Urethral cathecerization has been performed for cases of bladder calculi, prostatic obstruction and urethral inflammation over the last three millennia. The earliest catheters were fashioned from reeds, straws and curled up palm leaves. Hollow leaves of alliumfistulosum, an onion plant, coated with lacquer, were used as catheters in China around 100 BCE.1 The Sushruta Samhital an early Indian Surgical text (circa 1000 BCE), described gold, silver, iron and wood tubes lubricated with ghee (liquid butter) for evacuation of urine, management of urethral stricture disease, instillation of medication, and assistance in lithotomy.1 Hippocrates (4607 -377 BCE) never directly mentioned urethral catheterization but did describe bladder calculus disease and specifically recommended in his oath to leave lithotomy to experts in that art, one of the earliest references to subspecialization.2 In De Medicina (circa 30 CE), Celsus Aurelius Cornelius, a Roman encyclopedist, lists surgical instruments and appliances including bronze and lead pipes for urethral catheterization.2,3 The excavation of a surgeon's house in the Pompeii (79 CE) during the same time period revealed a variety of straight and curved bronze urethral catheters.'4 Shortly after the demise of Pompeii, Claudius Galen (138-201 CE) demonstrated his famous S-shaped metal catheter, which was used throughout antiquity.1 An expansion of the indications for urethral catheterization began with Rufus of Ephesus in 100 CE. In Disease of the Kidney and Bladder, he observed that a paralytic bladder, as in the case of spinal corcl injury, should be treated with catheterization. At approximately the same time, Soranus of Ephesus, an innovative obstetric and gynecological specialist, recommended catheterization of the bladder before the delivery of a newborn.' Catheter Coude Stright Tip

The first millennium ended with the advances of Avicenna (9807 -1037 AD), a Persian philosopher, scientist and physician. In Cannon of Medicine, Avicenna described uroscopy, the macroscopic inspection of urine to determine diagnosis and prognosis. he also warned against catheterization when a bladder was inflamed and cautioned that catheterization be performed gently and without force, using soft cheese as a lubricant. In 1036 CE Avicenna described the first flexible catheter made from stiffened animal skins.1,5 These catheters had limited use: the silver catheter gained popularity because it was easily formed, easily bent and was believed to have antiseptic function. Benjamin Franklin, in a letter written December 8, 1752, described a flexible silver catheter he designed for his older brother John, who suffered from bladder calculi.1,6  Catheter Olive Tip

Early catheters were relatively simple devices made from a variety of materials. Not until the late 17th and early 18th centuries did their construction became more complex. Many of the early catheters were rigid and thus greater skill was required when manipulating them into the bladder. The problem of manufacturing an instrument which was both flexible and yet sufficiently rigid in order to enable it to negotiate the urethra into the bladder was solved by a discovery made by Charles Goodyear, a hardware merchant from Philadelphia, in 1839. Natural rubber had the disadvantage of becoming too soft at body temperature and too hard when cooled. With the Goodyear patent for moldable hard rubber in 1851, the properties of firmness, flexibility and durability could be imparted to crude rubber via the process of vulcanization/' In 1860, Auguste Nélaton (1807-1873), physician to Napolean III, introduced a vulcanized rubber catheter which lives on today as the straight red rubber catheter with a sidehole near its tip.  Catheter Plug

Joseph Charrière, a French instrument maker (1803-1876) and contemporary of Nekton, developed a sizing system that is still used today. The system, known as the French scale, defines the caliber of each catheter as the diameter in millimeters times three. Thus a 1 mm diameter catheter is 3 French.4 In 1863, August Mercier (1811-1882) developed the coudé (French for "elbow") catheter by incorporating a bend near the tip of the catheter to facilitate passage of the catheter past distortions in the bulb of the urethra and elevations of the bladder neck.3'4 However, Mercier was not always credited with the discovery of the coudé catheter. Students at the WelshNational School of Medicine at Cardiff published a fabricated biography of Emile Coudé, the alleged inventor of the curved-tip catheter, in a student society journal. During the publication of the eleventh edition of Bailey's A Short Practice of Surgery, the hoax was discovered and biographical references to Coudé were deleted from the gallery proofs. Several letters of protest were subsequently written to the British Medical Journal and The Lancet describing the clever fabrication. With the hoax of Emile Coudé "straightened out," the discovery of the curved-tip catheter was conclusively attributed to August Mercier.7

The next stage in the development of the catheter was to create a self-retaining device for continuous drainage of the bladder. Originally most indwelling catheters were either taped or tied to the penis in men and were sometimes even sewed to the urethral orifice in women. Neither of these methods proved adequate. The first inflatable balloon-attached catheter was described by James Guthrie, an English military surgeon in 1825. However the instrument was employed for the dilation of urethral strictures and not as a catheter retaining device.4 In 1853 J. E Reybard invented the first retention balloon catheter. The catheter was made of woven fabric, dipped in linseed oil, baked and fitted with a small inflatable balloon.3,8 In 1927, Dr. Vincent Oddo of Providence, Rhode Island devised a retaining catheter by tying a 5 cc balloon made of prophylactic rubber to a two-way woven catheter. Unfortunately this catheter proved impractical because the quality of rubber available at that time caused the balloon to disintegrate soon after coming into contact with the urine in the bladder.1  Self Catheter Coude Tip

Frederic E. B. Foley (1891-1966), a urologist from St. Paul, Minnesota, used newly discovered methods for dipping and coagulating latex on metal forms to devise a one-piece latex self-retaining balloon catheter. The original device known as the "hemostatic bag catheter" was used to control bleeding following transurethral resection of the prostate. However the "hemostatic bag" was also found to retain the catheter in position perfectly and the catheter could thus be used for continuous drainage of the bladder. Dr. Foley demonstrated the first production model at the annual meeting of the American Urological Association in 1935.4,8,9,10,11 Paul Raiche, an engineer at the Davol Rubber Company of Rhode Island, refined Dr. Foley's idea and in 1936 obtained a patent for the process of manufacturing a one-piece latex catheter. Although the Davol Rubber Company retained the rights to the balloon catheter despite subsequent litigation, the Foley name has become synonymous with the balloon catheter.4,8

Joseph Lister (1827-1912), the English surgeon who applied the principle of antisepsis to surgery, experimented with urine putrefaction and found that urine was normally sterile and seemed to have the ability to resist bacterial infection. However, Lister also noted that normal urine could become contaminated by its own decomposition, by blood borne bacteria or after instrumentation. As Lister's clean technique and antiseptic principles became standard practice, urethral catheterization thereby achieved another degree of safety.

The preoccupation of physicians with the purely mechanical aspects of the catheter, such as design, construction and methods of facilitating their introduction and retention, has given way over the past thirty years to concern for the problems caused by prolonged retention of catheters in the bladder. A classical editorial by Paul Beeson, "The case Against the Catheter," presented a reasoned discussion of the problem, but unfortunately led to a great deal of panic among physicians, who came to associate urethral instrumentation with chronic pyelonephritis and septicemia. " Over time, evaluation of the data has resulted in a better understanding of the morbidity associated with the use of the urethral catheter. In 1970, Jack Lapides introduced the concept of clean intermittent catheterization, the idea that a clean but non-sterile technique was sufficient since any bacteria introduced by the catheter would be neutralized by the host defense.14 At the time, the fear of introducing bacteria seemed to outweigh the sense of host resistance that Lister had articulated one hundred years earlier, but over the next three decades the merits of clean intermittent catheterization would prove justified.

The urethral catheter is one of the most frequently utilized devices in the hospitalized patient. A review of the development of the catheter illustrates how far we have come from the days when catheterization was accomplished via onion leaves. However, even after three millennia, we continue to improve upon the design of the catheter. Using today's technology, the next step in the evolution of the urethral catheter will be to create a surface coating that will reduce bacterial adherence in order to further combat the risk of urinary infection.  Vinyl Connect Tubing