Thursday, August 28, 2014

THE DOCTOR'S BAG - IS THERE A SURGEON IN TOWN?


CUTTING FOR STONES!

by Keith Souter aka Clay More


I've talked a bit about pain control in the 19th century. Laudanum was the great solace of many pains, as was good old whiskey in copious quantities. One of the awful causes of excruciating pain that would have sent many folks scurrying to see the surgeon was that caused by urinary stones. Sometimes you were lucky and small stones would pass with the urine. If you were unlucky there was a danger that they could get stuck and an operation might be needed.

You needed to trust that surgeon!

Famous people who suffered with stones
History is riddled with urinary stone sufferers. Napoleon Bonaparte, King Louis XIV, Sir Isaac Newton, Samuel Pepys, Benjamin Franklin and Ian Fleming. The latter, the creator of James Bond said that he had his own internal diamond making factory.

Sir Isaac Newton the discoverer of gravity

Benjamin Franklin, scientist, philosopher and statesman

The Emperor Napoleon

A little medical background
A urinary stone is called a calculus, the plural of which is calculi. This is Latin for pebble(s). As mention above, they have afflicted people throughout history. The oldest recorded one was found in an Egyptian mummy from 4,800 BC.

The Latin word calculus, for pebble only describes a smooth type. Yet many people's experience is that their stones are small, sharp and jagged, like little diamonds. There are different types of stone, you see. It depends upon what they are made of.

Around 85 per cent of stones are made of calcium oxalate crystals. About 10 per cent are uric acid crystals, 2 per cent are cystine and the rest are magnesium ammonium phosphate, or struvite.

Calcium oxalate. Struvite. Cystine. Mixed

We describe stones according to their site. Thus renal stones are kidney stones, which can form in different parts of the kidney. Ureteric stones form and may block the ureter, the tube that runs from the kidney to the bladder. Bladder stones occur in the bladder.



Stones develop if the person has a condition that increases calcium levels, which we call hypercalcaemia. This can be an inherited tendency in 50 per cent of male calculi sufferers and in 75 per cent of female calculi sufferers. Some people have a condition called hypocitruria, which means that they have low levels of urinary citrate. This promotes calcium calculi formation because citrate normally binds with calcium and prevents stone formation.  About 40 -50 per cent of stone suffered have this condition.

Another cause is hyperoxaluria, as is gout, which promotes uric acid crystal calculi.

Urinary infections can also promote mixed stone formation. 

There are other things that can do it, but there is enough information for our purposes here. Suffice it to say that staying well hydrated is one of the most important things that you can do.

Kidney stones may cause little pain. Indeed they may be asymptomatic until they produce a blockage. Once stones start to move they cause excruciating pain, referred to as renal or ureteric colic (depending where it is). Nausea and vomiting usually accompany it. 

Cutting for stone
This was how surgical treatment was referred. Hippocrates, the father of Medicine wrote in the original Hippocratic oath that 'I will not cut for stone, even in those in whom disease is manifest; I will leave this operation to be performed by practitioners.' He believed that this was something that should be left to surgeons who specialised in it.

And indeed, can you imagine such an operation performed without anaesthetic?

The operation was carried out in the lithotomy position. That is, with the patient lying on the back with the knees drawn up to expose the perineum. The word comes from the Greek lithos, meaning 'stone- and tomos, meaning 'cut.' Nowadays we still use this position (and the name for it) for other procedures, but use stirrups for the feet to get in that position.  In centuries gone by, three men would be needed to hold the patient down.


Bladder stones were removed by this perineal approach. The perineum is the area between the genitals and the anus. It was a potentially very dangerous operation, with a high risk of haemorrhage, infection and incontinence afterwards. 

A range of instruments were used for this procedure, including scalpels, dilators, forceps, cystotomes (for cutting into the bladder), urethratomes (for cutting into the urethra) and lithotomes (for cutting the stones.)


Suprapubic lithotomy was also practiced by some surgeons. That is, the operation was down through the lower abdomen. Again, in pre-anaesthetic days it was a dangerous operation.

Transurethral lithotripsy was the greatest advance. The French surgeon Jean Civiale (1792-1867) developed this method by introducing instruments through the urethra, that is directly through the tube leading into the bladder. He invented an instrument called a lithotrite, which bored holes in the stone, then broke the stone up. It would have required great skill, since it was all done without the aid of imaging techniques, but since it did not require cutting into the bladder, it reduced complications.

Dr George Goodfellow
The great Tombstone doctor was known as the surgeon to the gunfighters. He was a surgical innovator. Among his achievements he was the first American surgeon to perform the perineal prostatectomy. Afterwards he travelled the USA demonstrating the operation.


Clay More's novel about Dr George Goodfellow is published in the West of the Big River series by Western Fictioneers. 

Available at Amazon.com:



And his collection of short stories about Doc Marcus Quigley is published by High Noon Press


Available at Amazon.com:


And his latest western  novel Dry Gulch Revenge is published by Hale on 29th August.




16 comments:

  1. Replies
    1. Thanks, Jo. I am always in awe at the things that doctors had to be prepared to do back then.

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  2. I always love your posts, Keith. And your stories. Always good stuff, thanks.

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    1. Thank you, Frank. I appreciate this kind words.

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  3. Thank the good Lord for ultrasound. So many ways nowadays to NOT cut into the body, or invade it minimally. But, as you know, the characters the Chuck Tyrell books bleed a lot. Further, in Road to Rimrock, Dr. Goodfellow puts in an appearance. Thanks for all the information, Keith, both on the blog and through the mails.

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    1. Absolutely, Charlie. It was practising medicine and surgery by your fingertips. I very much enjoyed Dr Goodfellow's appearance in Road to Rimrock. And you are welcome, any time.

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  4. Dr. Keith,

    Good Lord, Doc. I don't want to be a doctor, I don't want to get sick, I don't want to have stones, and I don't necessarily want to know the gruesome details. But, if I have to learn, it is always a distinct but queasy pleasure, to learn from you.

    Again Keith, a more than informative post of a medical ailment, albeit of the most squeamish kind for us layman, who were naively living their lives happily unaware (until now) of these medical diseases of the past and present that can so grossly affect us.

    Actually I think most of us know about stones, but certainly not in this detail.

    (A tongue in cheek response) thank you?

    Charlie

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    1. Thanks, Charlie. I always try to be careful about some of these topics and avoid being too lurid.

      And talking about tongue in cheek, you can get stones there too! Parotid calculi can be very painful. They block the parotid duct, the main salivary gland in the cheek. You can imagine how that can hurt when the saliva flows but cannot get out. (Sorry, didn't mean to get too lurid!)

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  5. Yikes. I'll be seeing those surgical instruments in my sleep.

    And, just think...passing kidney stones pales in comparison to childbirth.

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    1. You are so right, Vonn. Childbirth must be about top of the league table of pain. But it is generally better and more pain-relieved nowadays than in frontier days.

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  6. Terrifying and fascinating at the same time. Still, for those who were serious about helping those who were suffering I applaud their efforts to help. Thank you again for a useful post.

    Also, best ot you on the new books. Doris

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    1. Thank you, Doris. Surgery is of course continually changing. When I was a house surgeon, many moons ago, I remember assisting at operations that were considered routine. Thanks to drug treatments they are rarely done now (thinking here of the various operations for peptic ulcers.) Laparoscopic surgery has also transformed many operations, resulting in reduced complications and reduced recovery times. Such keyhole surgery has necessitated modern surgeons developing a different skill-set as they have to use different instruments. And now we are seeing the development of robotic surgery. Effectively, a surgeon may be able to operate on a patient in an operating theatre many, many miles away. The wonders of science!

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  7. Modern Medicine is great.
    Congrats on the new Black Horse western
    Jerry

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    1. Thanks, Jerry. Yes, we are fortunate these days.

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  8. Very interesting, Keith, as always! I love your columns and you always bring up something I'd never thought about. Those surgeries seem absolutely brutal. I wonder what the mortality rates were for surgery vs. no treatment at all. I hope they used lots of whatever painkiller was available. :shudder:

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  9. Thanks, Jacquie. Surgery would be a last resort.There were many treatments that were purported to work, yet most would have a strong placebic element and would depend upon nature expelling the stone.

    In about 1720 a woman called Joanna Stephens compounded a remedy made from baked egg-shells with a decoction of soap and other secret ingredients, with the specific purpose of dissolving kidney and bladder stones. Not surprisingly, people were willing to try anything that would keep them away from the surgeon’s knife. Her results were reported to be amazing.

    Her cause was championed by Dr David Hartley, who was later to become famous as the originator of the Associationist school of psychology. He suffered from recurrent bladder stones and experimented with the treatment. He wrote a series of papers explaining why eggs were used – (since the shells were made of calcium carbonate, which when heated would produce lime, which had been used for the treatment of stones since the days of the Roman writer Pliny) – and why soap was needed – (because the lime constipated and the soap would counter this.) He sincerely believed that Joanna’s secret cure would be of incredible benefit to the public. This cry was taken up by the Hon Edward Carteret, the Postmaster General. Soon other dignitaries attested to its value and Joanna was asked to reveal her secret which was obviously of ‘great importance to mankind.’ She agreed to do so, for the price of a mere five thousand pounds.

    A public subscription was started, which fell short of her fee, but she held firm. Parliament was petitioned and duly agreed to pay her. And as agreed she handed over her secret recipe, which was duly printed in The Gazette. The ingredients consisted of bird and snail shells, carrot seeds, soap, honey and various traditional herbs.

    Joanna took the money and lived comfortably and quietly ever after. Her wonder remedy gradually fell from favour, its magic having disappeared when the contents were no longer secret.

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