Intended for healthcare professionals

Views & Reviews Medical Classics

Picture of a Lithotomy

BMJ 2010; 341 doi: (Published 04 August 2010) Cite this as: BMJ 2010;341:c4156
  1. Desmond O’Neill, consultant in geriatric and stroke medicine, Dublin
  1. doneill{at}

    The bass viol (also known as the viola da gamba) is a supremely expressive but delicate musical instrument. It has been described as the closest an instrument can come to the human voice but was eclipsed by the more robust cello for several centuries. However, a renaissance over the past four decades has allowed us to enjoy again this subtle and emotionally direct instrument. Marin Marais (1656-1728) was one of the greatest of composers and performers of the viola da gamba, and his music gained a wider audience with the 1991 film Tous les Matins du Monde. Although little is known of Marais’s personal life, through his work we glimpse a wonderfully flexible and humorous musical personality. For example, La Gamme (The Scale) is a wonderful fantasy based on the notes of the scale but incorporating all the latest fads from Italian opera.

    Some of his works have medical themes, of which the most famous is the description of an operation to remove a bladder stone. The piece is short, as was the operation in those days—a skilled operator could perform the task in just under a minute. The course of the operation is easy to follow. Onomatopoeically there is a tremolo when the patient confronts the medical equipment; a rising diatonic scale when mounting the operating chair; descending parallel thirds when the catheter is introduced; fast and (for a viola da gamba) high pitched tremolo during the operation itself; punctuated rhythm in alternating fourths and rests finally dying away, representing the weakening flow of blood; and descending melodic movements when the patient is taken to bed.

    The tonal structure mirrors the tension: the preparation of the operation in E minor, the preparation of the actual incision in a quasi-undulating harmony, the painful part of the operation in the subdominant A minor, and the care of the patient after the surgical treatment in a modulation back to E minor. The suite’s next movement, les Rélevailles, pictures the recovery and joy on surviving the operation, not surprising considering that nearly half of those who underwent the procedure died. We do not know if Marais underwent lithotomy himself, but commentators suggest that the intensity of the musical experience is consistent with an intimate experience of this brief but brutal experience.

    For a doctor the fruits of listening to this piece are many. Apart from its innate musical pleasures it is in many senses a visceral time capsule of the origins of surgery, the ingenuity and hubris of our predecessors, and the importance of speed in medicine and surgery. Marais also caught some of the excitement of new developments in urology, which were propagated in France during his lifetime. The lateral perineal approach was pioneered by the surgeon Pierre Franco in the 16th century and popularised by an untrained pseudo-monk, Jacques de Beaulieu (1651-1714), possibly the Frère Jacques of nursery rhyme fame.

    Mendelssohn’s dictum was that it isn’t that music is too imprecise for words but rather that it is too precise. The aural, emotional, and cognitive impact of Marais’s description of major surgery have a combined potency that remains embedded in the consciousness long after the echoes of performance have died away.


    Cite this as: BMJ 2010;341:c4156