered during his army service (1915 - 1919). ¹⁰ The passage of an X-ray catheter was the most certain means of recognising a stone. Pelvic phleboliths gave misleading appearances. Diagnosis was difficult if a ureter divided just above the bladder and a stone lay within one channel. Six of his 50 military patients were operated on. Two stones were extracted by intravesical forceps, two impacted in the ureteral orifice were removed by suprapubic cystotomy and two by suprapubic opening of the ureter, a major operation with a mortality of 2%.

Wade later (1935) described two cases where calculus culminated in renal failure. ²⁶ In one, a woman of 45 years had suffered from tuberculosis of the hip joint. Some weeks after returning home, she developed complete anuria. The left kidney had been destroyed by an impacted ureteric calculus. The outlet from the right kidney had been blocked by a second calculus. However, this stone was removed surgically and renal function recovered.

Stricture
Wade referred to Hunner’s operation for stricture but ‘did not fall for it’.⁵ Outspoken, and with firm, individual opinions, he classed the relief of ureteric stricture, operations for floating kidney, and promiscuous gastro-enterostomy, as ‘surgical fashions’. ²⁷

SURGERY OF THE URINARY BLADDER

Tumours
Wade developed a special interest in urinary bladder cancer. ^28,29 Prior to 1939, there was a very limited understanding of the behaviour of vesical neoplasms. His articles demonstrate an intense dedication to the welfare of his patients and a preoccupation with new techniques for dealing with this potentially fatal affliction.

The first sign of a tumour was sudden, unexpected, painless haematuria in a healthy person. In his Edinburgh practice, 75% of individuals presenting with haematuria had tumours of the bladder, although sometimes an obscure renal pelvic papilloma could account for the bleeding. Wade recognised that invasive carcinoma might come from an extra-vesical tumour. With primary vesical neoplasms, there was a relationship between the degree of malignancy and the age of the patient. Cystoscopy was crucial to diagnosis and biopsy increasingly important. Ninety per cent of bladder tumours were papilliform. Multiple tumours were frequent.The rough area around the base of a papilloma had a ‘brushwood’ character distinct from primary epithelioma and adenocarcinoma.

Conservative Treatment
Benign villous papillomas were treated by repeated fulguration. There was a special place for diathermy, a technique introduced by Beer. ^5,29 However, there was a risk of implanting tumour cells, of the perforation of the bladder wall and of the need for repeated cystoscopy.

Partial Cystectomy
Early malignant tumours were treated by suprapubic cystostomy. Silver nitrate was infused to prevent the implantation of satellite tumours. Many preferred cystotomy and hemicystectomy to a more hazardous, radical operation. Preliminary laparotomy was followed by excision of the primary growth and of the portion of the bladder that was invaded. Wade chose to leave a divided ureter in situ so that it underwent a process of ‘natural re-implantation’ into what had come to be a diverticulum. ²⁹

Figure 6: Apparatus for collecting urine after the operation of total cystectomy. There is a healed midline incision through which the urinary bladder was excised; healed lateral incisions at sites where the ureters were implanted into the lateral aspects of the abdominal wall. The illustration is a reproduction of Figure 17 from Wade (1931) ²⁹

Figure 7: Benign hyperplasia of middle lobe of the prostate: ‘Median sagittal section of pelvic contents of man aged 73, who died from rupture of urethra with extravasation of urine into space of Retzius, showing hypertrophy of middle lobe of prostate which projects into bladder’. The illustration is a reproduction of Figure 27 from Wade (1914). 34 The artist of the watercolour painting has not been identified

Total Cystectomy
Inoperable vesical cancers, such as those in which both ureters were implicated, could be treated conservatively by the unreliable methods of radium implantation, external irradiation or Coley’s fluid. However, Wade favoured total cystectomy but this radical procedure was hazardous. ³⁰ Wade had experience of eight cases. He accepted partial cystectomy when there were only multiple, benign tumours but, even in such cases, he advised total cystectomy if symptoms persisted for as long as two years.

As a preliminary to total cystectomy, Wade implanted the ureters into the pelvic colon at independent operations. Debility was a contra-indication. Alternatively, therefore, the individual ureters could be implanted on to the lateral aspect of the abdominal wall but there remained a problem of obstruction and the apparatus worn for the collection of urine was cumbersome and unreliable (Figure 6). Cystectomy followed three weeks after ureteric transplantation. Pain could be reduced by carrying out a sympathectomy.

Vesical Exclusion
In selected cases, and for the relief of pain, vesical exclusion was an alternative to total cystectomy. Wade chose this subject when he delivered his Presidential address to the Section of Urology of the Royal Society of Medicine on October 28th 1937.³¹ He returned to this topic in the following year and in his last address to the Section. ^27,32 By that time, he had operated upon 60 cases.

The indications for vesical exclusion arose when the urinary bladder had lost its capacity to retain urine or when there was irreversible disease or destruction of bladder tissue. Wade (1931) conducted the operation under spinal anaesthesia induced by spinocaine. ²⁹ He invariably  recommended bilateral ureteric transplantation with the formation of a ‘urodaeum’ and ‘proctodaeum’ with differential functions, so that the urinary and intestinal contents were voided separately.

A high standard of nursing care was demanded, day and night, for ten days. The immediate post-operative mortality was high. The greatest hazards of vesical exclusion were among those treated for vesical carcinoma among whom the mortality was 52% for the earlier cases and 43% after January 1936. The risks to patients who had non-malignant conditions were much less; the mortality being 26% for the earlier series, and 9% after January 1936.

SURGERY OF THE PROSTATE GLAND
Wade defined ‘prostatism’, a syndrome due to hyperplasia - chronic lobular prostatitis (110 cases), fibrosis without hyperplasia (10 cases), and carcinoma (14 cases). ^ii,33 In untreated disease, death resulted from obstruction to urinary flow, hydroureter, hydronephrosis, uraemia and secondary ascending infection. In the early years of the twentieth century, the surgery of prostatic disease was in its infancy and the mortality was very high. Much effort, therefore, was devoted to modifying and improving surgical techniques.

Wade’s expertise was catalysed by his early studies of pathological anatomy during which he had dissected 134 glands. Fifty had been removed by suprapubic or perineal prostatectomy.³⁴ Histological sections of whole glands were performed.

Wade’s expertise was recognised when he addressed the 81st Meeting of the British Medical Association, in 1913, in Brighton where he encountered Young of Baltimore and Cunningham of Boston. With their support, he published his definitive article, work that soon attracted further publicity. ^34,35

Non-malignant Enlargement of the Prostate
Wade fully understood the importance of benign prostatic hyperplasia, which he termed chronic lobular prostatitis or simple enlargement of the prostate (Figure 7). ²⁴ Both Wade and Thomson-Walker found prostatic enlargement in 34% of men over the age of 60. Its high frequency and significance contrasted with that of malignant disease of the prostate. Untreated, prostatic obstruction was followed by chronic ill-health and death.

Conservative Treatment
Wade always balanced the risk of operation against the increasing hazards of palliation. The treatment of benign prostatic enlargement stressed the avoidance of urinary retention and sepsis. Ergot or strychnine could be given. Castration or vasectomy had been abandoned but external irradiation or the implantation of radium seeds were still occasionally advocated. There was a choice between forced voluntary vesical contraction and catheter - dependent life, a measure adopted only when operation was not possible.²⁴ Survival was for no more than two to four years. Occasionally, preliminary suprapubic cystotomy was recommended.

Operative Treatment³⁶
When Wade began prostatic surgery, this subject had passed through a first phase of innovation. Extraperitoneal suprapubic prostatectomy, blind or through an open incision, was preferred to a transperitoneal approach. Perineal prostatectomy had been developed but open dissection had replaced blind dissection, and transurethral prostatectomy by punch removal was being tested. When the urinary bladder was already open and infected, a 2-stage operation could be attempted. Retropubic prostatectomy was not introduced until 1945.³⁷

Suprapubic prostatectomy: After early attempts by McGill (1888) and Fuller (1895), the method of blind suprapubic prostatectomy used by Freyer (1901,1912,1920) earned widespread approval. ^38-43 Wade attended some of Freyer’s operations at St. Peter’s Hospital, London. ²⁷ The local complications included urinary incontinence, the return of obstruction, the loss of sexual activity, the persistence of a vesical fistula, epididymitis, and the formation of calculi. ³³ The systemic complications were haemorrhage, pain, shock, cardiac failure, uraemia, sepsis, and epididymitis. Prognosis was influenced by age, the dangers of sudden relief of retention, sepsis, circulatory failure, mental and nervous disorders, and alimentary disturbances.

Although recommended in an ideal case, suprapubic prostatectomy remained hazardous. ^33,35 Before 1913, the mortality rate in Edinburgh was 25%. It stayed at that level until at least 1920. Of 164 cases operated on by Wade during his early years, 54 died, a mortality of 35%. Walker (1933) quoted figures of 20% from St. Thomas’s Hospital and Wade recorded 22% from four other London hospitals. 36 By the late 1930s, the mortality in expert hands ranged from 3% to 5%. In general hospital practice, however, it was approximately 8%. ³⁶

Transurethral prostatectomy: The results of blind division of the bladder neck with a urethrotome had proved disastrous. The galvanocautery had also given poor results. The illuminated cystoscope offered scope for change. ⁴⁴ Young (1913) took advantage of this development, using a punch to excise tissue from the bladder neck. ⁴⁵ Haemorrhage often followed but this danger was overcome when Caulk (1920) introduced his cautery punch. ⁴⁶ In 1925, Walker substituted diathermy for the cautery. ⁴⁷ Wade remained sceptical and observed that ‘(in 1913), the practice of transurethral prostatectomy had swept through the United States’; he ‘did not take kindly to a prostatic gamble’. ²⁷

Perineal prostatectomy: Perineal prostatectomy had been promoted by Proust (1903,1904). A transverse, prerectal incision was used. ^48,49 The technique was employed extensively by Young (1905). ⁵⁰ Wade accepted this perineal procedure but recognised that it required accurate anatomical knowledge, experience, special instruments and a well-trained team. The operative mortality, two to six per cent, was relatively low but serious complications included urinary fistula, incontinence, poor control of bladder function, loss of sexual activity, epididymitis and post-operative stricture formation.

Malignant Disease of the Prostate
Wade devoted little space to the discussion of the surgery of this condition. During the years of Wade’s practice, life expectancy and the prevalence of disease changed significantly. In 1905, prostate cancer comprised no more than 2.3/1 000 of the cases of cancer seen at the Middlesex Hospital. ²⁴ In the 1920s and 1930s, benign prostatic hyperplasia was approximately six times as common as prostatic cancer. The latter has become the most common of all malignant diseases in the male. ⁵¹

The palliative treatment of prostatic cancer, in the period 1909 to 1939, consisted of the relief of symptoms by analgesics and other compounds, the passage of catheters and suprapubic cystotomy. Perurethral resection could be used to relieve obstruction. Radical operations were rare since it was accepted that in few instances was it possible to enucleate a ‘malignant prostate’. The operative mortality for radical prostatectomy was exceedingly high.

The first claim of a surgical cure had been made by Young (1905). ⁵² Two forms of perineal operation were described by Thomson-Walker (1936). ²⁴ In the first, the procedure was identical with that used for benign prostatic enlargement. In the second, the prostate and its sheath, the prostatic urethra, the adjacent portion of the bladder wall, the seminal vesicles and the lower ends of the vasa deferentia were excised. In 27 cases reported by Muir (1934), the mean duration of life after prostatectomy alone was seven-months, after prostatectomy and radiotherapy it was 22 months. ⁵³

DISCUSSION
Following graduation in 1898, Henry Wade became captivated by surgical urology. First, because of the time he spent in the University of Edinburgh as Demonstrator in Anatomy (1902) and then in Pathology (1903); second, because of the studies of experimental glomerulonephritis that became part of his 1907 M.D. thesis; ^54,55 and third, because of his work as Assistant Pathologist (1906-1908) to the RIE. Wade became Assistant Surgeon to the Leith Hospital and the RIE in 1909. He was appointed Surgeon-in-Ordinary at the RIE from 1924 until 1939 when he retired as Consultant Surgeon.

To place Wade’s practice of surgical urology in perspective, it is necessary to examine briefly the background of his specialty. ^56-58 For much of human history, peacetime urological surgery had been synonymous with lithotomy. ⁵⁹ Following the Listerian revolution, there was an extraordinary burgeoning of many aspects of the subject. ⁴³ It has been claimed that Guyon (1881) and Nitze (1897) founded modern urology. ^44,60,61 In the United Kingdom, urology was significantly advanced by Thompson (1868) and by Thomson-Walker (1936). ^24,62 In the United States, Young (1926) made many important contributions. ³⁰

The first surgical hospital devoted solely to urological surgery in London was St. Peter’s, which opened in 1860. Although the first urological department in a general hospital in Scotland is believed to have been that of Jacobs in the Glasgow Royal Infirmary in 1936, Wade had established such a unit in the RIE by 1924.⁶³

During the period 1924-1939, when Wade was in charge of Wards 15 and 16 of the RIE, he was responsible for many advances in the practice of urology. The key to his surgical success lay in his grasp of renal physiology and pathology, his use of new techniques of investigation, and his manual dexterity. However, infection remained an important cause of post-operative disability and death. The lessons of antisepsis and asepsis had not been fully learned. The first commercially available derivative of prontosil rubrum, sulphanilamide, was produced in 1936. That clean hands and simple antiseptics could prevent surgical infection were revolutionary ideas accepted slowly and haphazardly. ^64,65 In the period 1909 to 1939, wound infections were still commonplace. Whether gloves should be worn during operations was a matter for debate. ⁶⁶ Hands were washed or exposed to antiseptics but not necessarily scrubbed. Protective gowns were employed but the use of masks was controversial. Caps were not always worn.

Wade’s time as consultant urologist anticipated the many new methods of anaesthesia, resuscitation and transfusion that evolved during the Second World War and he retired before the introduction of antibiotic therapy. Advances in anaesthesia were slow. In 1939, the normal choice was between chloroform and ether. Methods of resuscitation improved but it was only towards the end of Wade’s time that a public blood transfusion service (1936) was established in Edinburgh.

Ultrasonography and computerised axial tomography exemplify modern diagnostic techniques, radical laparoscopic prostatectomy modern surgery. By considering the work of Henry Wade, a pioneer of Edinburgh urological surgery, it is possible to place these advances in perspective and to appreciate the successes and major benefits of modern surgery. It is difficult for contemporary readers to comprehend their degree and to understand the impact they have exerted on the relief of suffering and the prolongation of life. They are, of course, set against a period of increasing longevity and social change, of war and of revolution. In 1911, at the onset of Wade’s consultant practice, the mean expectation of life at birth in Scotland, expressed on a period basis, was no more than 50 years for men, 53 years for women. By 1981, these figures had become 69 and 76 years, respectively.

Wade’s fame and reputation were underpinned by the generosity and deep humanity that he learned from his father, a minister of the Church of Scotland. They were qualities that he hid successfully behind a facade of austere thrift. To these attributes were added manual dexterity, strength, determination, balanced judgement and fortitude. Together, these qualities combined to advance significantly one of the most challenging aspects of modern surgery.

In an era when radical laparoscopic nephrectomy, renal transplantation and the genetics of Wilms’ tumour are topics of common interest and debate, it is encouraging to recall how much can be accomplished under conditions that, by today’s standards, appear primitive and hazardous.

ACKNOWLEDGEMENTS
The sources for this study of Henry Wade include the Council Minutes of the Royal College of Surgeons of Edinburgh; the Minutes of the College Museum Committee; the Wade collection of anatomical and pathological specimens, of histological slides and of drawings and the catalogues of this material; his numerous wartime photographs, dating from 1914 to 1919; and many letters and other documents held in the Library of the Royal College of Surgeons of Edinburgh. The records of Henry Wade’s clinical cases are preserved in the archives of the Lothian Health Services Archive, University of Edinburgh Library. The minutes of the Section of Urology of the Royal Society of Medicine are retained in the Society’s Library at 1, Wimpole Street, London.

To Mr. J. Newsam, FRCSEd. and Ms. Robyn Webber FRCSEd. I am indebted for criticism of the manuscript. I thank Mrs. Sheena Jones MA., Administrative Secretary to the Museum Royal College of Surgeons of Edinburgh, for her assiduous interest and support. I am grateful to the Librarian of the College, Ms. Marianne Smith ALA., and to the Assistant Librarians, Mr. Steven Kerr and Mr. Simon Johnston, for assistance with the Wade archives. Dr. M. Barfoot, Lothian Health Services Archivist, facilitated access to details of Henry Wade’s career in the Royal Infirmary of Edinburgh. The Librarians of the Royal Society of Medicine prepared copies of the Minutes of the Section of Urology. The Librarians of the Royal Colleges of Physicians of Edinburgh and of London gave help in searching for documents/articles relating toWade. Mr. Max McKenzie, ABIPP, produced the photographs with his customary skill and Ms Sadie Maskery and Ms Nicky Greenhorn undertook the computer scanning of the histological sections and of some of the illustrative material.

I owe much to Dr. Neil McLean, FRCSEd. In 1996, he undertook the onerous task of re-assessing the histological sections of the kidneys from 73 of the patients on whom Henry Wade had performed a nephrectomy during the years 1922 to1927. In only four instances did Dr. McLean find it necessary to revise the original diagnosis and I record my thanks to him for permission to call upon the results of his research.

FOOTNOTES
ⁱ The broader term antegrade urography described the percutaneous injection of a contrast medium into the renal pelvis or calyces (antegrade pyelography), or into the urinary bladder (antegrade cystography) by means of a needle or catheter. (see page 167)

ⁱⁱ The condition now termed ‘benign nodular hyperplasia’ (see page 173)

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18. Swick, M. Excretion urography by means of the intravenous and oral administration of sodium ortho-iodohippurate: with some physiological considerations. Surg Gynecol Obstet 1933; 56: 62-5
19. Wade, H. and Band, D. Uroselectan: excretion urography. Trans Med Chir Soc Edinb NS 1929-30; 44: 203-20
20. Wade, H. The role of excretion urography in the diagnosis of disease. BMJ 1933;I:353-5
21. Wade, H. The treatment of tuberculous disease of the kidney from the standpoint of the surgeon. Edinb Med J NS 1933; 40: 166-175
22. Wade, H. The surgical pathology of tuberculous disease of the urinary tract. Ir J Med Sci 1928; 6: 245-58
23. Wildbolz, H. Chirurgie der Nierentuberculose. Stuttgart: F. Enke, 1913
24. Thomson-Walker J. Surgical Diseases and Injuries of the Genito-urinary Organs. London, Toronto, Melbourne: Cassell and Company, Ltd. 2nd edition, edited Walker, K., 1936
25. Wade, H. Renal tumours. Aust NZ J Surg 1935; 5: 3-17
26. Wade, H. The treatment of ureteric calculi. Proc R Soc Med 1935; 28: 582-590
27. Wade, H. Urological reflections. Proc R Soc Med 1946; 39(11): 751-4
28. Wade, H. The treatment of tumours of the urinary bladder. Trans Med Chir Soc Edinb NS 1926-27; 41: 1-19
29. Wade, H. The treatment of malignant tumours of the urinary bladder. Surg Gynec Obstet 1931; 52: 312-323
30. Young HH, Davis DM. Young’s Practice of Urology. Philadelphia: WB Saunders, 1926
31. Wade, H. Vesical exclusion. Proc R Soc Med 1937; 31: 277-292
32. Wade, H. The expectancy of life after ureteral transplantation. Edinb Med J 1939; 46: 61-82
33. Wade, H. Prostatism: the pathological basis of the operative treatment. Lancet 1913 II:299-300
34. Wade, H. Prostatism. The surgical anatomy and pathology of the operative treatment. Ann Surg 1914; 37: 321-59
35. Wade, H. Treatment of prostatism. Int Clin II Series 24 1914;1-12
36. Walker, KM. The Enlarged Prostate and Prostatic Obstruction. London: Humfrey Milford/Oxford University Press. Second edition 1933, pp 208-17
37. Millin, TJ. Retropubic prostatectomy. A new extravesical technique. Lancet 1945; 2: 693-6
38. McGill, AF. On supra-pubic prostatectomy, with three cases in which the operation was successfully performed for chronic prostatic hypertrophy. Trans Clin Soc Lond 1888; 21: 52-7
39. Fuller, E. Six successful and successive cases of prostatectomy. J Cutan Genito-urin Dis 1895;13: 229-39
40. Freyer, PJ. A clinical lecture on total extirpation of the prostate for radical cure of enlargement of the organ. BMJ 1901 II:125-9
41. Freyer, PJ. One thousand cases of total enucleation of the prostate for radical cure of enlargement of that organ. BMJ 1912;II:868-70
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44. Nitze, M. Eine neue Modifikation des Harnleiterkatheters. Zentralbl Krankh Harn Sex Org 1897; 8: 8-13
45. Young HH A new procedure (punch operation) for small prostatic bars and contracture of the prostatic orifice. JAMA 1913; 60: 253-7
46. Caulk, JR. Infiltration anesthesia of the internal vesical orifice for the removal of minor obstructions: presentation of a cautery punch. J Urol 1920; 4: 399-408
47. Walker, K. Perurethral operations for prostatic obstruction. BMJ 1925;I:201-4
48. Proust, R. Manuel de la prostatectomie périnéale pour hypertrophie. Paris: C. Naud, 1903
49. Proust, R. La Prostatectomie dans l’hypertrophie de la prostate. Paris: Masson et Cie 1904. Editeurs Libraires de lAcadémie de Médecine
50. Young, HH. Conservative perineal prostatectomy. JAMA 1903; 41: 999-1009
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52. Young, HH. Early diagnosis and radical cure of carcinoma of the prostate. Being a study of 40 cases and presentation of a radical operation which was carried out in four cases. Johns Hopk Hosp Bull 1905; 16: 315-21
53. Muir EG. Carcinoma of the prostate Lancet 1934;I:667-72
54. Wade, H. Experimental acute interstitial nephritis: the renal changes induced by the toxins of infective sarcoma in dogs. J Pathol Bacteriol 1908;XII:138-9
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57. Pousson A, Dennos, E. Encyclopédie française d’Urologie, ed. Paris, 1914
58. Ballenger EG. History of urology. Prepared under the auspices of the American Urological Association. Editorial Committee: Edgar G. Ballenger, William A. Frontz, Homer G. Hamer, and Brandsford Lewis. 2 volumes. Baltimore: Williams and Wilkins, 1933
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Copyright: 29 April 2003