Pepys and the de Gaulle Stone

If you like rugged, sparse scenery, try Connemara in Co Galway. Reading a guide on a short visit, I found that General de Gaulle had visited many years before, and that there was a statue of him in a village to commemorate this. Almost inevitably, this was re-named the ‘de Gaulle Stone’, and there are several others elsewhere in Ireland.

An amusing pun, and I’d almost forgotten it until I came across a passing reference to Samuel Pepys’s operation for a gallbladder stone in another book. Pepys certainly had a stone in a bladder, and started his diary after recovering from the operation; he may have had gallstones, but he certainly did not have an operation for gallstones.

Gallstones form in a diseased gall bladder. This sits just below the liver in the upper right hand side of the belly. Gallstones are ubiquitous today, and for example, around half a million gall bladders are removed each year in the United States. Gall stones have been found in Egyptian mummies. It’s pointless to remove the gallstones, and leave the gall bladder — you just grow more gallstones.

The first recorded operations for gallstones and the removal of the gall bladder — a cholecystectomy — were in the latter part of the 19^th century. Not before. For this operation a large incision in the belly was necessary, and if the surgical shock of such a procedure, without anaesthesia, wouldn’t have killed Samuel, he would surely succumbed to peritonitis soon afterwards. Now you may say that Caesarean Sections were common enough, so that Pepys could well have had a cholecystectomy, another major abdominal operation. Wrong. The original Caesareans were done on dead women in a desperate attempt to save the unborn child, and the mythology records Julius to have been so delivered. Today, almost all women who have a C-section are alive.

So, we can be entirely certain that Pepys did not have an operation for gallstones. What stone did he have?

He might have had a kidney stone, or one that had passed into the ureter en route to the outside, and if he did, again he wouldn’t have had an operation for it.

He did have a stone in his bladder, the other bladder, the urinary bladder. And he underwent a lithotomy, the operation of ‘cutting for stone’, a very ancient procedure. There’s a reference to in in the Hippocratic Oath. If you are squeamish, I’d suggest you skip the next paragraph or two.

For a lithotomy, the patient had to be suitably prepared, with strong liquor and restraints, and be put into the lithotomy position; lying flat, the hips were flexed to about 90 degrees, as were the knees — the 90-90 position. The barber-surgeon was between the outspread legs. Using a broadish, flat knife the surgeon plunged the knife into the perineum, about half way between the anus and the scrotum. The incision was described as being on the left of the midline, implying that the surgeon was right-handed. The knife was carried upwards and forwards in a relatively avascular or bloodless plane between the rectum and the prostate and so into the bladder. Using his fingers, the surgeon removed the stone. This operation, in skilled hands, took less time to perform than it takes me to describe. As operations of the time went, it would have been one of the more frequently performed ones.

Despite the creation of this artificial passage between the bladder and the outside, the operation seems to have been generally successful, and the opening closed spontaneously. A lithotomy operation does not enter the peritoneal cavity.

There is one long-term complication of lithotomy, though. It didn’t always happen, but at least for Pepys the suggestion has been made that he ‘suffered’ from it — though for him, it would have been rather serendipitous. The seminal vesicles lie in the path of the knife, and were often damaged. The patient is sterilised, a vasectomy by another name.

A bladder stone, but not a gallbladder stone. And an unexpected bonus for Pepys.