Gore blimey
We don’t know how lucky we are. The history of surgery is a bloody tale of ignorance and superstition, finds Mark Broatch.
The history of surgery is a bloody tale of ignorance and superstition.
Alan B Shepard was the first American to leave the planet. His Mercury spacecraft was in the atmosphere for only 15 minutes and 22 seconds, and he had already been pipped into space by Yuri Gagarin, the Soviet cosmonaut who had orbited the Earth for an hour just 23 days earlier.
But 37-year-old Shepard’s flight would lead to a much grander Russkibeating project – the journey to the moon. The Mercury flight led to Gemini, which led to Apollo, and six of the seven Mercury astronauts were involved in the missions that eventually took humans to our nearest neighbour, including John Glenn and the unfortunate Gus Grissom, who died in 1967 in a launch-pad fire.
Shepard’s dreams were also dealt a terrible blow. In 1963, he began to suffer from a form of Ménière’s disease – doctors call it idiopathic vestibular dysfunction but to you and me it’s an inner ear disorder with no readily identifiable cause. The symptoms were random attacks of dizziness and tinnitus followed by nausea so bad that Shepard would often throw up.
The only treatment then available, a diuretic medicine, didn’t work. So he was made head of astronaut training and gained a reputation for being permanently ill-tempered.
But a few years later, a fix was offered. A surgeon would drill a tiny hole in his head and insert a tube to drain excess fluid from his inner ear. It was a success. Shepard was reinstated as an astronaut in 1969. Two years later, he was commander of Apollo 14 and, at 47, the oldest astronaut to go the moon.
His job was to land the lunar module, a task that needed to be done standing up, so he could feel its minute wobbles using his own sense of balance. His landing was the most precise of all the Apollo missions.
A decade later, it was proven
You have to be desperate to take to your nether regions with a sharp knife, and Jan de Doot was desperate.
beyond any doubt that the operation Shepard had undergone was bogus. The therapeutic success of his endolymphatic shunt was found to have been entirely a placebo effect: he could have vomited into his suit and choked, or crashed the craft and killed all aboard, but he didn’t.
The operation had clearly convinced Shepard – and his bosses – that his illness was cured. “It can’t be anything else. The operation he got was exactly the same as tested in a randomised controlled trial that was proven to have a 100% placebo effect,” says Dutch surgeon Arnold van de Laar. “Of course, that’s not what Nasa wants to tell us.”
SURGEON’S-EYE VIEW
Van de Laar tells the story in the book Under the Knife, which revisits famous operations from a surgeon’s perspective. He drops in on the emergency room in Dallas after the 1963 shooting of President John Kennedy, marvels at Einstein’s cellophane-wrapped aneurysm, takes us from Queen Victoria’s chloroformed childbirth to Houdini’s fatal peritonitis, and from Lenin’s strokes to King Louis XVI’s circumcision by way of castrated singers and obscenely obese popes – and the man who cut out his own bladder stone.
You have to be pretty desperate to take to your nether regions with a sharp knife, and Dutch blacksmith Jan de Doot was a desperate man. He had suffered excruciating pain for years and had twice gone to a surgeon to be rid of the stone. The chance of dying in 17th-century Netherlands from just one such procedure – lithotomy – was 40%. And because the surgeons, evocatively called stonecutters, were ignorant con men who went in from below, most patients who survived became incontinent. I’ll spare you the details, but it involved several cuts from a knife he would have made himself, and the help of an apprentice to keep things out of the way. De Doot’s wife had been sent to the fish market. The stone was larger than a chicken’s egg, and doughty Jan survived for years.
Bladder stones are rare today, thanks to better personal and municipal hygiene, but they have dogged humans forever – stones have been found in mummified remains. They occur through repeated infections, when the accumulation of sedimented blood and pus grows like an onion at the exit of the bladder. “I think it would be such a terrible thing to have,” says van de Laar, 48, a gastrointestinal specialist in Amsterdam. “Every second of the day you feel like you have to pee immediately. And if that went on for maybe 15 years, you don’t have to be tough to take drastic measures. But of course, this guy, doing this thing, he was tough but also probably extremely stupid.” The moral of the story: change your underwear every day.
Under the Knife, which began life as a series of columns for a Dutch journal of surgery, makes it clear that it wasn’t neces- sarily the shot to the head that killed JFK, but suffocation and massive blood loss. When the gravely wounded President was brought into Parkland Memorial Hospital that warm November day with a large bullet wound to his head, he had a pulse but was unconscious and making slow, spasmodic movements.
He was barely breathing and a tube was inserted down his windpipe. As everyone knows, he didn’t survive, and an autopsy watched over by men in dark suits was conducted later that day in Washington DC.
X-rays showed no bullets in the body: both had passed through. The military pathologist, James Humes, couldn’t find the exit wound of the so-called magic bullet that was found to have also hit Governor John Connally in the front seat of Kennedy’s car. That’s because the surgeon on duty in Dallas, Malcolm Perry, who had been in the job for just two months, had widened the exit wound in Kennedy’s throat into a tracheotomy hole. That action by Perry, who, two days later, would try to save the dying Lee Harvey Oswald, and other events such as Jack Ruby’s shooting of Oswald and the disappearance of the President’s brain, created a swirl of conspiracy theories that will not settle even when every last file on the case is released.
From the point of view of a 21st-century surgeon, the actions of the President’s motorcade probably doomed Kennedy. “To me as a doctor, it’s very strange to see that he was not resuscitated on the spot but instead carried all the way to the hospital, which took about seven, eight minutes and probably caused him to suffocate,” says van de Laar.
That’s not common practice any more, and much else has changed in medicine in the past half-century. “If an American president was shot now, he would be put in an ambulance and immediately intubated.”
Van de Laar concedes that Kennedy, who had a massive head wound, would surely still have died, though he adds that people do survive such injuries, albeit with terrible brain damage. Did Oswald do it? He thinks
“If an American president was shot now, he would be put in an ambulance and immediately intubated.”
so. All the shots came from the same direction, the book depository. “Of course, I don’t know if it was Oswald standing there.”
BLOODY CHAOS
When we think of a medical operation today, we picture white rooms in which the silence is broken only by the reassuring beep of a heart monitor and the low murmur of conversation. Sterile caps and masks, gowns and gloves keep harmful bacteria far from the patient.
But surgery was once a noisy, bloody, chaotic enterprise that relied on speed, guesswork and superstition. Just 150 years ago, surgeons would wear a black coat when operating to camouflage the blood. Some would boast that their coats were so stiff with gore that they could stand on their own. Before the development of reliable anaesthesia, traumatically painful operations, such as amputations, were done quickly, not just to limit suffering but also to prevent the patient from twisting free of the doctor’s assistants (Scottish surgeon Robert Liston would call out before his operations, “Time me, gentlemen, time me!”). Mortality was high, patients often dying from infection, blood loss or shock.
The realisation in the 19th century that germs caused disease and simply washing your hands could save lives was vital for modern surgery, says van de Laar, who mainly does laparoscopic (keyhole) operations on the colon, including gastric bypasses on the obese. Other great medical advances he notes are anaesthesia, antibiotics, X-rays, laparoscopic surgery and the use of plaster casts to set bones correctly.
He would no doubt add the likes of modern imaging techniques (such as MRI, CT scans and ultrasound) and caesarean sections. But he says the biggest advance surgeons have made is “realising that you should do things only if there’s enough evidence and literature saying you should”.
Until the 1980s, and for some procedures until 1990, he says, operations were done because they had always been done; the results were not checked. Now, the evidence shows that many procedures, such as knee arthroscopies and even some cardiac surgery, are not necessary because medication or other options are available to treat the problem. Likewise, it was once thought that operations required the biggest cut a surgeon could make; now, incisions are ideally small and neat.
Practising evidence-based medicine often means waiting. Patients and their families don’t expect surgeons to do nothing, but waiting often provides the answer to the question of what treatment, if any, a person requires. Whether a problem is an infection, blockage, leak or tumour becomes clear.
But in the past, surgeons liked to be seen to be doing something. Bloodletting, for example, was done for centuries without any evidence that it worked. On the final day of his life, in 1799, George Washington was bled by his doctors of half his blood supply – an incredible 2.5 litres in 16 hours. Queen Caroline, the witty and charming wife of the dull George II, died in 1737 after being bled many times by her surgeon, John Ranby, whom even she called a “blockhead”. Caroline suffered from an umbilical hernia and, probably, a blocked intestine, a situation likely to have been made worse by several pregnancies and her incredible obesity (citizens could pay to watch the royal couple eat their meals on Sundays). Poor Caroline was in great pain for nearly a fortnight, but all Ranby could think of was cutting her to let the blood flow. Eventually he and other surgeons did try to operate, without anaesthetic, but it was too late and they had no idea what they were doing anyway.
BARBERS’ FRIENDS
Surgeons now are high-prestige, highly paid specialists, but it wasn’t always so. They were once so insignificant that in Amsterdam they shared a guild with barbers and makers of skates and clogs. From a little shop on the high street, when they weren’t bloodletting or burning off growths, they would tend to wounds, often with a branding iron or hot oil, drain pus from infections (everyone knew it was normal for pus to leak from a wound after surgery) and treat fractures – still some of the basics of the modern doctor, if in somewhat different surroundings. “Surgeons were often indifferent, naive, unclean, clumsy and bent only on money or fame,” van de Laar says.
By the 18th century, some knew a little
Surgery’s biggest advance is “realising that you should do things only if the evidence and literature say you should”.
science and anatomy, though their professional standards and attitudes to patients still left much to be desired. Anaesthesia’s emergence in the mid-19th century transformed surgery into a completely different profession, van de Laar says. Operations became precise, meticulous and dry. There was no noise, and tissue could be cut layer by layer, so limiting bleeding.
Anaesthesia may even have saved Queen Victoria’s marriage. It’s perhaps not widely known that Victoria and Prince Albert fought constantly and even came to blows, he says. A huge factor undoubtedly was the pain she endured during what she called the “animalistic” experience of giving birth (she also thought breastfeeding was disgusting and newborns ugly), followed inevitably by a year of postnatal depression. Along came a man called John Snow, who administered chloroform by way of drips to a handkerchief over her mouth, to the horror of other doctors and biblical scholars, who said women must suffer pain while giving birth. The Queen, however, was delighted, and again took chloroform for her ninth, and final, child.
BEING BIPEDAL
Our ancestors’ decision, some four million years ago, to stand upright was great for humans, but better still for surgeons. Varicose veins, groin hernias, piles, slipped discs, hip- and knee-joint wear and tear and heartburn all developed as a result of twolegged life, providing yet more evidence, if we needed it, against an intelligent designer.
“As a medical student you have your anatomy lessons and see these strange things,” says van de Laar: “The [kinked] course of an artery in your groin, or the groin hernia, or varicose veins because of the absence of valves in those veins.” Add to this modern society’s tanker-loads of sugary, calorific food, booze and tobacco, making us fat and hardening our arteries, and longer lifespans
“There is a great deal of tension involved in being a surgeon. Operating is a wonderful thing, but the responsibility weighs very heavily.”
ensuring there is time for swarms of cancers to grow, and surgeons are never idle.
Other surgeons have written of the supreme confidence of those in their profession. Van de Laar writes: “Are surgeons insane, brilliant or unscrupulous? Heroes or show-offs? There is a great deal of tension involved in being a surgeon. Operating is a wonderful thing, but the responsibility weighs very heavily.”
Most surgeons conceal that perpetual doubt behind an air of self-confidence. So they always seem omnipotent and untouchable. This is a front, he says, to allow them to bear the responsibility and keep the guilt at a distance.
“I know of only one other medical professional, the psychiatrist, who also has to put himself as part of the therapy to have it a success. Same with a surgeon. I have to literally put my hands in the patient for the treatment to be a success.”
Surgeons have to confront death in their practice, but far less often than their forebears. In 1800, for example, more than 40% of children would die in their first five years of life. In developed countries such as ours, that rate is now below 1%. Did people have to be tougher, given child and maternal mortality?
“Probably, yes. Death was always more present than nowadays. Children would die at a younger age. And when you were 35, 40 you were an old person.”
If van de Laar has a favourite operation, it’s probably the Nissen fundoplication. This is where the upper part of the stomach is wrapped and stitched completely around the bottom of the oesophagus to treat reflux disease. Rudolf Nissen was the one who wrapped Albert Einstein’s grapefruit-sized abdominal aortic aneurysm in cellophane and possibly gave him another seven years of life. Fundoplication is challenging but rewarding. “There’s a lot of improvement of quality of life for the patient.”
We are lucky to live when we do, he agrees, having so many options in medicine to cure and improve people’s quality of life. “Also, we’re lucky to live in a time when surgeons have some common sense.”
UNDER THE KNIFE: A HISTORY OF SURGERY IN 28 REMARKABLE OPERATIONS, by Arnold van de Laar (John Murray/Hachette, $37.99)