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:

THE DOCTOR by CLAY MORE

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

Available at Amazon.com:

ADVENTURES FROM THE CASEBOOK OF DR MARCUS QUIGLEY

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