Blood and Guts
Page 1
Table of Contents
Title Page
Title Page
Copyright Page
Dedication
Foreword
Preface
CHAPTER 1 BLOODY BEGINNINGS
CHAPTER 2 AFFAIRS OF THE HEART
Picture Section 1
CHAPTER 3 DEAD MAN'S HAND
CHAPTER 4 FIXING FACES
Picture Section 2
CHAPTER 5 SURGERY OF THE SOUL
TIMELINE
FURTHER READING
Index
PICTURE CREDITS
BLOOD
AND
GUTS
BLOOD
AND
GUTS
A HISTORY OF SURGERY
Richard Hollingham
Foreword by Michael Mosley
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ISBN 9781407024530
Version 1.0
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Published to accompany the BBC television series Blood and Guts, first broadcast on BBC2 in 2008.
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First published in 2008 by BBC Books, an imprint of Ebury Publishing. A Random House Group Company.
Copyright © Richard Hollingham 2008
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ISBN: 9781407024530
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To my mother, Penelope Ann Hollingham,
who would have made an excellent surgeon.
FOREWORD
by Michael Mosley
In the early 1980s I trained to be a doctor at the Royal Free Hospital in Hampstead, London. I had five wonderful years, made lifelong friends and met my future wife, Clare. So although I now work in television and no longer do any form of hands-on medicine, I have few regrets about the years I spent poring over books and dissecting corpses. I did at one point in my training think about becoming a surgeon; after all it was a branch of medicine that was sexy, glamorous and well paid. Then something happened that made me realize that surgery was probably not for me.
One of the essential manual skills we had to learn early on was how to stitch up wounds. We practised by sewing bits of orange peel together and were then let loose on patients. The transition from uncomplaining oranges to human skin was always going to be a challenge. I remember with some embarrassment my first time. I was down in casualty on a Saturday night, a third-year medical student, intensely nervous. The place was crowded with the usual mix of drunks and minor injuries. I was asked to stitch up one of the drunks, an old tramp with a badly battered face, who had fallen over and gashed his forehead.
I pulled on gloves over my sweating hands and, with the assistance of a nurse, got together needle and thread and began to sew. I was slow, meticulous and careful. My patient was garrulous, confused and uncooperative. Finally I finished. But as I tried to pull away my left hand, which I had been using to hold the wound closed, we both got a nasty shock. I had sewn my glove to his head. I cut the stitches and started again, but I think I realized at that moment that I didn't have the manual dexterity, the precision, the sheer attention to detail that marks out the best surgeons.
Since then I have been in many operating theatres and watched many surgeons perform their magic. Fifteen years ago a surgeon saved the life of my son, Jack, and I have met many other people whose lives have been transformed by surgery. All this stimulated my interest both in surgery and its history, particularly the individuals and their discoveries who got us to where we are today.
The actual decision to make a television series rather than just think about it emerged from a conversation I had with Janice Hadlow, the dynamic controller of BBC4. I had just completed a series for BBC4 called Medical Mavericks, a history of medicine told through the stories of self-experimenters. Janice suggested that a series on surgery would be the next obvious thing to do. We soon agreed that the best approach would be a five-part series covering five different areas of surgery, and I went off to decide what exactly those programmes should contain.
Making television programmes is a collaborative process, and the end product the result of many different people's thoughts and insights. After some debate with my production team we decided to go for trauma surgery, cardiac surgery, plastic surgery, transplant surgery and neurosurgery. Each area illustrates something different about how surgery has progressed, and each is packed full of colour-ful characters and moral dilemmas.
We also decided that the programmes should not be purely historical but should start with an example of the best of modern surgery in that particular field. We would then use the modern case to look back at how the various elements of that particular operation had come about.
Many of the operations I witnessed while filming were memorable, but the one I found particularly striking was performed by cardiac surgeon Steven Westaby at the John Radcliffe Hospital in Oxford. The patient was thirty-four-year-old Sophie Clark.
Sophie had a couple of serious cardiovascular problems, which she'd had since birth. The first was a defect in a heart valve, the second an aortic aneurysm. An aneurysm is a weakening and swelling of a blood vessel, rather like a faulty tyre. As with a tyre, the risk is that under pressure it will burst. If the problem lies in the aorta, the main artery of the body, this would almost certainly mean death. The operation to correct both these two defects was extremely complex.
First Sophie was anaesthetized – a development pioneered in the mid-nineteenth century by William Morton, James Simpson and others (see Chapter 1).
Then she was connected to a heart-lung machine, the first of which was built and tested by John Gibbon in 1953 (see Chapter 2).
Next her heart was stopped, using potassium chloride, a chemical more commonly used for making fertilizer.
Then her body was cooled from a normal body temperature of 37°C to a decidedly chilly 16°C. This was to slow her metabolism and cut her brain's oxygen demands during the operation. It's an approach that was first suggested by Bill Bigelow, who was in turn inspired by research he had been doing into the hibernating habits of groundhogs (see Chapter 2).
Finally, all her blood was drained. As Steve put it, 'Heart surgeons are basically plumbers. You have to get the blood out the way just as you have to switch off the water before you change the pipes.'
At this point Sophie looked like something from the morgue.
She was chilly to the touch, grey in the face, had no heartbeat, and the EEG technician could detect no signs of brain activity. She was as close to death as anyone I have ever seen.
Steve, under some pressure to get the operation done in as short a time as possible, did a magnificent job correcting her problems. He replaced her faulty heart valve with an artificial one, repositioned and reattached blood vessels using techniques first developed by Alexis Carrel (see Chapter 3), then warmed her up, started her heart, sewed her back up and the operation was done. She has since made a full recovery.
GOING FIRST
* * *
Not all surgery ends quite so happily. The thing about pioneering surgery is that it can, and often does, go wrong. The price of going first is that it is often those who come later who benefit from the lessons learnt. The history of surgery is littered with stories of patients who died while undergoing experimental procedures. In many cases, the sort of procedures attempted would not pass a modern ethical committee.
To be fair, the problem does not always lie with the surgical team. Take the case of Clint Hallam, the New Zealander who became the first man to have a 'successful' hand transplant. The operation took place in France in September 1998, and I remember vividly being impressed and slightly disturbed when I first saw this reported all over the news. I did not realize at the time that I would become involved and obsessed with Clint's story as it unfolded like a Greek tragedy.
In 1998 most people had got used to the idea of swapping body parts, as long as those parts were internal. Heart, liver, kidneys, lungs – all have long been eminently respectable organs to transplant, the main issues with them being around limited supply. Who should get the organ when it becomes available? Is it right to pay for organs? Questions like these were the main preoccupation. Suddenly we were confronted by something very different. Not only was the transplanted organ, the hand, quite obviously on display, but in some ways the operation itself was seen as 'cosmetic'. You can't live without a heart or lungs, and your quality of life without kidneys is poor. Surely, however, you can function perfectly well without a hand? The cost of keeping a transplanted organ is high. The drugs that prevent rejection will take something like ten years off your life. Many people felt that performing a hand transplant was morally indefensible.
Those who argued the counter-case – that a patient should have the right to choose whether thirty years with two biological hands was preferable to forty years with one – were not helped by what happened next. First it emerged that Clint had a criminal past (albeit for a minor tax fraud), then things began to go wrong with the transplanted hand. Clint stopped taking his pills and the arm started to be rejected.
At the time I was making a series for the BBC called Superhuman, looking at cutting-edge medicine. I sent a producer over to Perth, Western Australia, to film an interview with Clint. The transplanted hand looked absolutely terrible, more like a huge pink rubber glove than something human. It was useless for anything more sophisticated than holding a toothbrush, and it was clear that Clint now hated it. He talked about how people he met were repelled by it and said he was thinking about having it removed. However, he was still, in some wholly unrealistic way, also hoping to save it.
A year later I was flying back to London from California when I noticed Clint on the plane. We chatted about how things had been going and he told me that he was on his way to London to have the hand removed. It had reached the point where it was not just failing, but rotting. He had finally accepted that it was dead and the dream was gone. The following day he had it removed by surgeon Nadey Hakim.
So why did the world's first hand transplant go so badly wrong? When I asked Clint, he accepted that he had not been a model patient, but felt that his French medical and surgical team had not prepared him adequately for what was to come. In particular, he felt that the hand they had chosen to transplant was not well matched: 'I was ****ing angry with the doctors, and I am still angry that they didn't match it. It was huge and quite different to my other hand.'
Despite this, Clint told me that he does not regret having had the operation, and had recently rung around transplant surgeons offering himself as a candidate for a further hand operation. It's fair to say that there has been no rush to put him on a waiting list.
Since Clint's operation, more than thirty hands have been transplanted successfully. I went to Louisville in Kentucky to meet one of the most recent patients and try to understand what makes the difference between success and failure. On the way to the hospital I had a chat with my cab driver about his views on transplants. He felt that there should be no limits, that it should be down to the patient, the donor and the surgeon to decide. Oddly enough, he seemed most worried about where the donor organ had come from: 'I would not have an organ from anyone on death row as I would not like to have bad genes injected into my body.'
The surgeon who heads the transplant team at the Jewish Hospital in Louisville is Warren Breindenbach. Charming and hyperactive, Warren believes that what has been done so far is just the beginning; that eventually there will be no part of the body that's not transplantable.
Back in 1998 Warren and his team had been widely regarded as the ones most likely to perform the first hand transplant. Clint had travelled to Louisville and offered himself as a patient to the American team. That same year, on 23 September, Warren was in New York to meet Clint for further discussions when he turned on the television and discovered to his considerable surprise that not only was Clint in Paris, but he had had a hand transplant. The French had got there first. When I asked Warren if he felt disappointed he said, 'I think every human being always wants to be a leader, but I have told my team and I have emphasized over and over again: it doesn't matter who does it first. It matters who does it best.'
Since 1998 Warren has performed three hand transplants, and the latest is perhaps the most remarkable. In November 2006 he led a team of surgeons in replacing the right hand of fifty-four-yearold David Savage. What is unusual about this particular case is that David had lost his hand in an industrial accident thirty-two years earlier. As Warren explained, this made the operation rather tricky: 'We ran into problems which were novel and new, and the analogy I make is kind of like closing your house down for thirty-two years, then coming back and deciding you are going to take a shower. You turn on the faucet and it sputters a little, and sometimes it works and sometimes it doesn't, so we had some sputtering as we tried to get the blood to flow into the hand that we were transplanting. But it worked.'
The operation was, in the end, a technical triumph. But I wondered if David, unlike Clint, was truly comfortable with his new hand. When I first met David and his wife, Karen, I was instantly struck by how different his new hand was from his other one. While David is powerfully built, relatively dark-skinned and has thick black hair on his forearms, the new hand was smaller, paler and more delicate.
I asked David if he found it strange to have the hand of someone now dead, and he said 'no'. Since the operation, he had felt it was part of him. I then asked him if he had considered the possibility that this hand had come from a woman, and he said he had, but it didn't bother him. He had found the fact that the fingernails on the new hand grow twice as fast as those on his own hand slightly disconcerting, but his main feelings were of gratitude to the family of the unknown donor.
David is undoubtedly happy to have had the operation, and optimistic about the future. When I watched him in his physiotherapy session I began to see why. He can catch things, lift up objects and manipulate tools. He has around 60 per cent of the function of a normal hand, and with more physio he may eventually get to 80 per cent.
The nerves that supply sensation are regrowing, and feeling is slowly coming back. He described with enormous satisfaction some of the simple pleasures of being able to use both hands again: 'Last September I went to my granddaughter's birthday party and just grabbing hold of her and picking her up was a fantastic feeling.'
Warren Brein
denbach believes that successful surgery relies on cooperative patients. 'It's no good to only have a good surgeon. If you hook everything up properly but the patient goes home and doesn't use the hand, doesn't do physical therapy, then you get a lousy result. It is extremely important, the physical therapy and the cooperation, and that's where David has been an excellent patient.'
David's example made me question my initial scepticism about the benefits of this kind of surgery. I'm still not convinced that in his circumstances I would opt for a transplant, but I can certainly see why he did.
SELF-EXPERIMENTING
* * *
While making the series, I thought it would be interesting to immerse myself in the subject by repeating experiments from the early years of surgery. Things started innocuously enough with a spot of leeching. I had been puzzled as to why doctors and surgeons had gone on using bloodletting and leeches as a significant part of their practice well into the nineteenth century, so I met up with leech enthusiast Rory McCreadie, who promptly put a young, hungry leech on my arm.
After a few moments getting orientated, the leech bit and started to suck. Initially it was slightly painful, but then the bite went numb as the leech injected some form of local anaesthetic into the site. Rory and I now had to sit around for about an hour until the leech had gorged itself to the point where it was happy to let go. If you try to remove a leech before it is finished, it will leave its teeth behind inside you. Rory told me that in the eighteenth century leeches could be found all over England; a particularly good spot for them was Glastonbury in Somerset. Sadly, industrial pollution has wiped them out, and this particular one had been specially bred in sterile conditions on a leech farm.
Eventually the leech, now four times its original size, fell off. My blood then began to flow or, more accurately, slowly drip on to a plate. This is main point of the exercise. The leech injects an anticoagulant to stop your blood drying up when it is feeding. After it stops feeding you continue to bleed; the aim is to lose about a cupful of blood. In my case, I went on bleeding for nearly twenty-four hours.