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July 29, 2014

‘And so to bed…’

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January 2010 being the 350th anniversary of Samuel Pepys’s commencement of his famous diary, University of Limerick’s Prof Pierce Grace examines some of the book’s many medical references


January 16, 1664/65: He being gone, I by water to Westminster-hall and there did see Mrs Lane, and de la, elle and I to a cabaret at the Cloche in the street du roy; and there, after some caresses, je l’ay foutee sous de la chaise deux times [I gave it to her twice under the chair], and the last to my great pleasure: mais j’ai grand peur que je l’ay fait faire aussi elle meme [I was very afraid that I had undone her too?].
Mais after I had done, elle commencait parler [continued to talk] as before and I did perceive that je n’avais fait rein de danger a elle [I had nothing to fear from her]. Et avec ca, I came away; and though I did make grand promises a la contraire, nonobstant je ne la verrai pas long time [I don’t expect to see her for a long time?].….
So home to bed-with my mind un peu trouble pour ce que j’ai fait today [my mind a little troubled by what I’ve done today]. But I hope it will be la derniere de toute ma vie [the last time in my life].

Three hundred and fifty years ago on January 1, 1660 a young man began to keep a personal diary of his daily activities. That he did not want his contemporaries to read it is given by the fact that he wrote it in a shorthand code. But that he did want posterity to read it is apparent in that he bequeathed the bound diaries with the rest of his considerable library, including a book explaining the code, to Cambridge University.
The diary languished untouched until 1819 when the recent commercial success of the publication of John Evelyn’s (1620-1706) diary moved the University to have it translated by an impoverished undergraduate, John Smith, for £200.
The diary of Samuel Pepys would become much more famous than Evelyn’s chronicle although they covered the same period and the two diarists corresponded frequently.
The first translation of Samuel Pepys’s diary appeared in 1825 in a shortened version and then in new and revised editions in the 1870s and 1890s, respectively.
The Victorians were so shocked at what they found that it had to wait another 100 years before Latham and Matthews published the unexpurgated version in 11 volumes between 1970 and 1983.
The diary is currently being published on the web with a new entry appearing every day at: www.peypsdiary.com.
Samuel Peyps was born in 1633 of humble parents. His father was a tailor and his mother had been a washerwoman before marriage. However, Samuel had powerful relatives, one of whom became Lord Chief Justice of Ireland and another, Edward Montagu, who would become his patron.
Pepys was a great survivor. In his youth he was an enthusiastic republican and admirer of Oliver Cromwell. He witnessed the execution in Whitehall of Charles I on a cold January day in 1649.
After obtaining a Bachelor of Arts degree from Cambridge he worked as a clerk for two powerful members of the Commonwealth administration, George Downing (from whom we have the name Downing Street) and Edward Montagu. The latter’s star would rise and Pepys with him.
A royalist
After Oliver Cromwell’s death in 1658, his son Richard, a junta of army officers, the ‘Rump’ Parliament, General Monck and Admiral Lawson all vied for power, while over the sea in the Low Countries the exiled Charles Stuart bided his time.
Montagu became General-at-Sea in command of the fleet and, having secretly negotiated with the Stuarts in the Netherlands, he returned Charles II to England in May 1660.
For his trouble he was created 1st Earl of Sandwich and a Knight of the Garter, and made second in command of the navy to the king’s brother, James, Duke of York. Pepys was with him as his secretary when he returned the king to England and was rewarded by appointment as Clerk of Acts to the Navy Board at a salary of £350 a year, together with a house.
Montagu was killed in the Anglo Dutch war in 1672 but thanks to his new royal patrons, Pepys’s career blossomed. He would eventually become ‘Secretary for the Affairs of the Admiralty of England’.
As such he was a very powerful official responsible for the day-to-day administration of the English navy at a salary of £2,000 per annum and ample opportunity to accept bribes.
He became an MP and President of the Royal Society; during his presidency Newton’s Principia Mathematica was published. He finally fell from grace when he refused to swear the oath of allegiance to William and Mary when his patron, James Stuart, now King James II, was overthrown in 1688.
Pepys was imprisoned twice but defended himself successfully against charges of Jacobitism and retired from public life aged 57.
He died a rich man in 1703 and left his library of 3,000 books, including the coded diaries, to his alma mater, Magdalene College, Cambridge.
Restoration
Charles II’s court was one of the most licentious in the history of England. John Wilmot, 2nd Earl of Rochester (also Viscount Athlone), personified life at court and captured its style in his bawdy Restoration poetry and plays. He abducted an heiress whom he subsequently married and is said to have died from a combination of syphilis, gonorrhea and alcohol.
While Charles was willing to forgive most of the Puritans, those who had signed the death warrant of his father were ruthlessly dealt with. Those alive were hunted down and hanged, drawn and quartered; those already dead, including Cromwell and Ireton, were dug up and had their heads cut off.
For the duration of the reign of Charles II, Cromwell’s head was exhibited on a spike at Westminster not far from where his statue now stands. It was eventually reburied 300 years later in 1960.
Nulla puella negat
What shocked the Victorians in Pepys’s dairy were the explicit descriptions of his extramarital sexual adventures. His diary was written in a code called Shelton’s Tachygraphy. This was a shorthand system devised by Thomas Shelton, which was easy to use and extremely popular, running to more than 20 editions between 1626 and 1710.
It was used by the Puritans to record sermons but Pepys used it for his diary. However, when Pepys wanted to record his sexual activity he resorted to inserting foreign words in French, Latin or Spanish. He started this in September 1660 when he made advances to Diana Crisp, his neighbour’s daughter.
He wrote: ‘…. whom I took into my house upstairs, and there did dally with her a great while and found that nulla puella negat’, meaning ‘the girl refused me nothing’. That he was prepared to accept sexual favours as a bribe for a husband’s career advancement is apparent in his relationship with Mrs Bagwell, the wife of a ship’s carpenter at Deptford, with whom he had regular sexual contact.
All of this sexual activity, and there is a lot of it, is described in the diary in a matter-of-fact manner, among the numerous other concerns of his life and work. For example, after nulla puella negat he wrote: “So home by water, and there sat up late setting my papers in order, and my money also, and teaching my wife her music lesson, in which I take great pleasure. So to bed.”
Pepys’s health
Pepys is famous for having described the Great Plague (1665), the Great Fire of London (1666) and war with the Dutch (1667), but from a medical point of view his diaries are interesting because of his concerns with his health.
His eyesight deteriorated in the late 1660s and this is the reason he gave for abandoning his diary in 1669. The diary finishes on the May 31, 1669 with: “for all the discomforts that will accompany my being blind, the good God prepare me!”
Of course, he didn’t go blind; Sir D’Arcy Power writing in the BMJ in 1933 observed: “he would have had no further anxiety if it had been possible to order him spectacles +2Dc. +0.5.D. cyl. axis 90o”.
However, the problems that afflicted him most were from urinary calculi, specifically bladder stone. Pepys’s brother and mother had stones but they had the good fortune to pass them spontaneously.
As a student Pepys was regularly afflicted with pain and haematuria from stone. It is hard to know whether the stone had formed de novo in the bladder or whether he passed a renal calculus into his bladder where it grew. Bladder stone was much commoner in previous centuries and its prevalence has decreased considerably in the past 100 years, probably because of improved diet, nutrition and infection control.
By the cold winter of 1657, Pepys’s symptoms were so bad (“constant and dangerous and most painful sickness”) that he made the drastic decision of considering a lithotomy.
Cutting for stone
Lithotomy was not to be undertaken lightly in the 17th century. Apart from being horribly painful, it was a very dangerous operation with mortality rates of between 15 and 50 per cent. ‘Cutting for stone’ was one of the oldest operations known to surgery; its history went back to ancient times and it was performed by specific practitioners known as ‘lithotomists’.
By the mid 17th century, the favoured approach was called the ‘Marian Operation’, after Marianus Sanctus who published a description of it in 1522; also called the ‘apparatus major’ because of the number of instruments to be employed.
The patient was placed on the edge of a table or chair with his legs in the air. He was tied down so that his legs were held in flexion and his arms secured.
Two or three assistants were usually required to hold the patient in this ‘lithotomy position’. A grooved staff was passed into the bladder along the urethra. A vertical incision was made in the midline through the perineum anterior to the anus onto the grooved staff.
Without anaesthesia
The wound was then dilated with instruments and finger, deepened through the prostate and bladder neck into the bladder. The stone was grasped with a stone holding forceps and pulled out through the wound, either whole or in bits. This was all done without the benefit of anaesthesia and alcohol was forbidden. Haemorrhage, infection, incontinence and impotence were frequent complications in those who survived the operation. The pain must have been horrific.
Pepys probably did his homework and chose his surgeon well. He consulted Thomas Hollier, lithotomist and surgeon to St Thomas’s Hospital, who in 1657 had performed 40 lithotomies without a death. They decided on March 26, 1658 for the operation.
His father encouraged family members to pray for a good outcome and his cousin Jane Turner gave him the use of her house for the surgery. Pepys was not keeping a diary at the time, but John Evelyn has left a vivid description of a lith-otomy, which he witnessed in Paris in 1650.
Bound armes and thighs to an high Chaire
“The sick creature was strip’d to his shirt, & bound armes & thighs to an high Chaire, 2 men holding his shoulders fast down: then the Chirurgion with a crooked Instrument prob’d til he hit on the stone, then without stirring the probe which had a small channel in it, for the Edge of the Lancet to run in, without wounding any other part, he made Incision thro the Scrotum about an Inch in length, then he put in his forefinger to get the stone as neere the orifice of the wound as he could, then with another Instrument like a Cranes neck he pull’d it out with incredible torture to the Patient, especially at his raking so unmercifully up & downe the bladder with a 3rd Instrument, to find any other Stones…The effusion of blood is greate…..The danger is feavor, & Gangreene, some Wounds never closing.”
Pepys and Hollier got away with it and by May 1 Pepys was well again. According to Evelyn, who saw it later, Pepys’s stone was the size of a tennis ball; however, he was referring to real tennis with balls equivalent to the size of a modern squash ball.
Pepys was so pleased at the outcome that he decided to celebrate with a dinner every year on the anniversary of his operation for the rest of his life. He also had a special case made for his stone at a cost of 25s. Hollier was not so lucky, his next four patients all died.
Tangier
Pepys would have further trouble with stones in his left kidney, which he tried to ward off by keeping a hare’s foot in his pocket.
When it failed to do its duty his colleague Sir William Batten explained to him that it was because Pepys’s hare’s foot did not have a joint in it. As soon as he handled Sir William’s hare’s foot, which did possess a joint, he felt immediately better.
He was also advised to drink only old Canary or Malaga wine. Pepys was sterile but not impotent, possibly the result of his operation. His wife Elizabeth died in 1669 after a holiday she and Pepys had in France.
Pepys was very hard working and loved his job at the Navy Board and became one of the best administrators the British Navy ever had.
He did keep another diary in 1683 for a few months when he was part of a naval expedition to evacuate the English colony at Tangier, which was proving too difficult to defend against the surrounding Moors.
The English had tried to have a base at Tangier for their fleet similar to what would eventually be established at Gibraltar in the next century.
Mary Skinner would become Pepys’s mistress and companion for the rest of his life, but they never married, although she was referred to as Mrs Pepys by many of their acquaintances.
Pepys did acknowledge her when he died in 1703, leaving her an annuity of £200 along with plate, pictures and other effects.
Gangrenous bladder
An autopsy performed by his friends, the physicians John Shadwell and Hans Sloane (from whom we get Sloane Square and drinking chocolate) and the surgeon, Charles Bernard, revealed a large inflamed left renal mass containing stones (could this have been xanthogranulomatous pyelonephritis?), a gangrenous bladder and a reopening of the old lithotomy wound.
He was buried at 9pm on June 4, 1703 at his own request near his wife, Elizabeth, in St Olave’s Church in the City of London.
The church was gutted in the London Blitz but Pepys was undisturbed.
Perhaps we should leave the last word to his friend John Evelyn: “This day dyed Mr Sam Pepys, a very worthy, Industrious and curious person…’ But then he didn’t know what we know.
Pierce A Grace, MCh, FRCS,
Professor of Surgical Science,
University of Limerick.