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.

6 comments:

  1. Thank you for the references here, Samantha (and for the link to my musings!). When I went to Magdalene as an undergraduate in 1971 I had only the vaguest idea of who Pepys was, and no idea at all that he was the most famous Magdalenian and had bequeathed his library to the college. I've never made a special study of him, but he quite often crops up tangentially when I'm working on seventeenth-century stuff. I'd be interested to know of other accounts of surgery from that period...

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    1. You're very welcome, John! Pepys is rather tangential to the body of my work as well, but his story provides a introduction that I could not resist. Hmm...accounts of surgery are quite disparate & piecemeal. There's an older account in History Today about Prince Rupert's surgical operation for a head fracture (he was trepanned). Rupert went on to re-design surgical implements (see Royal Society papers).

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  2. Pepys’ history is really intriguing. I agree that it really takes an expert surgeon to make a successful operation. Especially during the time when all they had were manual medical instruments to perform the surgical procedure. In fact, Pepys’ operation could've been a successful one, if only they had been more attentive during the post-op period. This is the most crucial phase of the surgery, because this will show if the operation was successful or not.

    Kathy West @ Used Stryker

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    1. Thanks for the comment, Kathy! For the time period, Pepys's surgery was considered a success despite the post-op complications. It's quite fascinating how the definition of "success" in medical treatment has changed over the past few hundred years!

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