Sunday, 31 July 2011

Stones - Lithotomy

Carel van Savoyen’s Portrait of Jan de Doot, 
holding the kidney stone he removed from himself.

Stones are sometimes formed inside hollow organs, such as the kidneys, bladder, and gallbladder. Unable to exit naturally through the urinary system or biliary tract they cause considerable pain and sometimes death. Lithotomy from Greek for "lithos" (stone) and "tomos" (cut), is a surgical method for their removal.

Many famous people who suffered from kidney stone include Napoleon I, Louis XIV, George IV, Oliver Cromwell, Francis Bacon, Isaac Newton, Samuel Pepys, Lyndon B. Johnson, Benjamin Franklin and Michel de Montaigne.

Surgical accounts are common in the eighteenth century:

On the first of December 1739 a negro, of about 15 years of age, died in St George’s hospital. The preceding day the lateral operation had been performed on him, for extracting a stone, the symptoms of which he had laboured under for several years, and of which the surgeons were convinced, by the sounding of the probe. […] Many curious gentlemen were present at the aperture of the carcass; there was found in the internal and posterior lateral part of the bottom of the bladder, a bony cystis, as large as a chestnut, and full of a stony substance, which form’d a round hard body, that sounded against the point of the probe; this body was engaged in the internal membrane of the bladder, with which it was cover’d by a large base, which rose from the bottom of that organ, and rested on the rectum; so that, in the discharges of the excrements and the urine, and in certain situations of the body, it stopp’d up the entrance of the urethra, and irritated that orifice, so as to produce those symptoms which had been attributed to a stone in the bladder. (268-9)

Some days ago, M. Guerin, the father, shew’d me the bladder of a man of 50 years of age, who had been cut for the stone last year. He had found a great deal of resistance in introducing the probe into the bladder. The incision being made in the ordinary manner, he had introduced the pincers, and at once extracted two pieces of fungous excrescences of flesh, and thirteen stones, shaped like those of the patient I have before-mentioned, but smaller. He used injections, with a view to bring away a stone which he had touch’d with the the probe, but could not lay hold of it; the patient, however, died eight days after. Upon opening the carcass, twenty-seven stones, like the former, were found included in in particular cellules, some presenting one of their angles, and others one of their small faces to the mouths of their respective cellules. There was also on the right side of the bladder, an excrescence, in form of a mushroom, which in some measure stopp’d up the orifice of the bladder. (272)

From Memoirs of the Royal Academy of Surgery at Paris: containing a great variety of Cases in the chief branches of the Art, many of them very surprising and uncommon. Volume II (1750)

Memoir XII recounts a “Remarkable cure by cutting a new anus, and its mechanism” (247-63)
But the magnified images of stones are incredibly beautiful, as can be seen here.

Finally let's remind ourselves of the famous essayist Michel de Montaigne, whose affliction provided an opportunity to reflect on the misfortunes that accompany old age:

We must learn to suffer what we cannot evade; our life, like the harmony of the world, is composed of contrary things—of diverse tones, sweet and harsh, sharp and flat, sprightly and solemn: the musician who should only affect some of these, what would he be able to do? he must know how to make use of them all, and to mix them; and so we should mingle the goods and evils which are consubstantial with our life; our being cannot subsist without this mixture, and the one part is no less necessary to it than the other. To attempt to combat natural necessity, is to represent the folly of Ctesiphon, who undertook to kick with his mule.—[Plutarch, How to restrain Anger, c. 8.]

I consult little about the alterations I feel: for these doctors take advantage; when they have you at their mercy, they surfeit your ears with their prognostics; and formerly surprising me, weakened with sickness, injuriously handled me with their dogmas and magisterial fopperies—one while menacing me with great pains, and another with approaching death. Hereby I was indeed moved and shaken, but not subdued nor jostled from my place; and though my judgment was neither altered nor distracted, yet it was at least disturbed: 'tis always agitation and combat.

Now, I use my imagination as gently as I can, and would discharge it, if I could, of all trouble and contest; a man must assist, flatter, and deceive it, if he can; my mind is fit for that office; it needs no appearances throughout: could it persuade as it preaches, it would successfully relieve me. Will you have an example? It tells me: "that 'tis for my good to have the stone: that the structure of my age must naturally suffer some decay, and it is now time it should begin to disjoin and to confess a breach; 'tis a common necessity, and there is nothing in it either miraculous or new; I therein pay what is due to old age, and I cannot expect a better bargain; that society ought to comfort me, being fallen into the most common infirmity of my age; I see everywhere men tormented with the same disease, and am honoured by the fellowship, forasmuch as men of the best quality are most frequently afflicted with it: 'tis a noble and dignified disease: that of such as are struck with it, few have it to a less degree of pain; that these are put to the trouble of a strict diet and the daily taking of nauseous potions, whereas I owe my better state purely to my good fortune; for some ordinary broths of eringo or burst-wort that I have twice or thrice taken to oblige the ladies, who, with greater kindness than my pain was sharp, would needs present me half of theirs, seemed to me equally easy to take and fruitless in operation, the others have to pay a thousand vows to AEsculapius, and as many crowns to their physicians, for the voiding a little gravel, which I often do by the aid of nature: even the decorum of my countenance is not disturbed in company; and I can hold my water ten hours, and as long as any man in health. 'The fear of this disease,' says my mind, 'formerly affrighted thee, when it was unknown to thee; the cries and despairing groans of those who make it worse by their impatience, begot a horror in thee. 'Tis an infirmity that punishes the members by which thou hast most offended. Thou art a conscientious fellow;'

      Quae venit indigne poena, dolenda venit:
      "We are entitled to complain of a punishment that we have not deserved." (Ovid, Heroid., v. 8.)

consider this chastisement: 'tis very easy in comparison of others, and inflicted with a paternal tenderness: do but observe how late it comes; it only seizes on and incommodes that part of thy life which is, one way and another, sterile and lost; having, as it were by composition, given time for the licence and pleasures of thy youth. The fear and the compassion that the people have of this disease serve thee for matter of glory; a quality whereof if thou bast thy judgment purified, and that thy reason has somewhat cured it, thy friends notwithstanding, discern some tincture in thy complexion. 'Tis a pleasure to hear it said of oneself what strength of mind, what patience! Thou art seen to sweat with pain, to turn pale and red, to tremble, to vomit blood, to suffer strange contractions and convulsions, at times to let great tears drop from thine eyes, to urine thick, black, and dreadful water, or to have it suppressed by some sharp and craggy stone, that cruelly pricks and tears the neck of the bladder, whilst all the while thou entertainest the company with an ordinary countenance; droning by fits with thy people; making one in a continuous discourse, now and then making excuse for thy pain, and representing thy suffering less than it is. Dost thou call to mind the men of past times, who so greedily sought diseases to keep their virtue in breath and exercise? Put the case that nature sets thee on and impels thee to this glorious school, into which thou wouldst never have entered of thy own free will. If thou tellest me that it is a dangerous and mortal disease, what others are not so? for 'tis a physical cheat to expect any that they say do not go direct to death: what matters if they go thither by accident, or if they easily slide and slip into the path that leads us to it? But thou dost not die because thou art sick; thou diest because thou art living: death kills thee without the help of sickness: and sickness has deferred death in some, who have lived longer by reason that they thought themselves always dying; to which may be added, that as in wounds, so in diseases, some are medicinal and wholesome. The stone is often no less long-lived than you; we see men with whom it has continued from their infancy even to their extreme old age; and if they had not broken company, it would have been with them longer still; you more often kill it than it kills you. And though it should present to you the image of approaching death, were it not a good office to a man of such an age, to put him in mind of his end? And, which is worse, thou hast no longer anything that should make thee desire to be cured. Whether or no, common necessity will soon call thee away. Do but consider how skilfully and gently she puts thee out of concern with life, and weans thee from the world; not forcing thee with a tyrannical subjection, like so many other infirmities which thou seest old men afflicted withal, that hold them in continual torment, and keep them in perpetual and unintermitted weakness and pains, but by warnings and instructions at intervals, intermixing long pauses of repose, as it were to give thee opportunity to meditate and ruminate upon thy lesson, at thy own ease and leisure. To give thee means to judge aright, and to assume the resolution of a man of courage, it presents to thee the state of thy entire condition, both in good and evil; and one while a very cheerful and another an insupportable life, in one and the same day. If thou embracest not death, at least thou shakest hands with it once a month; whence thou hast more cause to hope that it will one day surprise thee without menace; and that being so often conducted to the water-side, but still thinking thyself to be upon the accustomed terms, thou and thy confidence will at one time or another be unexpectedly wafted over. A man cannot reasonably complain of diseases that fairly divide the time with health.

I am obliged to Fortune for having so often assaulted me with the same sort of weapons: she forms and fashions me by use, hardens and habituates me, so that I can know within a little for how much I shall be quit. For want of natural memory, I make one of paper; and as any new symptom happens in my disease, I set it down, whence it falls out that, having now almost passed through all sorts of examples, if anything striking threatens me, turning over these little loose notes, as the Sybilline leaves, I never fail of finding matter of consolation from some favourable prognostic in my past experience. Custom also makes me hope better for the time to come; for, the conduct of this clearing out having so long continued, 'tis to be believed that nature will not alter her course, and that no other worse accident will happen than what I already feel. And besides, the condition of this disease is not unsuitable to my prompt and sudden complexion: when it assaults me gently, I am afraid, for 'tis then for a great while; but it has, naturally, brisk and vigorous excesses; it claws me to purpose for a day or two. My kidneys held out an age without alteration; and I have almost now lived another, since they changed their state; evils have their periods, as well as benefits: peradventure, the infirmity draws towards an end. Age weakens the heat of my stomach, and, its digestion being less perfect, sends this crude matter to my kidneys; why, at a certain revolution, may not the heat of my kidneys be also abated, so that they can no more petrify my phlegm, and nature find out some other way of purgation. Years have evidently helped me to drain certain rheums; and why not these excrements which furnish matter for gravel? But is there anything delightful in comparison of this sudden change, when from an excessive pain, I come, by the voiding of a stone, to recover, as by a flash of lightning, the beautiful light of health, so free and full, as it happens in our sudden and sharpest colics? Is there anything in the pain suffered, that one can counterpoise to the pleasure of so sudden an amendment? Oh, how much does health seem the more pleasant to me, after a sickness so near and so contiguous, that I can distinguish them in the presence of one another, in their greatest show; when they appear in emulation, as if to make head against and dispute it with one another! As the Stoics say that vices are profitably introduced to give value to and to set off virtue, we can, with better reason and less temerity of conjecture, say that nature has given us pain for the honour and service of pleasure and indolence. When Socrates, after his fetters were knocked off, felt the pleasure of that itching which the weight of them had caused in his legs, he rejoiced to consider the strict alliance betwixt pain and pleasure; how they are linked together by a necessary connection, so that by turns they follow and mutually beget one another; and cried out to good AEsop, that he ought out of this consideration to have taken matter for a fine fable.

The worst that I see in other diseases is, that they are not so grievous in their effect as they are in their issue: a man is a whole year in recovering, and all the while full of weakness and fear. There is so much hazard, and so many steps to arrive at safety, that there is no end on't before they have unmuffled you of a kerchief, and then of a cap, before they allow you to walk abroad and take the air, to drink wine, to lie with your wife, to eat melons, 'tis odds you relapse into some new distemper. The stone has this privilege, that it carries itself clean off: whereas the other maladies always leave behind them some impression and alteration that render the body subject to a new disease, and lend a hand to one another. Those are excusable that content themselves with possessing us, without extending farther and introducing their followers; but courteous and kind are those whose passage brings us any profitable issue. Since I have been troubled with the stone, I find myself freed from all other accidents, much more, methinks, than I was before, and have never had any fever since; I argue that the extreme and frequent vomitings that I am subject to purge me: and, on the other hand, my distastes for this and that, and the strange fasts I am forced to keep, digest my peccant humours, and nature, with those stones, voids whatever there is in me superfluous and hurtful. Let them never tell me that it is a medicine too dear bought: for what avail so many stinking draughts, so many caustics, incisions, sweats, setons, diets, and so many other methods of cure, which often, by reason we are not able to undergo their violence and importunity, bring us to our graves? So that when I have the stone, I look upon it as physic; when free from it, as an absolute deliverance.

And here is another particular benefit of my disease; which is, that it almost plays its game by itself, and lets 'me play mine, if I have only courage to do it; for, in its greatest fury, I have endured it ten hours together on horseback. Do but endure only; you need no other regimen play, run, dine, do this and t'other, if you can; your debauch will do you more good than harm; say as much to one that has the pox, the gout, or hernia! The other diseases have more universal obligations; rack our actions after another kind of manner, disturb our whole order, and to their consideration engage the whole state of life: this only pinches the skin; it leaves the understanding and the will wholly at our own disposal, and the tongue, the hands, and the feet; it rather awakens than stupefies you. The soul is struck with the ardour of a fever, overwhelmed with an epilepsy, and displaced by a sharp megrim, and, in short, astounded by all the diseases that hurt the whole mass and the most noble parts; this never meddles with the soul; if anything goes amiss with her, 'tis her own fault; she betrays, dismounts, and abandons herself. There are none but fools who suffer themselves to be persuaded that this hard and massive body which is baked in our kidneys is to be dissolved by drinks; wherefore, when it is once stirred, there is nothing to be done but to give it passage; and, for that matter, it will itself make one.
I moreover observe this particular convenience in it, that it is a disease wherein we have little to guess at: we are dispensed from the trouble into which other diseases throw us by the uncertainty of their causes, conditions, and progress; a trouble that is infinitely painful: we have no need of consultations and doctoral interpretations; the senses well enough inform us both what it is and where it is.

By suchlike arguments, weak and strong, as Cicero with the disease of his old age, I try to rock asleep and amuse my imagination, and to dress its wounds. If I find them worse tomorrow, I will provide new stratagems. That this is true: I am come to that pass of late, that the least motion forces pure blood out of my kidneys: what of that? I move about, nevertheless, as before, and ride after my hounds with a juvenile and insolent ardour; and hold that I have very good satisfaction for an accident of that importance, when it costs me no more but a dull heaviness and uneasiness in that part; 'tis some great stone that wastes and consumes the substance of my kidneys and my life, which I by little and little evacuate, not without some natural pleasure, as an excrement henceforward superfluous and troublesome. Now if I feel anything stirring, do not fancy that I trouble myself to consult my pulse or my urine, thereby to put myself upon some annoying prevention; I shall soon enough feel the pain, without making it more and longer by the disease of fear. He who fears he shall suffer, already suffers what he fears. To which may be added that the doubts and ignorance of those who take upon them to expound the designs of nature and her internal progressions, and the many false prognostics of their art, ought to give us to understand that her ways are inscrutable and utterly unknown; there is great uncertainty, variety, and obscurity in what she either promises or threatens. Old age excepted, which is an indubitable sign of the approach of death, in all other accidents I see few signs of the future, whereon we may ground our divination. I only judge of myself by actual sensation, not by reasoning: to what end, since I am resolved to bring nothing to it but expectation and patience? Will you know how much I get by this? observe those who do otherwise, and who rely upon so many diverse persuasions and counsels; how often the imagination presses upon them without any bodily pain. I have many times amused myself, being well and in safety, and quite free from these dangerous attacks in communicating them to the physicians as then beginning to discover themselves in me; I underwent the decree of their dreadful conclusions, being all the while quite at my ease, and so much the more obliged to the favour of God and better satisfied of the vanity of this art.

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