Monday, 17 March 2014

"You Study What?" Or, "No, I'm not ashamed to say that I study 17thC surgery"

A typical conversation: 

Person: "You study what?"

Me: "I study surgery in early modern England.  Seventeenth century, mostly."

Person: "Right.  Why do you study that?"

Me: *sigh* "Well you see, the experience of surgery back then wasn't quite the same as it is today..."

Imagine, if you will, that you are 20 years old.  One day, you begin to have sharp stomach pains.  They come and go so you ignore them.  5 years later the pain has progressed to the point that you’re bedridden and, worryingly, you’ve started urinating blood.  You have a kidney or bladder stone that needs to be removed.  Who would you trust to remove it?      
This was the slide I used when I tried to articulate the main points of my thesis for the Queen's 3MT competition in 2013.
When we think of surgeons certain comforting images come to mind: medical degrees and white lab coats; a scientific knowledge base and membership in a regulatory organization.  Samuel Pepys, the famed diarist who lived in seventeenth-century England, didn’t have these indicators of professionalism to guide his choice.   

Despite suffering almost constant pain from the age of 20, Pepys resisted surgical treatment for five years before agreeing to be cut for the stone by Thomas Hollier on 26 March, 1658.  His worries about surgery were not unfounded; lithotomy was a frequently performed but sometimes deadly operation during the early modern era.  There were a multitude of potential complications: without anaesthetic the patient could go into shock, an unskilled surgeon could damage the surrounding tissue and organs, and unsterilized instruments or surroundings could lead to infections and even sepsis.  

16th & 17th century surgical tools.  The top two instruments would have been used in Pepys's surgery. (L) lithotomy dilator and (R) double-bladed bistoury.
In preparation for the surgery, Hollier bled and purged Pepys over several days, and placed warm compresses on the area of incision.  On the day of the surgery itself, he was bound, made to inhale a mixture of opiates and mandrake, a probe was inserted through the urethra and into the bladder to anchor the stone, a 3” incision was made at the side of the perineum, forceps were inserted and the kidney stone – described as tennis ball size – was extracted.   

Closer look at the bistoury.
Pepys’ surgical procedure did not end at suturing.   

In fact, the wound was not stitched at all; rather it was washed and dressed with a mixture of vinegar, egg yolks, various oils and left to heal by scar formation.  After enduring such an invasive operation, he was then subjected to further bleeding, purging, and various topical and oral medicines.   

Pepys was so pleased at the result that he created a display case for the stone – which he would bring out at dinner parties – celebrated the anniversary of the operation, and continued to employ the surgeon throughout his life to treat both himself and his wife.  It would be fair to say, I think, that – though a surgical practitioner – Hollier became something of a family physician to the Pepys family.[1]

Though ultimately successful, Pepys’ surgical experience sounds horrific.  He had little anesthesia; to prevent him from thrashing around in pain, his hands were bound to his knees and he was held in place by several strong young men.   

From: F. Tolet (trans. A. Lovell) A treatise of lithotomy: or, of the extraction of the stone out of the bladder (1683).
The actual operation took place in his cousin’s home, surrounded by family and friends – neither surgical instruments or surroundings were sterilized.  The lack of stitches left the incision open for infection and meant that it did not fully heal for months and it in fact reopened a few years before his death.  Moreover, it seems likely that inaccurate cutting on Hollier’s part may have been responsible for Pepys’ sterility; he and his wife Elizabeth tried unsuccessfully to conceive for years. 

I’d like to reiterate that this was an overwhelmingly successful operation; despite a plethora of risks, the patient survived. 

This being my solemn feast for my cutting of the stone, it being now, blessed be God! this day six years since the time; and I bless God I do in all respects find myself free from that disease or any signs of it, more than that upon the least cold I continue to have pain in making water, by gathering of wind and growing costive, till which be removed I am at no ease, but without that I am very well.
                                                                                               - Samuel Pepys, Diary, 26 March 1664

From the age of 20, Pepys’ symptoms were severe.  He was in constant pain which increased in colder weather, was occasionally bedridden, unable to urinate while standing, and he frequently noted bloody urine.  At 22, he married the 14 year old Elizabeth who, despite her sincere attempts, was unable to nurse him back to health.  A further three years passed before Pepys made the decision to pursue surgical intervention.   

Given the sheer amount of time and the physical suffering he endured, it is safe to say that Pepys did not make the decision lightly.  

What prompted Pepys to seek a surgeon and consent to a potentially deadly operation?  Was it just pure desperation?

At the end of the day, patients willing to undergo surgical operations had to overcome a basic visceral fear and place their trust in an individual who was part of an oft maligned occupation.  

Pepys, though fascinating, was not the only 17th century person to grapple with the cost-benefit analysis of suffering from illness vs suffering under the surgeon's knife.

I've been researching 17th century surgery & surgical practitioners since 2006.  I've read countless surgical treatises, commonplace books, diaries, guild documents, wills, prayers, correspondence, ballads, novels, & casebooks.  I can honestly say that given Pepys's circumstance, I still don't know what choice I would have made.

Suffer with the stone or suffer the surgeon's knife?  What would you choose?  Let me know here or on Twitter - I'm @medhistorian

***Check out John Yamamoto-Wilson on "necessary" suffering here.

[1] For more on this see Claire Tomalin’s excellent biography Samuel Pepys: The Unequalled Self  (2003); Arthur Bryant, Samuel Pepys, The Years of Peril, (London: Cambridge University Press, 1935), Appendix, 311; Sir Eric Riches, “Samuel Pepys and his stones,” Annals of the Royal College of Surgeons of England 59 (1977), 11-16; GCR Morris, “A Portrait of Thomas Hollier, Pepys’ Surgeon,” Annals of the Royal College of Surgeons of England 61 (1979), 224-229.

Monday, 3 March 2014

Excrementious Matters

I attracted my very first internet troll on Twitter a few weeks back and very proudly announced it to my friends.  One of them, quite familiar with the rather strange medical stuff I tend to (over)share (sometimes over dinner) suggested that my troll may have been attracted by my scatological posts.[1]  Now, until then, I hadn’t realized that I’d told and retold so many medical history poop stories to my friends.    

Now, internet world, you too will have the opportunity to see what it’s like to be the friend of an early modern medical historian with a questionable sense of humour.

I shared the first of these on Twitter recently.  I’m including it here again because it’s kind of awesome.

1.      What’s Old is New Again

The Pearle of Practise (1594) is simply amazing and features some of the most fascinating medical receipts I’ve ever had to pleasure to read. 

Indeed, one of my fondest research moments was the recent rediscovery of my notes on the treatise that read: “random stuff about hens for belly etc.; 80 of eels for deafness, glue, ulcer; barbills to vomit and purge and bees for baldness; 81 frogs for legs and children and heat in blood and centumpedes for stitch in side and crickets to pee.”[2]

The work was collected and printed by James Fourestier, a physician and clergyman who was twice examined by the College of Physicians and deemed wanting.  Indeed, the College thought his medical knowledge “absurd and inadequate.”  Fourestier wrote the book as a thinly veiled advertisement for his sale of John Hester’s (a deceased distiller) medical formulations.

One of the many medical treatments that caught my attention years ago is found on the bottom left of page 44 here and states that “Diuerse Souldiars in the warres haue beene cured thereof [of diarrhea/the flux], by setting their fundament in warme Horse dung.”

Now, I’m sure many of you have seen this condensed medical history timeline that starts at 2000 B.C. with “here eat this root,” cycles through prayers, potions, snake oil, pills, and antibiotics and then in 2000 A.D. declares “that antibiotic is artificial, here, eat this root!” 

There’s a “medicine is culturally constructed” statement in there that’s very important, but that’s a blog entry for another time.  For now, I want to focus in on some gorgeous juxtaposition. 

Have you heard of fecal transplants?  Because we do that now.  It took 400+ years, but we’ve refined the idea expressed by Hester/Fourestier here.  Rather than “like curing like” in the Paracelsian way, we have the repopulation of healthy bacteria through enemas.

There seems to be some problems deciding how to regulate fecal transplants.  This is discussed here and on this advocacy site.

2. To Cure Shingles

A dear friend of mine recently had a painful bout of shingles.  If only I had this cure months ago!  Though, how/where could we collect the dove’s excrement here euphemistically referred to as “dirte”? 

One wonders if the combination somehow soothed the burning pain of shingles.  The author, Thomas Dawson, here promises that a bout of the shingles would be cured within 3 plaisters or over the course of 9 days.  To put that into perspective, an outbreak of shingles lasts generally from 3-5 weeks and can be shortened with antiviral medicines, steroids etc.

For the shingles a remedie.

Take Doues dirte that is moystye, and of Barly meale heaped halfe a pound, and stamp these well together, and do therto halfe a pinte of vineger, and meddle them together, and so laye it to the sore colde, laye wall leaues thereupon, and so let it lye three dayes vnremoued, and on the third day if neede require, laye thereto a new plaister of the same, and at the most he shalbe whole within three plaisters.

3. A Poor Man’s Cure?

Richard Hawes’s The Poore-Mans Plasterbox (1634) was meant – at first glance – to provide low cost medical advice to the poor who could afford neither a physician, nor a surgeon.  Despite the title, however, Hawes included some recipes that seem a bit pricy and made some distinction between those with bruises who could & could not afford “a bed to sweat in.”  Pictured is his description of a truly horrific cure (A Good Remedy for a Poore Man, pg 10).

Hawes himself, at least, recognized that this was a terrible option and stated “this is so good meanes as may be used, but it is neither cleanly, nor chargeable.”

4. Didn’t Anyone Think of the Smell?

Well, yes.  In interesting ways.  Andrew Boorde’s 1550 treatise on how to set up one’s home stated that “no fylthe nor dunge be within the courte, nor cast at the backesyde, but the dunge to be caryed far from the mansion.” 

Alright, so living near excrement was unhealthy and noisome but it was an important medical treatment.

William Salmon, a renowned 17th century quack doctor, related the story of a woman who gained a fortune by this panacea:

Fresh Cows-dung gathered in the morning, lb xij. Spring or River-water lb xxx. mix and digest twenty four hours; let it settle, and then decant the clear brown Tincture.

How to use cow dung water topically.  Just in cases you needed to know.
Unlike the topical remedy  prescribed above, the tincture Salmon mentioned was meant to be ingested.

Interestingly, Salmon went on to explain that the tincture was not at all malodorous and repulsive because:

By reason it is extracted from Cows-dung, it has a pretty kind of sweet scent, as if it was perfumed with Musk, or some other odoriferous thing.

As a late 17th century popular medical treatise stated:

A turf of fresh earth often smelt to; or to receive much the sent of Cow-dung is good and necessary for hot blooded people.

5. A Necessary Part of One’s Beauty Regimen

Forget shaving.  Or waxing.  Or plucking.  Or any of that stuff.  Do you have a cat?  You should get a cat.  And something that lays a lot of eggs.

Take the shells of fifty two Eggs, beat them small, and still them with a good fire, and with the water anoint your self where you would have the hair off: Or else Cats Dung that is hard and dryed, beaten to powder and tempered with string Vinegar, and anointed on the place. 

BONUS: Wellcome MS MS.7073/78 is a collection of medical receipts & directions by Caleb Lowdham, an Exeter surgeon.  Here's his take on the "juice of horse dung" as a panacea. Taken from the digitized Wellcome collection.

If anyone is brave enough to try any of these recipes (not that I advise it), please do let me know here or on Twitter.  I'm @medhistorian

[1] To date, I may have shared a maximum of 2 medical history poop stories via Twitter :P
[2] I have no idea what my undergraduate self thought as she scribbled that down, likely tucked away in the old history of medicine section at Mac’s Health Sci library.  

Works Cited:

Anonymous. Kitchin-Physick.  London: Dorman Newman, 1676.

Boorde, Andrew.  The Boke for to Lerne A Man to Be Wyse. London, 1550.

Dawson, Thomas. The Good Husvvifes Iewell. London: Edward White, 1596.

Hawes, Richard. The Poore-Mans Plasterbox.  London: Thomas Cotes, 1634.

Hester, John.  The pearle of practice. London: Richard Field, 1594.

J.W. A Choice Manual. London: R. Norton, 1653.

M.W. The Queen’s Cabinet Opened.  London, Obadiah Blagrave, 1679.

Salmon, William.  PharmacopÅ“ia Bateana. London: S. Smith, 1700.