Blood and Guts Page 26
In 2006 Carter was offered the chance of having electrodes implanted in his brain. In his case, the technology, known as deep brain stimulation, would act as a jamming device. The implants would block the nerve signals in the sick areas of his brain that were causing him so many problems. The operation was not going to be easy – surgeons needed to implant the devices at the base of the brain, in an area called the basal ganglia. As it would be impossible to cut open Carter's brain, the surgeons at the National Hospital for Neurology and Neurosurgery would be operating 'blind'.
With a brace resembling a medieval torture device clamped to his head, Carter lies on the table in the bright glare of the operating theatre lamps. His head is marked with dots, and a large plastic sheet is stretched across his balding scalp. He stares at the ceiling as the final preparations are being made by the androgynous gowned and masked figures around him. In the twenty-first century lying on an operating table is still a nerve-racking experience, made worse if you know you are going to be conscious when a man you barely know starts drilling holes into your head. An injection of local anaesthetic and surgeon Marwan Hariz is ready to start.
Hariz presses a scalpel into the top of Carter's head, slicing deep to the bone. 'No pain, just noise,' explains the surgeon as he holds an oversized dentist's drill to the incision. A thin trickle of blood and tissue is sucked away with a tube as the drill penetrates deeper. A syringe-like device is clamped over the aperture and a wire implant is lowered into Carter's brain. Hariz guides the implant deep through the folds and ridges of his patient's brain, careful to avoid damage.
'You might feel something and you might feel nothing.' This is the moment of truth. 'Whatever you feel, tell us.' The surgeon presses the button to activate the implants. 'No special sensation?' Carter starts to feel a tingling in his left foot. It's working – Hariz has got the implants in the right place. Carter's brain has been electronically enhanced.
Two years later Stuart Carter can walk, laugh and smile. When he puts his hand down on a table he can pick it up again. He is free from the mental trap that Parkinson's imposed. If you look carefully at the top of his head, you can see two small bumps. You can even follow the path of the wire leading away under his skin and down his neck. It terminates in a flat box beneath his shoulder – the stimulator that sends electrical pulses to his brain.
Today there are tens of thousands of people walking around with brain implants. Some, like Carter, have electrodes deep within the brain to stimulate or block nerve signals. Many others have cochlea implants in their ears to cure deafness. Scientists are developing implants to enhance memory, to help the blind to see, or simply to connect our 'wetware' to computer software. Delgado's vision of using electronic devices in the brain to combat disease and disability is finally being realized.
Advances in brain surgery over the past 150 years have come at tremendous human cost. From patients bleeding to death on the operating table to victims of Freeman's crude lobotomies and brain implants to 'cure' homosexuality, the history of brain surgery is full of examples where surgeons have strayed well beyond the bounds of what is morally or ethically acceptable. It is still difficult to read Freeman's notes on Howard Dully without becoming angry, or contemplate Ervin's and Mark's ideas on mind control without feeling utter revulsion.
THEN AND NOW
* * *
If you look back through the history of surgery, there are some remarkable individuals: pioneering surgeons, such as Ambroise Paré, Ignaz Semmelweis and Joseph Lister, who helped make operating safe; surgeons such as Dwight Harken, Walter Lillehei and Harold Gillies – brave men who had the courage to fail; but there is also a third group – surgeons such as Walter Freeman and Alexis Carrel – who seemed to operate in their own peculiar moral universe.
Whether these people were brilliant, courageous or misguided, the history of surgery is full of individuals who were prepared to have a go to see what happens. Sometimes they succeeded, sometimes they failed. Some patients lived, many others died. But even in death, they will have helped future patients to live.
Without the surgeons who stole corpses from gibbets, who cut into beating human hearts, or who first attempted to operate on the human brain, modern surgery – from routine procedures to repair a damaged knee to hi-tech operations to implant a device in the brain – would not have been possible.
Nevertheless, despite all the advances, there are still many things that challenge twenty-first-century surgery: artificial hearts are cumbersome, organs still get rejected, reconstructive surgery cannot always restore a face, a brain tumour can still kill. Even the most minor surgery is not without risk: hospital patients still die of major infections; anaesthetics are not 100 per cent reliable; the knife can still slip.
Most of us know people who have gone into hospital for an operation and never come out. Surgeons are remarkable people but, despite the impression some of them might give, they are not gods. There are good surgeons and bad surgeons, but even the best surgeons are fallible. When we submit to an operation we put an immense amount of trust in those who wield the knife. In most cases our trust is fully justified, but the history of surgery suggests that sometimes it is not.
If you need an operation, just be grateful that you are alive today and not 170 years ago – the next patient on Robert Liston's operating schedule.
TIMELINE
10,000 BC Evidence that trepanning was in widespread use.
1500 BC First recorded plastic surgery (nasal reconstruction).
c. AD 157 Galen appointed as surgeon to the gladiators at Pergamum in western Turkey.
1536 Vesalius acquires a skeleton and begins to unravel human anatomy.
1545 Ambroise Paré publishes his first Treatise on Gunshot Wounds.
1597 Gaspare Tagliacozzi publishes the first-ever book on reconstructive surgery.
1765 Tooth transplants from living donors are popular.
1834 Robert Liston is appointed professor of clinical surgery at University College Hospital, London.
1846 The first operation is carried out with ether anaesthetic.
1847 Ignaz Semmelweis successfully combats puerperal fever.
1847 James Simpson develops the chloroform anaesthetic.
1848 The first death from chloroform is recorded.
1848 Phineas Gage survives having an iron rod fired through his head.
1857 Louis Pasteur discovers that germs cause living matter to decay.
1865 Joseph Lister treats a patient using 'antiseptic' techniques.
1884 Rickman Godlee and A. Hughes Bennett perform 'successful' brain surgery.
1894 Assassination of French president Sadi Carnot and start of Alexis Carrel's career.
1902 Luther Hill conducts successful heart surgery.
1903 Gladys Deacon has paraffin wax injection.
1912 Alexis Carrel wins Nobel prize.
1917 Harold Gillies performs facial reconstruction operations and develops tube pedicle.
1931 Harvey Cushing conducts his two thousandth brain tumour operation.
1935 Carrel publishes his book on the future of humanity, Man, the Unknown.
1935 Egas Moniz performs first 'leucotomy' operation.
1936 Walter Freeman and James Watts carry out first lobotomy operation.
1939 Archibald McIndoe begins treating Allied casualties.
1943 Willem Kolff invents a successful dialysis machine.
1944 Dwight Harken cuts into a beating human heart.
1944 Death of Alexis Carrel.
1946 First female to male sex change operation.
1946 Walter Freeman performs the first transorbital lobotomy.
1951 Paris surgeons attempt kidney transplant with organs from executed criminals.
1952 F. John Lewis carries out the first successful open-heart surgery.
1953 John Gibbon performs successful operation using heartlung machine.
1954 Walter Lillehei conducts first cross-circulation operation.
&
nbsp; 1954 First successful kidney transplant (between two identical twins).
1955 Lillehei and Dick DeWall invent a reliable heart-lung machine.
1955 Denis Melrose develops a method of stopping and starting the heart during surgery.
1957 Surgeons in Boston use radiation to destroy the immune system in transplant patients with limited success.
1958 Denis Melrose performs open-heart surgery on live television.
1960 Howard Dully is lobotomized by Walter Freeman.
1964 José Delgado stops a rampaging bull by remote control.
1967 World's first heart transplant performed by Christiaan Barnard.
1967 Freeman performs his last lobotomy.
1970 Frank Ervin and Vernon Mark propose using brain implants to suppress violent tendencies in black rioters.
1976 Roy Calne begins experiments on cyclosporine.
1978 First successful transplants using cyclosporine.
1998 Clint Hallam receives the world's first hand transplant.
2001 Clint Hallam's hand is amputated.
2005 First successful (partial) face transplant.
FURTHER READING
I was surprised when I started writing Blood and Guts how few books are available on the history of surgery. There are some excellent books on medicine, particular surgeons or episodes, but few broader histories. If you want to find out more about a particular era, surgeon or practice (such as lobotomy), I have listed some suggestions below. A few of the books are out of print, but, thanks to the wonders of the Web, are usually obtainable. Rather than give a long list of my sources and references for this book, which would run to a separate, sprawling and dull chapter, I thought it might be helpful to point to some general sources of surgical history, facts and inspiration.
I cannot recommend highly enough a visit to the Old Operating Theatre Museum and Herb Garret near London Bridge (www.thegarret.org.uk). Here, up a narrow winding staircase at the top of a church, is the original operating theatre from St Thomas' Hospital, complete with operating table and surgical instruments from the early nineteenth century. The museum also has displays on early medicines, bleeding and the development of anaesthetics and antiseptics. One of my favourite exhibits is a walking stick that a surgeon had his patients bite on during operations, to help them cope with the pain. You can still make out the tooth impressions.
Another fascinating museum is the Hunterian at the Royal College of Surgeons near Lincolns Inn (www.rcseng.ac.uk/museums). I have not written much about John Hunter (see Chapter 3), but in the museum you will find an incredible collection of the weird and wonderful. You will also see how much he achieved in advancing our understanding of human biology.
If there is one single institution that made this book possible, it is the Wellcome Library (on Euston Road in London). I have spent many happy hours there, leafing through old books, papers and journals. The library contains Robert Liston's books on Victorian surgery and the case notes for the first anaesthetic. It holds translations from Vesalius and Semmelweis, papers on the first heart surgery, and even descriptions of groundhogs (see Chapter 2). The biggest problem with the Wellcome Library is that it is very easy to get diverted. I spent an afternoon reading graphic case notes on early eye operations, only to realize that there was no space for them in the book. The library is free to join and much of it (particularly the images) is accessible online (http://library.wellcome.ac.uk).
The library is housed alongside the Wellcome Collection, where you will find beautifully displayed surgical knives, cupping bowls and an exhibition on the latest developments in biotechnology.
The book that I think gives the most complete account of surgical history is A History of Surgery by Harold Ellis (Greenwich Medical Media, 2000). Ellis is a world expert on surgical history, and although the book was probably aimed at a medical and surgical readership, it is clearly written and well illustrated. Unfortunately, the book is out of print, but I understand a new edition is in the pipeline. For a glimpse into the mind of a surgeon I recommend Atul Gawande's thrilling and entertaining Complications: A Surgeon's Notes on an Imperfect Science (Profile, 2002). In a similar vein David Wootton's Bad Medicine: Doctors Doing Harm since Hippocrates (Oxford University Press, 2006) suggests that, until relatively recently, doctors were often doing more harm than good.
I also relied on several human physiology and anatomy textbooks. I hope that, with their help, I have not made any glaring errors in my anatomical explanations. The other book that proved invaluable was my mum's nursing textbook from the 1940s, A Complete System of Nursing (Temple Press, 1947) which gave useful information on the treatment of patients and an alarming insight into just how basic medical practice was even then (penicillin is mentioned only briefly as it was not yet widely available, and anaesthetics were still administered from a 'drop bottle' on to a mask).
Below are a few further reading suggestions:
The Greatest Benefit to Mankind, Roy Porter (HarperCollins, 1997) This substantial book covers the whole history of medicine, but is readable throughout. Porter has written many books on medical history, all of which are equally impressive.
Moments of Truth: Four Creators of Modern Medicine, Thomas Dormandy (John Wiley, 2003)
Stories about four of the people who helped shape modern medicine, including an excellent section on Ignaz Semmelweis.
Seven Wonders of the Industrial World, Deborah Cadbury (Fourth Estate, 2003)
Based on the BBC series of the same title, it includes a section on John Snow, and in the chapter on the transcontinental railroad gives an excellent account of the environment that Phineas Gage (see Chapter 5) would have worked in.
King of Hearts, G. Wayne Miller (Crown, 2000)
Although the writing style is sometimes a bit sentimental, this is nonetheless a gripping biography of Walter Lillehei.
The Knife Man, Wendy Moore (Bantam Press, 2005)
An extremely entertaining and evocative biography of John Hunter.
Transplant: From Myth to Reality, Nicholas L. Tilney (Yale University Press, 2003)
This is a rather skewed account of transplant surgery from a US perspective, but it does give an insider's overview of the discipline's development. Far better, I think, is Joseph E. Murray's Story of the First Human Kidney Transplant (Mitchell Lane, 2002).
There are three superb books relevant to the chapter on plastic surgery: Gillies: Surgeon Extraordinary, Reginald Pound (Michael Joseph, 1964); Gladys, Duchess of Marlborough, Hugo Vickers (Weidenfeld & Nicolson, 1979) – a fascinating account of an extraordinary life; The Reconstruction of Warriors, E.R. Mayhew (Greenhill Books, 2004). I also recommend taking a look at Jacqueline Saburido's website (www.helpjacqui.com).
An Odd Kind of Fame: Stories of Phineas Gage, Malcolm Macmillan (MIT Press, 2000)
This is a forensic account of Gage and the myths surrounding him. The book is meticulously researched, but does come from an academic perspective, so it can be a bit dry at times. However, Macmillan's research in uncovering the story of Gage is truly impressive.
Harvey Cushing: A Life in Surgery, Michael Bliss (OUP, 2005)
There is so much more to say about Cushing than I have been able to, and it can be found in this well-written and accessible account of his brilliant and complex life.
The Lobotomist, Jack El-Hai (John Wiley, 2005)
If you read only one other book (apart from mine) on the history of surgery, make it this one. It is superbly researched and entertainingly written. If you want more, get a copy of My Lobotomy by Howard Dully (Vermilion, 2008). It includes some of Freeman's original notes and Dully's personal journey to try to understand why he was lobotomized.
The Terminal Man, Michael Crichton (Arrow Books, 1972)
Although this is a work of fiction, in the light of some of the experiments being conducted at the time, it turns out to be terrifyingly close to reality.
Finally, if you want an insight into the, shall we say, hinterland of medical researc
h, I suggest taking a look at Alexis Carrel's Man the Unknown (Harper & Bros, 1935) and The Culture of Organs (P.B. Hoeber, 1938). Likewise, José Delgado's Physical Control of the Mind (Harper & Row, 1969) is worth flicking through, if only for the pictures.
INDEX
Accident and Emergency (A&E)
acromegaly
Adams, Joseph
aggressive behaviour, controlling
alcohol
and hypothermia induction
as pain-reliever
Allies
American Academy of Arts and Sciences
amputation
accidental
arm
finger
hand
leg
in the Roman era
tying off of blood vessels
anaesthetic
chloroform
endotracheal intubation
ether
and plastic surgery
and wound exposure times
anatomy
16th-century ideas of
Galen's study of
ancient Greeks
Anderson, Thomas
aneurysm, aortic
animal studies
blood vessel closure
heart surgery
neurosurgery
transplant surgery
anti-coagulants
antibiotics
antibodies
antiseptic operating techniques
carbolic acid
in neurosurgery
salt solution
antisocial behaviour, controlling
aorta
aortic aneurysm
apothecaries
appointment of surgeons
Aristotle
arm
amputation
compound fractures
arrogance
arrow wounds
arteries
16th-century anatomy of
aorta
carotid
femoral
Galen on
iliac