Sunday, May 17, 2009

“Have a go to see what happens”

Blood and Guts – A History of Surgery is a fascinating, gruesome, layman-friendly book, packed with anecdotes and horror stories. Author Richard Hollingham, following Michael Mosley's TV series, takes us from Galen's treatment of gladiators in the Second Century AD, through Vesalius and Paré in the Sixteenth Century to 2006, where Stuart Carter was freed from paralysis by Parkinson's disease through the use of electrical brain implants.

Hollingham argues there were four obstacles to successful surgery: surgeons needed to understand the workings of the body (usually through dissection of dead bodies); they had to learn from the experience methodically; they had to bypass the pain of an operation (by inventing anaesthetic); and they had to prevent infection.

So we follow the haltering steps towards achieving these goals, such as the discovery of chloroform and carbolic soap. We also see some of the cul-de-sacs we've since backed out of – usually the result of surgeons insisting they know best rather than looking at the evidence.

Hollingham is also hot on the statistics – no two patients are the same, so operations are judged not on a single win or lose, but the percentage of success when trying the same procedures time and again. Before the discovering of carbolic soap, infection was fought by operating quickly; Liston could remove a leg in 30 seconds.
“The morality 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 Hoispitals, surgeons were sending one ion four patients tot he mortuary, or 'dead house', where the all too frequent post-mortems took place.”

Richard Hollingham, Blood and Guts, p. 38.

Yet Hollingham is also quick to show that the medical heroes are also all-too human.
“Jealous rivals would whisper that Liston was so quick that he once accidentally amputated the penis of an amputee ... 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.”

Ibid., pp. 41-2.

All to often the effort is, “Well, we don't know, but we'll try this...”, and slowly, over the centuries, that philosophy has benefited us all.

The two world wars meant the raw material with which to make extraordinary advance in grafts and the treatment of burns. There are harrowing stories of the multitude of operations suffered by men without faces – and there are also harrowing photos. This is really not a book for the squeamish. But I'm less squeamish of blood and guts per se as unnecessary pain and procedures...

There's some terrifying stuff about lobotomies. The 1941 operation on Rosemary Kennedy (sister of future President John F.) left her,
“a very different person. Slow and emotionless, she was hardly able to move or speak. Although she eventually learnt to walk again, she was left permanently disabled and ended up in a residential institution in Wisconsin ... Freeman never said a word about the case. It was in his best interests not to publish the details of any high-profile failures.”

Ibid., pp. 279-80.

Walter Freeman refined and developed the lobotomy, after it had first been performed in 1935 by Portuguese surgeon Egas Moniz. By 1946 Freeman was now offering a new refinement, the “transorbital” lobotomy. The “transorbital” bit is where they shoved an ice-pick up through your eye socket to detach bits of your brain. It was a shockingly quick procedure, and doctors were quick to recommend it, too.
“Freeman ... personally performed about three and a half thousand lobotomies, and trained doctors across the world. In total, it is thought that around one hundred thousand people were lobotomized.”

Ibid., p. 283.

The case of Howard Dully, an eleven-year-old boy who wasn't getting on with his step-mum, is like something out of a fairy tale. Her evidence for why the wayward child should receive the treatment included that “he daydreamed and scowled if the TV was tuned to some programme other than the one he liked,” (p. 285). Using “orbitoclasts” - a step up from ice picks – Freeman operated on the boy on 16 December 1960.
“Howard has spent most of his life coming to terms with what happened to him. He suffered problems with work, relationships and money. He drifted in and out of jobs and in and out of jail. Gradually, he was able to piece his life back together. Today he holds down a job as a bus driver. There is absolutely nothing about him to suggest that he has two black holes in his brain. What saved him from going completely off the rails was probably his youth. Howard's young brain was able to rebuild neural pathways and compensate for the damage Freeman inflicted.”

p. 287.

Yet Freeman is not portrayed as monster, for all he “operated on a total on nineteen children, including a four-year-old,” and he ignored criticism and the new drugs that “did much the same thing only without the danger or permanence of surgery,” (p. 287). Hollingham lays as much blame on the authorities who let Freeman continue working “when the procedure was discredited and opposed by almost the entire medical establishment,” (p. 288).
“But it is difficult to reconcile the image of a monster with the kind and gentle doctor his patients encountered. When the lobotomy was conceived it seemed to provide the only treatment for chronic mental illness. It certainly transformed some people's lives for the better.”

p. 288.

In fact, Freeman spent the last five years of his live travelling “some fifty thousand miles” tracking down former patients to see how they had fared.
“To the end of his life he believed in what he had done, and he believed he was right.”

p. 289.

Hollingham says “Freeman's greatest failure of judgement was not knowing when to stop,” (p. 288), but that sits uncomfortably with what follows. In the 1950s, the US intelligence agency were “toying” with “brainwashing individuals, invariably communists”. In 1967, psychiatrist Frank Ervin and neurosurgeon Vernon Mark's proposal in “the prestigious Journal of the American Medical Association” to prevent urban riots by subduing black rioters with brain implants (one of Ervin's medical students, Michael Chricton, later wrote The Terminal Man). In 1972, psychiatrist Robert Heath proposed using “brain implants to 'cure' homosexuality,” (all p. 293).

And yet Hollingham doesn't talk about one of the biggest areas of surgery today – and one of the most morally problematic. Cosmetic surgery is booming, yet its only mention in the book is the cautionary tale of Gladys Deacon, a beautiful lady in 1903 who wanted a more beautiful nose. The hot paraffin wax surgeons injected her face turned her into a “freakish waxworks dummy” (p. 222).

Nor is there much on the philosophy of surgery – the Hippocratic oath, the impact of the National Health Service on surgeons (who insisted, when it began, that they kept their private work) and the role of the private sector today. Perhaps the NHS bits would be too parochial for a book that tries to cover the global history of surgery (and its covered anyway in NHS plc), but who pays for surgery – and for surgeon's mistakes – would have lifted this fascinating pop-history into something more profound.

(No, I've not yet read Bad Science.)


emilyyyyyy x said...

can you find out what was the fastest time Robert Liston did an amputation?

0tralala said...

According to Blood and Guts page 38, it took him 30 seconds to remove a leg.