Blood and Guts

by Richard Hollingham

  I actually found the whole experience surprisingly restful. Having experienced it, I can see that if the surgeon and his patient both believed in its benefits, then being leeched could have a powerful placebo effect. Unfortunately, it was a treatment with potentially serious side effects; some surgeons managed to bleed their patients to death. Examples include George Washington, who in December 1799 got a cold while out horse-riding. He died after his doctor repeatedly bled him, extracting in total around five pints of blood. I decided to stick to just the one leech, and took it home as a family pet.

  My next experiment concerned pain. I wondered if any of the pain-relief treatments available to surgeons prior to the discovery of ether as an anaesthetic in 1846 would have been effective. So I went to a pub to find out.

  First, I had myself hypnotized, then I tried sticking a needle through the web of my hand. It really hurt. Next I drank five double vodkas on an empty stomach and tried piercing my hand again. I felt supremely confident, right up to the moment when the needle went in. It was still really painful. Finally, I decided to try something a little bit more scientific: nitrous oxide. Also known as laughing gas, nitrous oxide had been widely used, mainly as a stimulant, since 1800.

  A friendly anaesthetist arranged for me to try some nitrous oxide in the safe environment of an operating theatre. I took a few deep breaths and almost immediately began to feel the effects. I was intoxicated and euphoric. I was extremely pleased with myself and babbling with enthusiasm. But how good was nitrous oxide going to be at preventing pain?

  My friendly anaesthetist had kindly brought along a device that violently stimulates the muscles of the forearm. When I had shaken off the effects of the first whiff of gas, I tried it. The result was painful and distinctly unpleasant. Next he gave me the highest dose of nitrous oxide he considered safe. Once again I went from being entirely sober to wildly intoxicated in a matter of seconds. When I was passed the pain-dealing device I seized it with enthusiasm. Once more my muscles twitched madly, but this time it wasn't painful at all; it was just funny. I could have gone on happily pressing the button for quite a while, but then the nitrous oxide wore off and suddenly my arm started to hurt and it wasn't funny any longer.

  What I learnt from this bout of self-experimenting is that with-out the discovery of ether and then chloroform's anaesthetic qualities, it is unlikely that surgery could have progressed. None of the other options were powerful, consistent, long-lasting or safe enough to have allowed complex surgery to take place.

  Few of the other things I tried out were quite as unpleasant as trying to force a needle through my hand, though immersion in near-freezing water came close. This was a re-enactment of an experiment first done by Bill Bigelow, whom we meet in Chapter 2, a pioneering researcher into hypothermia. Bill was convinced that if you cool down an animal, you can slow its metabolic rate and oxygen consumption. Do this with a cardiac patient, he reasoned, and you buy the surgeon more operating time. Rather than testing this idea on a dog, as Bill had done, the production team decided to test it on me.

  So on a bitingly cold winter's morning I went for a dip in Hampstead Heath's men-only swimming pond. The temperature of the water was just above freezing as I arrived wearing trunks and some high-tech equipment. I had waterproof monitors to measure my heart rate and blood pressure. I also wore a mask that would measure my rate of oxygen consumption.

  When I first went into the water it was extraordinarily painful, and I did quite a bit of whimpering. My pulse rate and blood pressure both doubled, while my consumption of oxygen also shot up. This was my body's instinctive response to the initial shock. After about five minutes my pulse rate and blood pressure had both fallen below my pre-immersion rates, but my oxygen consumption was still well above normal.

  I had discovered what Bigelow also found in his dog: that cold induces violent, involuntary shivering, which increases oxygen demands. This was extremely bad news, as it meant that hypothermia would make operating on the heart more, not less, difficult. Bill persisted with his experiments, however, and soon found ways to abolish the shivering. When he did that, the animal's oxygen needs did indeed fall. Bill Bigelow's experiments led to the successful use of hypothermia in operating theatres, something I had witnessed at the John Radcliffe Hospital.

  The application of cold, pain and leeches were all suitably historical, but I was also interested in trying rather more high-tech experiments. For the neurosurgery film, I thought it would be interesting to find out what it would feel like to have parts of my brain switched off.

  For many years neuroscientists have known that different parts of the brain do different things, and that creating an accurate map of the brain is important for safe surgery (see Chapter 5). In the early days doctors would find a patient who had had a brain injury, study what they could or could not do, wait till he or she died and then dissect their brain.

  These days they have more sophisticated tools, which include transmagnetic stimulation (TMS). This involves using a powerful magnetic field to scramble brain cells temporarily in targeted parts of the brain. Having switched off that section of the brain, the scientists can deduce what it does by seeing what the volunteer is no longer able to do.

  I wanted to see the effects of interfering with my motor cortex, the bit of the brain that governs fine movements, so I went to visit Dr Joe Devlin of University College London. It was a strange experience. When he turned on the TMS machine I completely lost control of the fine movement of my fingers. However hard I tried, I could no longer write, pour a glass of water or touch the tip of my nose with my finger. As soon as the machine was turned off, everything returned to normal.

  This particular experiment made me reflect on how reliant we are on exquisite coordination between different parts of the brain and the body; how we only really appreciate what our body does when it no longer performs in the ways we expect. It is, of course, when things go wrong that we call first on the doctor, then on the surgeon.

  We are extremely fortunate to live in an age when we have anaesthetics, antibiotics and machines for looking inside the body and the brain. We benefit enormously from the experiments and experiences of all those who went before. When I look back at what has been achieved in a comparatively short period of time by pioneers on both sides of the knife, I feel awe and immense gratitude.

  In the course of researching and making the television series on which this book is based I met a lot of surgeons and their teams. I'm deeply impressed by what a varied, skilful, interesting and dedicated bunch of people they are, and I am very grateful for having had the opportunity to see them in action.

  I'd especially like to thank Jonathan Hyde, Robert Marston, Ian Hutchinson, Alice Roberts and Peter Butler for their time and patience. Also Paulo Santoni Rugio, eighty years old and still doing facial reconstructive surgery in Cambodia.

  I'd like to thank the production team at the BBC for their patience, insights and sheer hard work: Claudia Lewis, Kate Shiers and Kim Shillinglaw for driving the series editorially; Emma Jay, Giles Harrison, Hannah Liptrot, John Holdsworth and Sadie Holland for directing and producing the programmes; Giselle Corbett, Max Goldzweig, Sophie Guttner, Ruth Lacey, Fiona Marsh, Andrew Mayer, Laura Mulholland, Caroline Sellon and Sophie Wallace-Hadrill for providing the support work that made sure it all actually happened.

  PREFACE

  My mother always wanted me to be a surgeon. As a child, I spent more time hanging around hospitals than was probably normal. Mum was a nurse, so my sister and I became somewhat expert at navigating our way around the corridors of the Norfolk & Norwich Hospital. And, like most kids, I was often to be found in the Accident & Emergency department when I had gashed my leg, knocked my head in the playground, or swallowed a fish bone. I had my first operation when I was ten.

  It was an operation on my right eye to correct a squint, and my family had absolute trust in the surgeon that it would be a success. Almost every moment, from being admitted to the hospital right up until
the operation itself, stands out in my mind. I was in the children's ward in the old part of the hospital. It was reached through a long, chilly, stone-floored corridor. A few shabby partitions had done little to transform the ward from its Victorian origins. The ceilings were lofty, the radiators cast iron and the windows grimy.

  I was given an injection before being taken to the operating theatre and remember examining the exciting cracks in the ceiling above my bed as the sedative took hold. I was wheeled along the corridor, up a ramp (which the porter had to make a run at) and to the operating theatre in the new part of the hospital. Outside the door of the theatre I was asked to count down from ten. I have no idea how far I got.

  When I woke up my eye was covered with a bandage. The vision in the other eye was a blur. Someone brought me some ice cream. Three days later I was out of hospital and eventually went back to school. The operation was not a complete success. My right eye is still scarred (the scar is apparent when I get tired) and I had to have another series of operations a few years later, with a different surgeon, to correct the problem completely.

  It is only when I look back at my first surgical experience that I wonder whether our trust in the surgeon was misplaced. Could he have done a better job? Was he having an off day? Was he desperate to get away for a round of golf? Surgery is risky, but we have somehow come to take it for granted that surgeons know what they are doing and that operations will be successful. However, even today, the decision to go 'under the knife' should not be taken casually. Imagine what it was like fifty years ago or even one hundred and fifty years ago.

  In writing this book I've tried to re-create the surgical experiences of the past. It is a book about surgeons and the patients they operated on. Everything I have described really did take place and is based on accounts, reports, photographs, films and paintings from the relevant period. I have not had to exaggerate or sensationalize. In fact, in some cases I have had to tone down the stories to make them readable. I can assure you that the operating table at University College Hospital was stained with blood and that the operating theatre was next to the mortuary. Surgeons did inject paraffin wax under the skin, bombard patients with massive doses of radiation, and stick ice picks through their eye sockets – all in the interests of medical progress. There are some truly horrific episodes in the history of surgery that I have done my best to recount as accurately as possible.

  There is, however, one important disclaimer. I came across the same problem encountered by the producers of the excellent BBC series that this book accompanies. There are so many stories that it proved impossible to include them all. As a result, this book is a history of surgery rather than the history of surgery. I have tried to include most of the more significant events, but also some of the most shocking, dramatic and entertaining. I have missed out whole areas of surgery, including orthopaedics and gynaecology, and some grisly early operations, such as those to remove bladder stones (you don't want to know). The chapters are arranged thematically rather than chronologically, which I hope makes the subject more accessible. I have also included a further reading section at the end to help you find out more. The only bits of the TV programmes that you won't find in the book are the presenter Michael Mosley's own contributions.

  As you will have realized, I never did become a surgeon, journalism proving a much easier (albeit less lucrative) career path. However, I have for many years been fascinated by the history of medicine and surgery. One of my favourite TV programmes as a child was Your Life in Their Hands, when surgeons were shown performing real operations. One of my favourite museums is the Old Operating Theatre in London (see page 301).

  Despite being immersed in the subject, there were certain events that even I found difficult to write about. Some of the accounts and pictures of injured soldiers and airmen, for instance, are deeply disturbing. I hope I have done justice to these remarkably brave men. I also hope I have given a fair account of some of the more controversial surgical treatments developed over the years, such as cross-circulation, lobotomy and brain implants. I am sure when you read this book you will find the stories equally compelling.

  I owe an immense debt of gratitude to my wife, Susan, for putting up with me and for all her insightful editing and constructive criticism. I must also thank my mum, Penelope, who lent me a pile of books from her years in nursing and helped out with Chapter 1. As far as family goes, I also need to mention my son, Matthew, who was very patient with me at the Old Operating Theatre ('Is this it, Dad?' 'Yes, but isn't it fascinating?' Long pause. 'Can we go for a pizza now?'), and my father, Peter, who was the most recent Hollingham to go under the knife.

  None of this would have been possible without the efforts of the programme production team, all of whom have been immensely helpful (their names are listed in the Foreword). They conducted much of the original research and, of course, have made some excellent TV programmes.

  Thank you to the following people who helped me make sure I got my facts straight: Vivian Nutton from University College London (UCL); Alison Cook and Jonathan Hyde from the Royal College of Surgeons of England, and the various other surgeons Alison coerced into reading the drafts; Simon Chaplin, also from the Royal College of Surgeons, who put me right about Hunter; Peter Elliott from the Royal Air Force Museum, who helped me out on Spitfires and Wellingtons; Steven Wright from UCL, who provided a plan of Liston's hospital; and Stuart Carter, whose story is featured in Chapter 5. Finally, I would like to thank Martin Redfern and Christopher Tinker at BBC Books for their encouragement and support.

  CHAPTER 1

  BLOODY

  BEGINNINGS

  OPERATING DAY

  University College Hospital, London,May 1842

  * * *

  The operating theatre was positioned at the centre of the hospital, next to the mortuary. It was separated from the public areas by thick walls and a long corridor. This arrangement had two significant advantages: it helped shield passers-by from the screams; and its proximity to the mortuary meant that surgeons could move easily from operation to post-mortem, often with the same patient.

  As it was, most people did their best to avoid the precincts of the hospital on operating days, and the staff did their utmost to distract anyone within screaming distance. It was not good for morale, particularly for those in the surgical wards who would soon go under the knife.

  The steeply raked semicircular wooden galleries of the operating theatre had been swept that morning. The dust hung in the air, dancing in the few shafts of sunlight that managed to penetrate the grime of the high windows. A smoky coal fire burnt in a grate in the corner. At the centre of the room, where the surgeon would be performing, the gas lights hung from the ceiling on a chain above the operating table.

  The table was made of deal – a cheap pine timber – and resembled a crude workbench. High and narrow, with a wedge-shaped block for the patient's head, it was bolted to the floor with thick iron brackets. The grain of the wood was marked with deep grooves and stained brown by the coagulated blood and soiled blankets of previous patients. Beneath the table was a box of sawdust, fresh that morning, although some still remained from previous operations, stuck to the side of the box like hardened brown putty.

  One of the assistant surgeons, known in the hospital as a 'dresser', laid a thick woollen blanket on the operating table while his colleague carried in a case of surgical instruments. Both the men were nearing the end of their training and had already assisted in dozens of operations, although neither of them could say they had got used to it. The dresser carefully took the instruments from the deep velvet padding of the case. He laid them out in strict order on a tray placed on a small cabinet near by. He knew if he got the order wrong he would be in terrible trouble. He checked his notebook to make doubly sure.

  Operating instruments:

  Two straight knives made of hardened steel, twelve inches long, with an embossed ebony handle and the sharpest of pointed blades

  A saw, short and polis
hed, with fine sharp teeth and a good strong grip

  One pair of forceps

  Assorted sponges

  Threaded needles to tie blood vessels

  Short pliers or nippers to trim any jagged remnants of bone

  The dresser covered the instruments with a cloth. There was also a bowl of water so that the surgeon could rinse the blood off his hands between operations.

  Everything was ready. The first operation was scheduled to begin at noon.

  In the male surgical ward the patient, rested and well fed, was as prepared as he would ever be. His bowels had been emptied that morning by means of an enema syringe, the resulting discharge being reported as 'copious and of bad quality at first' (the patient, the case notes recorded, was well rid of it). Two porters arrived to take the man to the operating theatre.

  As they prepared to lift the patient from his bed on to a canvas stretcher, they could see that he was in a bad way. The poor man's lower leg had begun to suppurate: a thick fluid trickled from the open wound – a mixture of blood and pus seeping between the jagged ends of broken bone that protruded through the skin of his calf. The porters tried not to get too close. The smell of decay, like that of rotting meat, was almost more than they could bear. Without an operation the patient would die, that much was a certainty. The only cure for such a compound fracture was amputation, but with the infection creeping up the man's leg so fast that you could almost see it, the decision had been taken to remove his leg at the thigh.

  The patient had sustained the injury on the Great Northern Railway when he had slipped between the platform and a moving train. Fortunately, the company's terminus at King's Cross was only a few hundred yards from University College Hospital. This meant he would be operated on by Britain's finest surgeon, Robert Liston. Liston had recently been appointed as the hospital's most senior surgeon, and professor of clinical surgery at the university. Author of the latest surgical textbook, he was the foremost surgeon of the age. And he knew it.