A Difficult Calculus

A bladder stone develops from an infinitesimal mineral mass of concentrated urine that gradually accretes layer upon layer to sculpt what is called a calculus (Latin for pebble, whose use in abacuses gives us the English word calculate.) It is the intense pain they inflict, however, that has magnified them into stones—we find it hard to imagine that something precipitating so much anguish could be so small. The body forms other types of stones, too, all of which are equally painful if left untreated. Though these other stones are today more common, it is those that form in the bladder that used to be most prevalent, enough to warrant mention in the Hippocratic oath. Used in some variants still, the passage from the first English translation reads: “I will not use the knife, not even on sufferers from stone, but will withdraw in favor of such men as are engaged in this work.”^[1]

Hippocrates, founder of the Koan school of medicine, generally believed in passive treatments; his unwillingness to cut does not surprise. But the ominous not even hints at the suffering of those afflicted and the urgent need to get the stones out. The reluctance left the field open to lithotomists, as those “engaged in this work” were known. Often transient, at times doubling as barbers, they conducted the grueling procedure and made sure to skip town soon after, as their patients often did not survive. Reading accounts of the practice can be quite horrid. One of the earliest, from the first-century BCE medical treatise De medicina by Aulus Cornelius Celsus, reads: “Then the skin over the neck of the bladder next the anus should be incised by a semilunar cut, the horns of which point towards the hips; then a little lower down in that part of the incision which is concave, a second cut is to be made under the skin, at a right angle to the first, to open up the neck of the bladder until the urinary passage is opened so that the wound is a little larger than the stone.”^[2]

To cut for stones was one of earliest surgeries that entered the body to remove something and became dramatically more successful over time. Barber-surgeons were eventually replaced by professionalized medical practitioners, and new techniques and specialized instruments, such as those documented by Abul-Qasim Khalaf Ibn Abbas Alzahrawi in his Al-Tasreef (ca. 1000 AD), spread throughout Europe and remained widely used until the beginning of the eighteenth century, which saw the shift to the modern suprapubic, rather than perineal, method. The suprapubic procedure—in which the incision is made somewhere between the navel and the pubic bone, rather than between the anus and genitalia as was the case with the Celsan method—was first performed in the sixteenth century by Pierre Franco out of necessity on a patient whose condition made the perineal method unviable. It was successful, but Franco still advised against it and it wasn’t until the early 1700s that surgeons such Johann Bonnet and Jan Greenfield (originally Groenvelt) made it the standard protocol.^[3] John Douglas, a surgeon who published extensively on the subject, argued that it was “much easier on the patient, much sooner done by the operator and the cure more certain than after any of the other methods now in use.”^[4]