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Urology pearls

Pain: nothing is quite like passing a kidney stone

Shahar Madjar, MD, Journal columnist

Some weeks ago, in the midst of the COVID-19 pandemic, a patient of mine told me that she no longer believes scientists, or in science. “It’s all political,” she said.

The following story is a first in a series of articles on the power of science.

My father had kidney stones and his physician, Dr. Ehrlich, was a urologist whose office was just a short walking distance down the hill from our home. I had nothing better to do, so I joined my father to his doctor’s visit. I was only 10 years old, but I can still remember that the doctor’s face seemed dead serious and the situation felt dire.

Ehrlich scheduled my father for surgery. I could see the fear in my father’s eyes and hear it in his voice, and yet, he agreed to have the operation because he had experienced the intense pain of kidney stones before and was more fearful of that pain than of Ehrlich’s sharp scalpel.

How bad was my father’s pain? My own patients tell me that the pain of passing a kidney stone is ten out of ten in severity and sharp. Looking at a visual pain scale, they point at the drawing all the way to the right. It is a picture of intense suffering: a face as red as a ripe tomato, tears rolling down the cheeks, wide-open eyes, the corners of the mouth drawn down and eyebrows that point upwards in an expression of worry.

Women tell me that passing a kidney stone is worse than the pain they had experienced delivering a baby.

My father wasn’t alone in his willingness to submit to a surgeon’s knife. Men and women who had stone pain were willing to undergo surgery long before surgery was perfected, and even before the discovery of antibiotics (by Alexander Fleming in 1928), or anesthesia (first used in 1846). The risks of severe bleeding, devastating infection, even untimely death were high. Surgery was an unpleasant gamble where life and death wrestled each other and nobody could tell which would have the upper hand.

To appreciate another man’s pain, read John Evelyn’s description of a procedure for bladder stones he saw performed on five male patients at the Hopital de la Charity in Paris in 1650: First, the patient was bound to a high surgical chair; his legs, neck, and arms fixed up with long linen strips to keep his limbs out of the surgeon’s way.

Two strong men were holding him at his knees and feet, and two others at the arm-pits and hands. To find the stone’s position, the surgeon introduced a crooked, angled probe through the patient’s urethra and into his bladder, blindly searching for the stone and fixing it in place.

The patient’s face was sponged as the surgeon cut along a line extending from the patient’s scrotum to his anus. He cut through the skin and the tissues underneath, and toward the neck of the bladder. With his forefingers, he then sought for the stone, and with another instrument that looked “like a crane’s neck,” finally extracted the stone. He then used another instrument to search for other stones. The wound was finally sewed up. John Evelyn writes: “The effusion of blood was greate … The danger is feavor, & Gangreene, some Wounds never closing.”

To appreciate another man’s pain, listen closely to “The Portrait of the Bladder Stone Operation,” a musical composition written in 1725 by the French composer Martin Marais. Marais was a gifted viol player who played in front of King Louis XIV and later became the leader of the royal orchestra. “The Portrait of the Bladder Stone Operation” begins with a high note and an accompanying low hum indicating the appearance of the surgical apparatus and the loneliness of the patient.

The composition then follows the patient as he climbs into the operating chair; the melody twists and turns as his arms and legs are knotted; a trembling motif appears as the surgeon cuts into the skin; a higher pitch is heard as the surgeon introduces the forceps into the bladder, and turns even higher as he extract the stone; and, in “the highest note in the viol literature,” the patient’s voice falters from the pain and screaming; finally, the movement ends with marching chords as the patient was carried into the recovery room. In Marais’ composition, one can hear the blood gushing, and the musical shrieking, screaming of pain.

Back to my childhood. I remember my father standing on a beach along the Mediterranean Sea. I see him in my mind: wearing a swim suit, looking into the horizon; I notice two long incisions on each side of his back indicating, like long fault lines, the painful fractures in his life as he endured these extensive surgeries to rid himself of kidney stones, to escape pain even more intense.

Editor’s note: Dr. Shahar Madjar is a urologist at Aspirus and the author of “Is Life Too Long? Essays about Life, Death and Other Trivial Matters.” Contact him at smadjar@yahoo.com.

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