What the kidneys don’t return to the body via the bloodstream, they pass on to the second and more familiar of our bladders, the urinary one, for disposal. Each kidney is connected to the bladder by a tube called a ureter. Unlike the other organs discussed here, the urinary bladder doesn’t produce hormones (at least none yet found) or have a role in body chemistry, but it does at least possess a kind of venerability. “Bladder” is one of the oldest words in the body, dating from Anglo-Saxon times and predating both “kidney” and “urine” by more than six hundred years. Most other words in Old English with a median d sound morphed into a softer th sound, so that “feder” became “feather” and “fader” became “father,” but “bladder” for some reason resisted the gravitational pull of common usage and has stayed true to its original pronunciation for well over a thousand years, something few other parts of the body could claim.
The urinary bladder is rather like a balloon in that it is designed to swell as we fill it. (In an average-sized man it holds about a British pint, or about six-tenths of a quart; in a woman, rather less.) As we age, the bladder loses elasticity and can’t expand as it once did, which is part of the reason old people spend much of their lives scouting for restrooms, according to Sherwin Nuland in How We Die. Until very recently, it was thought that the urine and bladder are normally sterile. Occasionally bacteria might sneak in and give us a urinary tract infection, but there were no permanent colonies of bacteria in there. For that reason when the Human Microbiome Project was launched in 2008, with the intention of tracking down and cataloging all the microbes within us, the bladder was excluded from investigation. We now know that the urinary world is at least somewhat microbial, too, if not apparently vastly so.
One unfortunate feature the bladder has in common with both the gallbladder and the kidneys is a tendency to form stones—hardened balls of calcium and salts. For centuries, stones plagued people to a degree almost unimaginable now. Because they were so difficult to deal with, they often grew to a most prodigious size before the victim finally accepted the necessity—and very high risk—of surgery. It was a horrible procedure, combining unsurpassed levels of pain, danger, and indignity in a single mortifying operation. Patients were calmed, to the extent possible, with infusions of opiates and mandragora (a form of mandrake), then placed on their backs on a table with their legs pushed back over their heads, their knees bound to their chests, and their arms bound to the table. Usually four strong men were called upon to hold the patient still while the surgeon scavenged about for stones. Not surprisingly, surgeons who performed the procedure were celebrated for their speed more than any other quality.
Probably history’s most famous lithotomy, or stone removal, was that experienced by the diarist Samuel Pepys in 1658, when he was twenty-five years old. This was two years before Pepys started his diary, so we don’t have a firsthand account of the experience, but he mentioned it frequently and vividly thereafter (including in the diary’s very first entry when he finally started it) and lived in loquacious dread of ever having to undergo anything like it again.
It’s not hard to see why. Pepys’s stone was the size of a tennis ball (albeit a seventeenth-century tennis ball, which was slightly smaller than a modern tennis ball, though the distinction could fairly be called academic to anyone carrying one). While four men held Pepys down, the surgeon, Thomas Hollyer, inserted an instrument called an itinerarium up his penis and into the bladder to fix the stone in place. Then he took a scalpel and quickly and deftly—but excruciatingly—cut a three-inch-long incision through the perineum (the area between the scrotum and the anus). Peeling back the opening, he gently cut into the exposed and quivering bladder, thrust a pair of duck-billed forceps through the opening, captured the stone, and extracted it. The entire procedure from beginning to end took just fifty seconds but left Pepys bedridden for weeks and traumatized for life.*
Hollyer charged Pepys twenty-four shillings for the operation, but it was money well spent. Hollyer was famous not just for his speed but also for the fact that his patients very generally survived. In one year, he performed forty lithotomies and lost not a single subject—an extraordinary achievement. Doctors in the past were not always anything like as dangerous and incompetent as we are sometimes led to think them. They might have known nothing of antisepsis, but the best of them did not lack for skill and intelligence.
Pepys for his part marked the anniversary of his survival for some years thereafter with prayers and a special dinner. He kept the stone in a lacquered box, and for the rest of his life showed it off at every opportunity to anyone willing to marvel at it. And who could possibly blame him?
* Pepys’s complaint is often wrongly described as kidney stones. I regret to say I repeated that error in my book At Home: A Short History of Private Life. Pepys had kidney stones aplenty, too—he passed them regularly throughout life—but Dr. Hollyer (sometimes spelled Hollier in other accounts) would not have been able to extract such a large stone from the kidneys without killing him. The experience is recorded fully and memorably in Claire Tomalin’s esteemed biography, Samuel Pepys: The Unequalled Self.
9 IN THE DISSECTING ROOM: THE SKELETON
Heaven take my soul, and England keep my bones!
—WILLIAM SHAKESPEARE, THE LIFE AND DEATH OF KING JOHN
I
THE MOST POWERFUL impression you get in a dissecting room is that the human body is not a wondrous piece of precision engineering. It’s meat. It is nothing like the plastic teaching models of torsos lined up on shelves around the perimeter of the room. Those are colorful and shiny, like children’s toys. An actual human body in a dissecting room isn’t toylike at all. It is just dull flesh and sinew and lifeless organs drained of color. It is slightly mortifying to realize that the only raw flesh we normally see is the meat of animals that we are about to cook and eat. The flesh of a human arm, once the outer skin is removed, looks surprisingly like chicken or turkey. It’s only when you see that it ends in a hand with fingers and fingernails that you realize it’s human. This is when you think you might be sick.
“Feel this,” Dr. Ben Ollivere is saying to me. We are in the dissecting room at the University of Nottingham Medical School in England, and he is directing my attention to a piece of detached tubing in the upper chest of a male body. The tube has been sliced through, evidently for demonstration purposes. Ben instructs me to stick my gloved finger into its interior and feel it. It is stiff, like uncooked pasta—like a cannelloni shell. I have no idea what it is.
“The aorta,” Ben says with what seems like pride.
I am frankly amazed. “So that’s the heart?” I say, indicating the shapeless lump beside it.