Blood and Guts

by Richard Hollingham

  The room goes quiet as Liston strides through the door. 'Sharp features, sharp temper' is how his colleagues describe him. Most of his students (and many of his staff) are scared of Liston, but he is good at what he does and his operations are always well attended. True, there are those who have to attend them, such as the surgery undergraduates, but there are usually also rival surgeons and even visiting dignitaries in the audience. This is, after all, the very latest surgical practice, the best the British Empire has to offer.

  Liston – six feet two inches tall, domineering and self-assured – hangs up his frock coat, takes an apron from the peg and rolls up his sleeves. 'Good afternoon, gentlemen,' he says to the now packed theatre. 'Today I shall be performing an amputation of the thigh in the usual manner.'

  The two porters take this as their cue to carry in the patient. They lift him as gently as possible on to the operating table. The patient winces. This, he thinks, must be how condemned prisoners feel as they are led to the scaffold. His eyes dart around the room, his heart pounds, his utter terror mitigated only by the excruciating pain from his leg whenever he moves – a pain overlaid by a duller, steady, nauseating ache. He wants to vomit but can only gag.

  Liston had made surgery his life's work and knew it had the power to save lives, but even he – described by his enemies as arrogant and aloof – operated only as a last resort. He also made every effort to instil in his students some sense of the feelings and fears of the patient. 'These operations must be set about with determination and completed rapidly, in order that dangerous effusion of blood may be prevented,' he told them. 'They are not to be undertaken without great consideration.' In short, it was all about speed.

  The porters shut the doors and stand guard, arms folded, defying anyone to pass them. It has been known for patients to try to make a run for it, but this one only groans and mumbles indistinctly. It is probably a prayer. Most patients pray – it's amazing how many people find religion in the operating theatre. Many also beg or plead to be taken back to the ward even though they know that without surgery they will die. Others lie on the table calmly, as if possessed by some inner strength. Women, Liston finds, are often the most composed.

  A dresser slips the strap of 'Petit's improved tourniquet' around the patient's upper thigh and pulls it through a small clamp. A wedge-shaped ridge on the strap is placed against the artery but not yet tightened, its purpose being to prevent blood loss during the operation. Without the tourniquet the patient's entire body would bleed dry in less than five minutes. Applying it properly was a matter of some skill. Tighten it too early and the upper leg would swell with blood. Too late and the patient could bleed to death.

  Liston has himself witnessed the disastrous effects of a poorly applied tourniquet and is fond of telling the story in his lectures. 'A scene of indescribable and, under other circumstances, most laughable confusion ensued,' he says. 'Two assistant surgeons got on the table and pressed with all their might and main on the groin to stop the bleeding.' Liston is, in this instance, good enough not to reveal the surgeon responsible, but the story serves to remind people of his intolerance of error. The fate of the patient is not recorded.

  With Liston in charge, there will be no such mistake today. One of the dressers takes a handkerchief from his pocket and ties the patient's good leg to the table to keep it as far away as possible from the knife. Two other assistants firmly hold the patient's shoulders and arms to stop him struggling. They try to keep their hands away from his mouth. He can squirm but cannot move; scream but not bite. The patient glances at the instruments, then at the ceiling. Finally at the audience – witnesses to his fate.

  Liston motions for a young student to come forward from the gallery to support the limb that is going to be removed. The nervous pupil knows that if his grip slips or the leg bends, causing the bone to snap rather than be sawn through cleanly, he will suffer Liston's anger and abuse. He also hopes that Liston himself keeps a steady hand.

  The surgeon clamps his left hand across the patient's thigh. His right hand reaches for his favourite knife, marked with a series of notches – one for each operation. The knife glitters in the flickering gaslight. Liston turns to the galleries; everyone is leaning over the railings to witness the action. 'Time me gentlemen!' Those familiar with a Liston operation already have their pocket watches ready.

  In one rapid movement, he slices into the flesh, and a dresser immediately screws down the tourniquet to stem the rhythmically spurting fountain of blood. Drawing the blade under the skin with the grain of the muscles, Liston pulls it towards the hip, down to the bone, then sweeps it around the leg and back towards the knee to leave two U-shaped incisions on the top and bottom of the thigh. There is nothing theatrical about the patient's cry. It is a chilling, horrible scream of terror. He is weeping now, struggling, mewling, whimpering.

  Liston flings the knife into a tray and grabs the saw. His assistant puts his hand into the cut, fingers reaching right the way down to the bone. He pulls back the mass of skin, muscle, nerves and fat towards the hip to expose as much bone as possible. Liston places his left hand on the exposed bone and, with his right, begins to saw through it with rapid but precise strokes.

  The student supporting the leg is concentrating so much that he barely realizes when he's holding its full weight. He looks down with a shudder, kicks the box of sawdust towards him and drops in the severed limb. It lands with a thud, sending up a small cloud of bloody sawdust.

  The saw falls to the floor and, with his assistant still holding back the flesh of the stump, Liston bends close to tease out the main artery in the thigh – the femoral artery on the underside of the leg. The stump begins to ooze as Liston's bloodied hands reach for the needle and thread. He ties off the blood vessel with a reef knot. A 'good, honest, devilish tight and hard knot,' as he will later tell his students. He notices other, smaller, blood vessels and knots the ends together, holding the thread in his mouth at one point to make sure it is really tight.

  Liston shouts at a dresser to loosen the tourniquet. A gently flowing stream of blood meanders between the ridges of the blanket to drip into a pool on the floor. But the pool is small, not large enough to be life threatening. The assistant allows the flesh he has pulled aside to spring back so that the bone is once again covered and protected by soft tissue. The two U-shaped flaps of skin are pulled together over the stump. A thin line of coagulating blood seeps between them.

  The operation is over. From first cut to final stitch, the whole procedure has taken only thirty seconds. Thirty seconds of remarkable dexterity, flashing blades, rapid movements and brilliant showmanship. Thirty seconds of such pain that few patients are ever able to put it adequately into words. The memory of those thirty seconds will haunt them for the rest of their lives. If they live.

  Fortunately, the mortality rate from Robert Liston's operations was remarkably good. Between 1835 and 1840 he conducted sixty-six amputations. Ten of his patients died – a death rate of around one in six. About a mile away at St Bartholomew's Hospital, surgeons were sending one in four patients to the mortuary, or 'dead house', where the all too frequent post-mortems took place.

  Given that many surgeons were appointed through patronage or, more usually, nepotism, there was a large degree of surgical incompetence even in the most renowned hospitals. Surgeon William Lucas at Guy's Hospital in south London was generally kept away from the operating theatre for everyone's safety. In one thigh amputation he cut the U-shaped flaps of skin the wrong way round leaving a raw stump and a dismembered limb with two excess flaps of skin. His botched operations (the word 'botched' became synonymous with failed surgery) were notorious. They were thought to be the main reason that a young dresser at Guy's, John Keats, abandoned the surgical profession to become a poet.

  In rural areas the local physician was expected to carry out his own operations. The medical literature of the day is littered with accounts of attempted surgical procedures and their consequences. Martin A. Evans,
a physician in Galway, recorded a typical example from his casebook in the Lancet medical journal of 1834. His patient was forty-five-year-old Martin Conolly, whose leg was crushed by falling timber. Having persuaded the man that amputation offered the only chance of survival, Evans conducted the surgery, but his account gives little detail about the procedure itself, except that it was 'done by circular incision without assistance'. It is unlikely to have been as quick and efficient as Liston's operation, but was performed 'in the usual manner'.

  As soon as the limb was removed Conolly reported feeling better and stronger, but in a few moments became faint and gradually weaker. 'He died,' reported Dr Evans, 'without having lost four ounces of blood during the entire process.' Evans attributes this not to any surgical failure resulting in massive internal bleeding, but to the patient. 'He had been a strong man, but was fearful of consequences, the only cause to which I can attribute his sudden dissolution.'

  Patients had every reason to be fearful. Liston usually operated on reasonably fit young men or women with strong constitutions, and considered long operations cruel. That his were speedy affairs helped minimize blood loss and reduced the risk of disease. Liston also believed in keeping wounds clean. After the skin had been stitched together – with stitches known as 'sutures' (from the Latin word meaning 'to sew') – he advocated dressing the wound with sheets of lint dipped in cold water. These were to be frequently changed as the wound suppurated, with warm poultices applied to reduce the swelling and 'encourage discharge'.

  Not for Liston the filthy bandages and straps of some of his rivals. These, as he was fond of saying, only encouraged 'putrefaction, fermentation, stench and filth'. It wasn't unusual for surgeons to reuse bandages and dressings already stiff with blood. For convenience, one surgeon proudly kept a drawer of 'plasters' passed from patient to patient over the years. Well, he and others reasoned, why waste them?

  Liston would also wash his hands before operating and always wore a clean apron. Or at least it started off clean at the beginning of the day. Other surgeons took pride in conducting operations in the same frock coats they had used for years. The blood and pus that had built up into a hardened crust of material were regarded with respect. Surgeons were, after all, respected members of society; they had almost the same standing as doctors.

  Liston and most of his contemporaries could, with some justification, claim to save lives. They had a firm grasp of anatomy, knowing with some certainty the name and position of every bone, muscle and organ in the body. They also knew broadly what each organ did, even if they had only a limited understanding of the underlying mechanisms. Crucially for Liston's generation of surgeons, they had also developed the skills and dexterity to stop their patients from bleeding to death on the operating table.

  The decision to operate was determined by the pain the patient could withstand. In some quarters pain was seen as a prerequisite for a successful operation – a stimulant to the body's natural powers of recuperation. Perhaps the Galway patient had not been in enough pain? Many operations took far longer than the few seconds required for a basic amputation. Liston considered some of these too cruel. A mastectomy, for example, would take several minutes, the breast being slowly dissected 'with all due caution and deliberation'.

  Neither was there any understanding of infection – what it was or how it was spread or prevented. Although Liston chose to operate in a clean apron with relatively clean hands, instruments and dressings, these practices owed everything to his sense of cleanliness and common sense rather than any theory of disease or how it was controlled.

  The speed with which he conducted his operations, which included the removal of tumours and growths, and even reconstructive surgery (see page 217), was a hallmark of his work. Sometimes, though, his arrogance would get the better of him. (Indeed, the arrogance of surgeons is a theme throughout the history of surgery.)

  Jealous rivals would whisper that Liston was so quick that he once accidentally amputated the penis of an amputee. On another occasion he was asked to look at a young boy with a swelling on his neck. A junior surgeon was convinced that the tumour was connected to the main artery in the neck – the carotid. 'Pooh!' said Liston as he drove a knife into the tumour. Unfortunately, the junior surgeon was right. The boy died within minutes.

  However, the most worrying incident for his students occurred during an amputation when Liston accidentally amputated an assistant's fingers. The outcome of this operation was horrific: the patient died of infection, as did the assistant, and an observer died of shock. It was the only operation in surgical history with a 300 per cent mortality rate.

  Liston's operations were messy, bloody and traumatic but, despite the occasional setback, he was one of the best surgeons of the day. His patients suffered terribly, but a fair proportion of them came out of hospital alive. This eminent surgeon owed his relative success to two thousand years of surgical development. A tortuous history involving dismembered criminals, wounded soldiers and Roman celebrities.

  INSIDE THE BODY

  Pergamum, Roman province of Asia Minor (Western Turkey), AD157

  * * *

  The gladiatorial display was the zenith of Roman entertainment, a glamorous spectacle of skill, excitement and bloodshed. The day of the contest was one of celebration, and the amphitheatre was packed with expectant crowds ready to be entertained.

  The day started with a display of exotic creatures gathered from the far reaches of the empire – leopards, wild horses and an angry bear. The animals were goaded in mock hunting demonstrations. A few were killed, but others were saved and employed as executioners to tear apart local criminals who were tied to stakes in front of the baying crowd. As the gladiators entered the ring, they waved to acknowledge the screams of the spectators, who idolized them as celebrities, their beautifully toned bodies admired by men and adored by women.

  The gladiators fought in pairs – a warrior in heavy armour pitched against a nimble opponent with a net and trident; a fighter with swords against one with spears and daggers. Although the event was staged, the brutality of the fighting was terrifyingly – and thrillingly – real. The men fought to injure, to wound, to win. They were taught to aim for the arteries of the neck, and behind the knee. It was a fight to the death, but they shouldn't kill. The choice of whether a gladiator would live or die was the prerogative of the sponsor. He alone could decide whether the victor should deliver a final, fatal blow. The sponsor could not afford to allow too many gladiators to die – it would be like killing half the cast of actors after each performance of a play – as he would have to buy replacements.

  Within the hierarchy of Roman society, gladiators were near the bottom of the heap. They were slaves and members of what was considered a disreputable profession. This was a standing they shared with prostitutes and, of course, actors. But despite their lack of freedom and their apparently low status, gladiators were rightly treated as the elite sportsmen they were. Their rigorous training was complemented by a high-energy diet and the very best medical treatment. The post of physician to the gladiators in Pergamum, or any major city of the empire, was a prestigious one. Celebrity gladiators required their own celebrity surgeon. This was the perfect position for a showman such as the ambitious Claudius Galen.*

  * No one seems to know for sure what Galen's first name was. 'Claudius' is used in many references, but some historians suggest it was more likely to be Aelius or Julius.

  Galen was a servant of the healing god Asclepius and had studied alongside distinguished physicians. This did not necessarily make him a surgeon, but he did know how to impress. When he was interviewed for the post of physician to the gladiators, Galen took along a monkey. He then proceeded to slice open its stomach and sew it back together again. 'Can anyone else do that?' he asked. He got the job and, as an added bonus, the monkey survived.

  In his new role Galen would learn to deal with everything from minor sports injuries, such as muscle strains, to serious battle wounds. When the sur
vivors of the contests left the arena Galen would be waiting to set bones or amputate limbs. He became an expert at stemming blood flow and restoring the fighters to health. As one of the first trauma surgeons, he was perfectly placed to study the inner workings of the human body. The exposed guts of a defeated gladiator, spilling out from a stomach wound, enabled him to examine the digestive system. An amputation revealed the bones, muscles and structure of the tendons, the bands of tissue that connect bone and muscle. He noticed how blood vessels pulsed and that some blood was brightly coloured. Galen later claimed that no gladiator under his medical care had died, but, even given their superior fitness, this is hard to believe. The physician, though, had a legend to build and a reputation to maintain.

  As Galen's career advanced, he extended his studies of anatomy to animals – dead or, quite often, alive. He held public lectures and demonstrations where an animal was publicly dissected. Pigs seemed to bear the brunt of Galen's experiments as he considered them to be most similar to humans. His favourite demonstration involved severing the nerves in the neck of a live pig. As he cut them away, the wriggling animal became increasingly paralysed. First unable to move its hind legs, its front legs would then become still. With the final slice, Galen could stop the pig squealing.

  In the manner of a true celebrity surgeon, Galen eventually became a personal physician to the emperor Marcus Aurelius. His ultimate ambition, though, was to become as famous as the Greek 'father of medicine' himself, Hippocrates. Galen hoped to be immortalized by the medical profession as someone who understood how the human body functioned. However, his only direct knowledge of human anatomy came from his work as a surgeon. Dissection of dead bodies was rare, and many considered it unclean and blasphemous. As a respected member of Roman society, Galen could not risk even suggesting such a thing, so instead he based most of his descriptions of human anatomy on what he had learnt by dissecting animals. The rest he surmised from consultations with his patients, or simply made up.