Annals of the Royal College of Suirgeons of England (I977) vol 59

Samuel Pepys and his stones

Sir Eric Richles MC MS FRCSHonorary Curator of Ilistorical Surgical Instruments, Royal College of Surgeons ofEngland. Past Treasurer of Christ's Hospital

IntroductionIn the early hours of Wednesday 26th May1703 Sainuel Pepys died at Clapham. Hisdeath was reported to his friend John Evelynby John Jackson, his nephew, who advised anautopsy. This revealed a nest of seven stonesin the left kidney, irregular in shape, weigh-ing 42'oz; they were linked together and thekidney was entirely ulcerated and adherent.

I begin with his death rather than his birthto show that as well as functional symptomshe had organic calculous pyelonephritis.Recently Newman' aptly called the functionalsymptonis 'the wind of colic'. They includedthe oft-repeatedl distension and constipation ofmulcous colitis, all made worse by anxiety andimproved by relief after a successful operation,or on its anniversary, or by the magicalproperties of a hare's foot, especially if itincluded a joint as advised by Benjamin Bat-ten on 2oth January I665. Pepys was buriedin a vault of his own making near his wifeand his brother Thomas at St Olave's Church.

Samuel Pepys, the son of a tailor, was bornon 23rd February I633 at Salisbury Court nearSt Bride's Church in the City of London. Hecame from an East Anglian family from whomthe Pepys of Norfolk descended. He spent hisyouth partly in North London at Kingslandand partly in the country at Brampton inHuntingdonshire. He went to HuntingdonGrammar School and from i646 to I650 toSt Paul's Sch(ool, wvhere he received a classicaleduication and won a Spendluffe Scholarship atMagdalene College, Cambridge.

In I653, when he was 2o and still at Cam-bridge, he had the first symptoms of stone inthe urinary tract. After a long walk to Barn-well Abbey on a hot summer day he and hisfriends slaked their thirst at Aristotle's WellWith great draughts of cold vater. On returnhe was seized writh the violent pain of renalcolic and lay for sorme days in agony7; the

enlightened lay opinion' was that the 'her-editary' stone hitherto lodged in his kidneyswas carried into the bladder. Pepys himselfattributed it to the weight of water he haddrunk; it was attended by haematuria. Herecovered and on leaving Cambridge hadacquired a wide circle of friends, a taste forbeer, and a BA. He was offered employmentby his cousin, Sir Edward Montagu, and inI655, at the age of 22, he fell deeply in loveand married Elizabeth de St Michel, a FrenchHuguenot who was only I5.He soon began to have increasing symptoms

of stone. In East Anglia stone in the bladderin children and ycoung people was common.They all had a similar diet and lived in thesame environment; his mother, his brother,and his aunt had stone. On 24th August i 66o'he found his Mother was not very well andgave her a pint of sack'. Notwithstanding thissensible treatment her pain became greater andgreater and on 5th December she had justnevly voided a stone which she had dropperAinto the fire; she found it again toi show tohim. She recovered wvell and lived for sixyears. His brother John also had the symptomsand 'makes bloody water with great pain, itbeginning juist as mine did. I pray God helphim'. Hi_.Autnt Jane at Brampton 'voided agreat stone, the first time that ever I heardshe was trouibled therewith'.

Aetiology and siteIn the case of Pepys himself his first stonewas formed in the left kidney. There vw as,however, a high incidence of primary vesicalcalculus in children wvhich inpired the Norwichschool of lithotomv described bv Batty Shaw'.Bladder stone was endemic in Norfolk and inthe surrounding countrvside. Suggestedcauses wNere the cold north-east vinds, thechialk subsoil with resultant hard water, andthe inadequiate supply of milk contrasted vith

Paper read to the Section of the Ilistory of Medicine of the Royal Society of Medicine on3rd March T976. Published by lpemission of the Fditor of the Proceedings of the RoyalSociety of Medcine.

12 Sir Eric Riches

the abundant amount of beer, made fromnative barley. The standard of living of thefarm workers was low; the average diet wasdeficient in cheese, meat, protein, and vege-tables and contained too much cereal. WilliamEngland4 believed that a defective diet wasthe main cause, but by I949 Ridley Thomas5found that primary bladder stones in youthhad vanished between the years i 910 andI930. This coincided with the change fromgrain-producing to mixed farming. Andersen6discounts a lack of vitamin A as a major causeof stones and believes that primary bladderstones are caused by a diet consisting almostexclusively of one cereal. He has shown percontra that stones in the upper urinary tracthave increased concomitantly with a rise inliving standards7.

Pepys lived well, certainly in comparisonwith the East Anglian farm labourers. Per-haps that is why his stones started in the kid-ney; he had them already at the age of 20,passed two, (after renal colic) when he was 32,and had them when he died at the age of 70.One that descended to the bladder was re-moved when he was 25. It did not preventhis taking a degree at Cambridge, working asa clerk in the Exchequer, and getting married.

Primary stones in the kidney, especiallywhen fixed, are more likely to remain 'silent'than those in the bladder, but they cause painin the back, Pepys's frequent complaint. Eithercan cause haematuria; a bladder stone moreoften causes pain on micturition or movement.Pepys evidently had symptoms from bothsources-chronic back pain from fixed renalstones and acute renal colic if a stone descendedthe ureter- as well -as the functional symptomsalready mentioned.

XTesical calculi coexisting with upper tractcalculi are surprisingly rare. Swift Joly' foundthat out of I 97 patients with stone in the upperurinary tract, only 6 (3.04%/O) had stones in thebladder as well. In a similar series of 564patients with stones in the upper tract I havefound only 29 (5.14%) with stones also in thebladder.

It seems probable that Pepys would fall intothis small category of those who have bothrenal and vesical stones; it was quite usual forhim to be unusual.

CompositionPrimary stones from the bladder were lamin-ated, the layers varying with the reaction ofthe urine. Two are illustrated. One from theMiddlesex Hospital Museum (Fig. i), removedby Mr Amott in I84I, came from a boy ofI5 who had had symptoms for 9 years. An-other (Fig. 2), from a boy of I4, was removedby lateral lithotomy under general anaesthesiaby Mr Henry Mitchell in i8589; it was largerand adherent and slipped from the forceps atthe first attempt. Each has a nucleus of uricacid or ammonium urate with layers of calciumoxalate, uric acid, and calcium phosphate.These are the endemic primary bladder stonesof East Anglia in the 17th century. J GCrosse'0, a Norfolk surgeon, reported that55% of bladder stones affected patients underthe age of 20.The picture has now changed; today bladder

stone more often affects older patients and isassociated with outflow obstruction or in-fection or occasionally a foreign body or a para-thyroid adenoma.

Pepys's symptomsAlthough Pepys did not start his Diary untilhe was 27 (ist January i66o), nearly two yearsafter he had been cut for the stone, he left arecord, written in I677 when he was 4511, ofthe symptoms which made an operation essen-

FIG. I Vesical calculus from a boy of 15 re-moved by perineal lithotomy by Mr J MArnott in I84I. About the size of the ball usedin real tennis as played by Charles II.

......... ........ .. ..... . - - 1

FIG. 2 Vesical calculus from a boy of I4 re-

moved by lateral lithotomy by Mr HenryMitchell in I858. About the size of a modernlawn tennis ball.

tial. He wrote, 'I remember not my life with-out the pain of the stone in the kidneys (evento the making of bloody water upon extra-ordinary motion)'. From the age of 20 thebladder stone gave a constant succession offits of pain till the age of 25. When theweather was very cold he had to pass urinepainfully and frequently and the blood in italarmed him. He knew that although theoperation was common, it was dangerous andpainful, and he accepted the decision. He was

only a small man but he had great courage

and bravely faced the dangers and the pain oflithotomy. In default of an anaesthetic a

sponge soaked in a complicated mixture ofopiates and mandragora was given to thepatient to inhale"2. Speed in operating wasessential.

Operations in vogue in I658I will tabulate those operations I described tothe Section of Urology of the Royal Society ofMedicine 4I years ago".

Perineal approach Various types ofperineal lithotomy preceded the suprapubicoperation.The lesser operation of Celsus had been used

for about i6 centuries. It was intended forchildren and required only two instruments,

Samuel Pepys and his stones 13

a knife and a hook.The greater or Marian operation (1522) was

used for Pepys. I will give the details but mustfirst say that it was improved by PierreFranco, who incised the bladder neck insteadof tearing it as advised by Pare"4 and oftenmade it a two-stage procedure. This operationremained in vogue until nearly the end of theI7th century. Many of the self-taught itiner-ant lithotomists used it".

Lateral lithotomy replaced the Marianoperation. Frere Jacques learnt the techniquefrom Pauloni. After one successful operationhe was allowed to operate in Paris. Crowdsof up to 200 came to watch him; tickets wereissued and guards posted. His mortality washigh (40%) so he had to leave Paris andlearn some anatomy. It was left to Cheseldenof St Thomas's in I7I8 to perfect it; he wasborn too late to, operate on Pepys, whoselithotomy preceded Cheselden's appointmentby 6o years.

Suprapubic lithotomy This, 'the highoperation', was first performed 'faute demieux' by Pierre Franco in i 56 on a childof two and used by John Douglas in 1 7 I9 andby Cheselden in 172316.

Perineal lithotomy has become a rareoperation. Cheselden was said always to turnpale when about to cut for the stone andCharles Bell also blanched"7.

Pepys's lithotomyThe lithotomist chosen for Pepys was ThomasHollyer, of St Thomas's, where he was 'surgeonfor scald heads' in I638. He married a nieceof Edward Molins, lithotomist at St Bartholo-mew's, and succeeded him'8. His son, Thomasjunior, became lithotomist at Bart's as wellas St Thomas's in association with JamesMolins. Lithotomists were jealous of theirprivileo-es but still flourished as surgeons untili 86q'", 20Thomas Hollyer (I 6oq-70) was described

by John Ward (1647-73)21 as the great surgeonwho had been a poor boy in Coventry, wherehis father was a cobbler or at best a poor shoe-maker. He was by all accounts a skilful stonecutter; he had been a pupil of Edward Molinsand he called in James Molins as a consultant.Hollyer had cut 40 patients in one year and all

14 Sir Eric Riches

FIG. 3 Instrutments used in the operation bythe Apparatus Major. From above: groovedstaff, lithotome, gorget, conductors, crow's-beak forceps, duck-bill forceps, Pare's dilator(aperiens), button, scoop. (Reprinted from theAnnals of the Royal College of Surgeons21.)

recovered, but the next four all died. Onehad a ragged stone, difficult and dangerous toremove; for the rest it has been assumed thathis instruments, which were never sterilized22,had become septic.The operation took place on 26th March

I658 at Salisbury Court, the home of Pepys'scousin Jane Turner; only wealthy patientscould afford to go into hospital. Dr Molinsprescribed elaborate preoperative medicationcontaining mandragora which appears to havebeen effective. Pepys's relations and friendswere present, as was the custom. Preparationa few days earlier was by purging, bleeding,and fomentation to the perineum. He was

placed on the table with his buttocks raised,his legs flexed, and the hands bound to theknees. Immobilization of the limbs was furtherensured by four strong men.A typical set of lithotomy instruments is

shown in Figure 3. A curved probe or bougiewith a slit on its left side was thrust throughthe urethra and into the bladder23. Thescrotum was lifted by an assistant to, leave theleft side of the perineum exposed. A cut wasmade on to the slit in the probe, no largerthan the thumb, avoiding the seam of theperineum and the anal orifice. The gorget wasinserted into the opened urethra and thechannel kept open with the pair of conductorsor guiders. The staff was withdrawn. Thevoracious and vociferous crows-beak or duck-bill forceps were passed into the bladder tosearch for the stone. If the opening was toosmall Pare's dilator was inserted and openeduntil the forceps with the stone could be with-drawn21. It was examined for cracks or facets;any blood clot or fragments were removedand no pieces left behind. Other forceps wereavailable-for example, Pare's and AstonKeys'. A very large stone could be crushedby heavy forceps (Brodie type) and removedpiecemeal.

Pepys's operation was a success. The stone,as big as a tennis ball25, was complete andintact. The wound healed but reopened 40years later, three years before his death. Pepyshad a case made for the stone so, that he couldshow it to encourage others similarly afflicted;it cost him 24 shillings.The personal experience of another patient

has also been described2". He was an intelligentman who had many of the same symptoms asPepys; they began in i8oi when he was 23and became worse in stages, including oneof constipation and flatulence. By I 8 i i hehad pain, difficulty, chordee, and haematuriaand finally could pass urine only on his kneeswith his head on the bed. A doctor attemptedto sound him but failed; the patient the;nseized the bougie and passed it himself, hit-ting the stone. Cline did the Marian operationfor him in 1812 with no general anaesthetic.He did not wince at the incision; the bougiegave him his first real pain and it was relievedwhen the bladder was opened; the forcepscaused considerable pain. He heard Cline say,

Samuel Pepys and his stones I5

'I have got it', and withdrawal producedindescribable pain because the bladder em-

braced the stone firmly. He found the opera-tion less painful than some of his previoussymptoms. Eighteen months later, after leftrenal pain, he passed a small stone on threeoccasions.

RecoveryPepys was lucky to recover from such anoperation with no complications. He was sosatisfied with the result that he kept itsanniversary on 26th March as a regularfestival. In less than two years he was at seaand 'was in as good health as ever in hislife'. This was his invariable report on theanniversary, but details of his functional com-

plaints in between times are not lacking.Four years after the operation (26th March

I662), being again by God's mercy in verygood health, he gave a dinner party followedby a musical afternoon. To save his guests fromthe chores he had a man-cook to dress thedinner and Jane to help with the washing up.

In October i66i he had an attack of acuteleft epididymo-orchitis which kept him offwork for four days. The old pain returned ifhe sat too long bare-legged to pare his corns.It continued intermittently throughout I662and I663. Hollyer agreed that it was due toconstipation and assured him that it was

nothing to do with the stone. Pepys spentseveral days in bed but was able to go to a

very fine lecture at Barber-Surgeons Hall on

the kidneys, ureters, etc. and to see the speci-mens on which it was based. His thirst forknowledge was insatiable. At home he couldplay a little music, read, teach his wife'arithmetique', and eat a very good meal 'asmuch as he used to do'. Hollyer's enema of a

pint of strong ale, 4 oz of sugar, and 2 oz ofbutter produced excellent results. He told himthat all the slime in his urine was a good signand showed there was no fear of the stone.Pepys ended I 663 on a subdued note and I 664continued on the same lines.

In May an attack produced most extra-ordinary anguish, crying, and roaring, but on

getting by chance on his knees in bed itstopped within an hour and he slept well.Hollyer now thought that the stone had re-

curred and brought something to try and dis-solve it.

It would seem likely that during this periodof recurrent pain a stone was passing downthe left ureter but getting arrested from timeto time. His lumbar pain was persistent andhe was very worried, as was his father27. Hisnew general practitioner, Dr Burnett, said hehad an ulcer in the kidney.

i665 was an eventful year. In January theorchitis recurred and the severe pain in theleft testicle ran up presently into the leftkidney and kept aching all night. On thenext day, 7th March, the pain became sosevere that he had to go home at noon. Inbed it began to abate. Anon he rose to passwater and out came two stones, with no pain.Later he passed water again very freely andplentifully.

This was the ultimate stage of the leftureteric colic; the ureter was unblocked, thestones entered the bladder, and were smallenough to be passed.

His annual report for I665 was excellent.Despite the hard winter he never had a fit ofcolic. He again gave the credit to the hare'sfoot; he had now bought a hare in order toget the whole foot with the joint in it, whichhe was told would be more effective.He still thought that the severe ureteric colic

was due to the 'bruise' of the testicle and hadno association with the passage of the twosmal stones.He began to take a new interest in life and

in his lady friends. He still had wind, whichwas worse if he ate alone, when he ate toomuch and too quickly. On a cold morning hedrank a cup of good drink which, he said,'I am fain to allow myself during this plaguetime, my physician being dead and surgeonout of the way whose advice I am obliged totake'. He commented now that overfastinghad filled him with wind, mightily, and nothingelse had done it.The main event of i666 was the Fire of

London. It extended from Pudding Lane toPye Corner, fortunately stopping short ofSeething Lane. Pepys was anxious and busybut free from urinary symptoms.The eleventh surgical anniversary was the

last one recorded in the Diary; his sight wasfailing. He continued his self-imposed workfor the Royal Mathematical School of Christ'sHospital and produced a 'short reflection' of

i6 Sir Eric Riches

62 pages.My time is up. I too must forbear and be

contented to set down no more than is fit foryou and all the world to know. I cannot re-frain from giving you a final message of goodwill, which I am sure would have beenmightily approved of by Samuel Pepys.

ReferencesI Newman, C E (1976) Records of the Osler Club,

26th February.2 Bryant, A (I933) Samuel Pepys, The Man in theMaking, London, Cambridge University Press.

3 Shaw, A B (1970) Medical History, I4, 22I.4 England, W (I830) Observations on the Func-

tional Disorders of the Kidneys. London andNorwich.

5 Thomas, J M R (I949) British Journal of Urology,2I, 20.

6 Andersen, D A (I962) British Journal ofUrology, 34, i6o.

7 Andersen, D A (I968) In Renal Stone ResearchSymposium, p 7. London, Churchill.

8 Joly, J S (1929) In Stone and Calculous Disease ofthe Urinary Organs, p 429. London, Heinemann.

9 Mitchell, H (i 858) Transactions of the Patho-logical Society, 9, 342.

io Crosse, J G (I846) Report of the FourteenthAnniversary Meeting of the Provincial Medicaland Surgical Association held at Norwich.Worcester.

ii Bryant, A (I935) Samuel Pepys, The Years ofPeril. Appendix, p 3"I. London, CambridgeUniversity Press.

I2 Garrison, F H (I921) Introduction to the Historyof Medicine, 3rd ed. Philadelphia and London,Saunders.

I3 Riches, E W (I935) British Journal of Urology,7, I 40.

14 Keynes, G (ed.) (I95i) Ambroise Pari's Apologieand Treatise, p I89. London, Falcon EducationalBooks.

I5 Desnos, E (I 9I4) Encyclope'die fran aised'Urologie, vol. i, p i.

i6 Cheselden, W (1723) A Treatise on the HighOperation for the Stone. London.

17 Miles, A (I9I8) The Edinburgh School of Surgerybefore Lister. London, Black.

i8 Moore, N (I9I8) The History of St Bartholo-new's Hospital, vol. 2. London, Pearson.

I9 Parsons, F C (I934) History of St Thomas'sHospital, vol. 2, p 30. London, Methuen.

20 McInnes, E M (i963) History of St Thomas'sHospital. London, Allen and Unwin.

2I Ward, J (I647-I673) Diary, transcribed by theMedical Society of London, vol. I, pp I-280;vol. 2, p 5o6.

22 Power, d'A (I 930-3 i) British Journal ofSurgery, i8, i, i85, 353, 541.

23 Riches, E WV (I968) Annals of the Royal Collegeof Surgeons of England, 43, I85.

24 Tolet, F (I708) Traite' de la Lithotomie. Paris.25 Evelyn, J (I952) Diary, vol. 2, p 42, ioth June

I669. London, Dent.26 Marcet, A (I8I9) Medical and Chirurgical Trans-

actions, io, I, 147.27 Heathe, H T (I955) The Letters of Samuel

Pepys and his Family Circle, letters 7 and I64.Oxford, Clarendon Press.