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Overview
Today, astonishing surgical breakthroughs are making limb transplants, face transplants, and a host of other previously un dreamed of operations possible. But getting here has not been a simple story of medical progress. In Blood and Guts, veteran science writer Richard Hollingham weaves a compelling narrative from the key moments in surgical history. We have a ringside seat in the operating theater of University College Hospital in London as world-renowned Victorian surgeon Robert Liston performs a remarkable amputation in thirty seconds—from first cut to final stitch. Innovations such as Joseph Lister's antiseptic technique, the first open-heart surgery, and Walter Freeman's lobotomy operations, among other breakthroughs, are brought to life in these pages in vivid detail. This is popular science writing at it's best.
Product Details
| ISBN-13: | 9781429987325 |
|---|---|
| Publisher: | St. Martin's Publishing Group |
| Publication date: | 06/04/2024 |
| Sold by: | Barnes & Noble |
| Format: | eBook |
| Pages: | 321 |
| Sales rank: | 935,816 |
| File size: | 485 KB |
About the Author
RICHARD HOLLINGHAM is a science journalist, author, and BBC radio presenter. He has written and presented a number of radio series on science, the environment, and international politics. His popular science book, How to Clone the Perfect Blonde, was longlisted for the coveted Aventis Science Prize in 2004.
Read an Excerpt
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 polished, 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.
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 hadalso 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'.
(Continues…)
Excerpted from "Blood and Guts"
by .
Copyright © 2008 Richard Hollingham.
Excerpted by permission of St. Martin's Press.
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
Excerpts are provided by Dial-A-Book Inc. solely for the personal use of visitors to this web site.
Table of Contents
Foreword by Michael Mosley,
Preface,
Chapter 1: Bloody Beginnings,
Chapter 2: Affairs of The Heart,
Chapter 3: Dead Man's Hand,
Chapter 4: Fixing Faces,
Chapter 5: Surgery of the Soul,
Timeline,
Further Reading,
Index,