Blood and Guts

by Richard Hollingham

  Cauterizing was not only brutal, it was also ineffective. By the time the surgeons had amputated a limb, a tremendous amount of blood had already been lost. Many soldiers bled to death before the arteries could be sealed shut. Even if they didn't die immediately, they would often lose so much blood that their chances of recovery became even slimmer.*

  * Paré also had to deal with increasing numbers of casualties suffering severe burns. Lines of gunpowder would be laid by the enemy to create explosive walls of flame, cannons could misfire, and there were regular accidents with powder flasks and kegs. The salves available for burnt skin caused horrible blistering, and wounds often became infected as a result. Paré developed new treatments for burns and revised traditional ones. In one instance he used the juice of onions mixed with salt, which he applied to the wound with a cloth. He reported it as being a remarkable treatment.

  Paré started desperately looking for better and more humanitarian ways of treating battle wounds. His priority was to work out a more effective method of stemming the flow of blood. What little spare time he had was devoted to studying anatomy texts. When the guns went silent, he spent the evenings drawing diagrams and making reams of notes. His aim was to seal the arteries themselves – rather than the entire wound – block them off to prevent the worst of the blood loss.

  His solutions were simple. His first invention he called a 'crow's beak'. The beak consisted of a set of curved forceps that could be clamped across the artery to block the flow of blood. Although other, smaller blood vessels would still be open, this device stopped the worst of the bleeding and bought him time during operations.

  Next Paré devised a way of tying off blood vessels during amputations. This was not a completely new idea, but there is no evidence that it had been tried in practice before. Once the artery was clamped off using the crow's beak, he would tie off the vessel downstream of the forceps using silk thread. This 'ligature' would permanently block the artery. Starved of blood, the portion below the ligature would eventually die and drop off.

  Paré published his first book, Treatise on Gunshot Wounds, in 1545. In it he detailed his experiences in combat and the lessons he had learnt. His practice of not using a cauterizing iron or boiling oil was widely adopted by those who read his work. The book revolutionized trauma surgery, or at least it did in many parts of mainland Europe. Unfortunately, because the book was written in French and not translated into Latin or English, other surgeons – particularly in Britain – continued to use cauterizing as a 'treatment'.

  From a young, inexperienced, barely qualified surgeon, Paré went on to become one of France's most celebrated medical practitioners. His treatise was finally translated into English in 1617 as The Method of Curing Wounds Made by Gun Shot (Also by arrows and darts). The book is gloriously illustrated with a gruesome woodcut of a 'man of wounds'. The man has an axe through his head, a bullet through his leg and a dagger in his side, in addition to wounds from swords, arrows, spears and darts. Seventeen wounds in total. Even an accomplished surgeon like Paré would be hard pushed to treat him successfully.

  Paré's crow's beak and ligature, although brilliant innovations, were less effective in practice. To stem the flow of blood completely following a thigh amputation, for example, more than fifty ligatures are required – although around ten would probably suffice to stop the worst of the bleeding. But in the dirt, smoke and poor light of a makeshift field hospital, even applying ten ligatures would prove completely impractical.

  Likewise, trying to apply the crow's beak to a slippery artery that was spurting out blood at high pressure, while struggling to hold down a screaming patient, was an appalling challenge. It wasn't until the invention of an effective tourniquet (such as the 'Petit' type used by Liston) that ligatures really came into their own. But Ambroise Paré's contributions to modern surgery are nevertheless considerable. Above all, his efforts to reduce his patients' suffering shines through as a fine example to future generations of surgeons.

  Thanks to Vesalius, Galen's mistakes had been corrected and surgeons now knew how the body fitted together. Paré had worked out how to tie off blood vessels and prevent patients from bleeding to death. What both men had in common was the courage to question the status quo; to challenge incorrect medical dogma. These were surgeons who trusted what they saw with their own eyes and learnt from their own experiences. Two major barriers to successful surgery had been broken. It would be more than three hundred years before the next major obstacle – pain – was overcome.

  TWENTY-FIVE SECONDS

  University College Hospital, London, 1846

  * * *

  Frederick Churchill of 37 Upper Harley Street was admitted to hospital on 23 November. Unmarried, and employed in service all his life, he had started as a footman and for the past sixteen years had worked as a butler.

  A clerk noted down everything as the dresser asked a series of questions. The case notes would later run to some ten pages.

  Aged thirty-six, Churchill was five feet eight inches tall with a fair complexion. His state of mind was cheerful and his sleep was generally sound. His habitual state of health was good, although not as strong as it had been eight or nine years ago. He was, the dresser noted, rather thin. Churchill's medical history included an attack of gonorrhoea eighteen years previously, and another attack around ten years after that.

  In the year 1840 the patient had experienced a swelling in his right knee that became very painful. Severe pain was also experienced following a later fall in which the same knee was violently bent. In 1842 'considerably more' swelling and a 'discoloration of the leg ensued' following an injury to the left limb.

  There had, the dresser recorded, been some outpatient treatment ordered by a medical man, but this had been discontinued. Then, in 1843, the swelling had been opened up – cut into with a knife – and 'a number of irregularly shaped bodies' were pressed out. These bodies appeared to have a fibrous, granular structure and varied in size from a pea to a large bean. They were preserved in alcohol and examined under a microscope. There were sufficient of these bodies to fill a two-ounce bottle.

  'It is Professor Liston's opinion,' the dresser concluded, 'that these bodies are the remains of extravasated [forced out] blood.' Churchill's appearance was described as like that of someone in 'good but not robust health'. The right knee was much swollen and a probe could be passed through the cavity in the joint. Following this, Churchill was ordered to remain in bed. 'A thin serous discharge is given out. Pulse 80. Ordered to have a full diet and milk 1 pint.'

  On 25 November Professor Liston examined the patient himself. He passed a probe into the knee and made an incision. Probing with his finger he could feel bare bone and the head of the tibia, one of the lower bones of the leg. He pulled on the bone to see if it was loose but this did not appear to be the case. Liston ordered that clean warm-water dressings should be applied and Churchill should undergo complete rest.

  Churchill's condition began to deteriorate. He lost his appetite and the dressers noted that his tongue had become furred. More substantial food was ordered – a chop daily, a pint of beef tea and a pint of porter. On 27 November he experienced a terrible attack of pain extending from the hip to the toes. The swelling in the knee had increased and he suffered shivering, sickness and headache. Hot fomentations (poultices) were applied, which helped to relieve the pain.

  On 17 December the dresser recorded that the patient 'had a kind of hysterical attack and was much excited', but by 20 December his appearance had improved and he appeared to be 'more healthy'. The next day he would go to the operating theatre to have the limb removed. Frederick Churchill had yet to be told that he would be part of a groundbreaking experiment.

  At twenty-five minutes past two on the afternoon of 21 December, the porters carry Churchill into the operating theatre. As usual the galleries are filled with undergraduates nervously anticipating what was usually a dramatic, and often horrific, event.

  Churchill is utterly terr
ified. He had known when he was admitted to hospital that it would probably come to this. At least with Professor Liston the ordeal would be over in a matter of seconds. Could he bear the pain? Could he appear strong in front of all these men?

  Liston enters. The room goes quiet. 'We are going to try a Yankee dodge today, gentlemen, for making men insensible.' For the first time in the United Kingdom an amputation is about to be attempted using an anaesthetic. There had already been some trials at the hospital using hypnotism, or 'mesmerism', but the results had been mixed. Fundamentally, it was difficult to prove the scientific rationale for mesmerism, and among men of science it was considered superstitious nonsense.

  The 'Yankee' Liston spoke of was the American inventor of the ether anaesthetic, William Morton, a Boston dentist. Morton had been trying a gas called ether – a pungent mixture of alcohol and sulphuric acid – on his patients during the extraction of teeth. (Given the generally poor state of dental health, there was no shortage of subjects.) Morton's process of 'insensibility' reached the attention of surgeons at the Massachusetts General Hospital in Boston, who were keen to use ether during operations. In a submission to the American Academy of Arts and Sciences, a surgeon at the hospital, Henry Bigelow, described the effects of ether both for dentistry and more serious operations. He reported a tooth extraction on a 'stout' boy of twelve. Upon wakening, the boy declared it was 'the best fun he ever saw'. The boy insisted on having another tooth extracted. In early November 1846 ether was tried on a young girl having her leg amputated above the knee. She lasted the whole operation without feeling a thing.

  But Churchill doesn't know any of this. He lies on the operating table. A rubber tube is held to his mouth and he is told to breath through it for two to three minutes. The tube is connected to a flask containing ether gas. As Liston stands ready with his knife, the only sound in the room is Churchill's deep anxious breaths. Eventually the man becomes still.

  After the rubber tube is removed from Churchill's mouth, a handkerchief laced with some drops of ether is laid over his face. Liston looks up at the galleries. The students are more excitable than usual – this would truly be one for the history books.

  'Now gentlemen, time me!'

  Liston slices his knife into Churchill's thigh. The tourniquet is tightened, Liston's swift movements cut the familiar U-shaped incisions, sweeping around the leg, pulling aside the flesh to expose the bone, to and fro with the saw, the ligature ready and the stitches in, the severed limb lying in a pool of congealing blood in the sawdust.

  'How long, gentlemen?'

  'Twenty-eight seconds.'

  'Twenty-six seconds'

  'No, I made it thirty!'

  'Thirty?' exclaims Liston.

  'Twenty-five seconds!'

  This last figure has the time recorded in the case notes for the operation. Churchill has remained insensible throughout, not a sound came from his lips, not a groan, not even the slightest grimace.

  'When are you going to begin?' exclaims the patient a few moments later.

  This is greeted with peals of laughter from the gallery. There was rarely laughter after an operation. Churchill looks terrified. 'Take me back, I can't have it done!' Only when his amputated leg is held up for him to see does he believe that the operation has already taken place. He looks down to see his gently weeping stump. Later Churchill recalled feeling only a sense of great coldness and the memory of 'something like a wheel going round his leg'. The porters come forward with the stretcher to take him back to the ward. 'This Yankee dodge, gentlemen, beats mesmerism hollow!' declares Liston.

  Later in the day another patient is given ether inhalation during an operation for an ingrowing toenail – previously an unbearably painful procedure. Flushed with success, Liston rushes off a quick letter to the Lancet, writing of the 'most perfect and satisfactory results'.

  It is some minutes after Churchill is laid back in bed that he starts to feel any pain. By seven in the evening it has become excruciating. A dresser ties off more ligatures, making a total of ten altogether. Later, the two U-shaped flaps of skin are tied together with a series of sutures. Considering the agony, Churchill is remarkably cheerful, and as the evening progresses the pain begins to subside.

  The patient is to remain in hospital for another seven weeks. On 31 December the dressers report that he is improving daily, the stump is healthy and 'discharging a small quantity of good pus'. A bandage is applied. By the end of January he is walking around on crutches. Frederick Churchill's case notes record that he was 'discharged, cured' on 11 February.

  Soon, thanks to the pioneering efforts of a Boston dentist and Liston's reputation in Britain, almost every surgeon wanted to try ether. This Yankee dodge was surely the future of surgery. Some still felt that pain was an essential part of the healing process, but given the choice, what patient would want to go to them for an operation? During the Crimean War (1853–6), for instance, by which time anaesthetics were commonplace, surgeon John Hall was reported as saying, 'I like my patients to feel the smart of the knife.'

  Liston took to holding parties at which ether was passed around the assembled guests. These social events usually included a cross-section of the capital's best-known artists and sportsmen, as well as surgeons, doctors and other gentlemen and their wives. Much hilarity ensued when the gas was tried out by some of Liston's assistants and they were seen to lapse into insensibility.

  The relatively small doses of ether applied before operations meant that patients were 'under' for only a few minutes at most, yet the possibilities the successful relief of pain offered were endless. Operations no longer had to be so fast. Surgeons could take their time; they could attempt more complicated procedures. Robert Liston would not live to see the full potential of anaesthetics realized. He died in a sailing accident less than a year later. But by then his era of lightning-quick surgery was over.

  THE MEDICAL STATE OF THE ART

  * * *

  While surgeons were saving lives with new techniques, medical science was struggling to catch up. The work of doctors had barely advanced since the Middle Ages, and if surgery was an inexact science, then Western medicine was more akin to a faith, a bit like astrology – scientific method built on foundations of sand. Treatments had changed little over the proceeding centuries and were limited in their scope. There were few cures available to doctors, and fewer genuinely effective drugs. Apothecaries boiled up all sorts of weird mixtures with varying results. A typical example from Guy's Hospital includes 'bath of herbs and sheep heads' prescribed to a woman suffering from an 'unknown illness'. How marinating the poor lady in offal was going to cure her was anyone's guess. Still, she probably paid handsomely for the privilege.

  At best, all doctors could hope to do was to assist the natural process of healing. This might work for influenza, but would be completely ineffective against tuberculosis, syphilis or a heart condition. Even in the 1840s, the work of the physician was still firmly rooted in superstition. When you called on a doctor to attend you – and they did not come cheap – you might reasonably expect some sort of treatment. But the physician's options were limited. Medical practice was still based on the theory of the four humours developed by Galen. It was the job of the doctor to balance the bodily fluids of yellow bile, black bile, phlegm and blood.

  As the understanding of anatomy had advanced over the centuries, most Victorian doctors knew this view of physiology no longer made sense. Yet the treatments available remained largely unchanged. Doctors could prescribe drugs. Some were effective for pain relief but others, such as mercury, were downright dangerous. Physicians would induce vomiting or diarrhoea in the patient to purge the body. They could also drain away excess blood. All these treatments made sense if you accepted the idea of the humours. They made no sense at all if you looked at the growing scientific evidence against them.

  Bloodletting was as important to early Victorian medicine as it had been for almost two thousand years. Draining blood allowed doctors t
o remove 'morbid' matter from the bloodstream. This, the logic went, would be replaced by new healthy blood. Doctors carried scalpels or lancets (hence the name of the medical journal) to cut the skin and allow the blood to drain into shallow bowls. Others employed 'cupping' techniques, where small glass bowls were heated and placed over the lanced area of skin. The bowls cooled, forming a vacuum which helped to suck blood from the body.*

  * Cupping also proved effective for pain relief, and was in common use in hospitals until the 1950s.

  Some doctors preferred using leeches rather than cups. When leeches are attached to the skin they secrete a chemical that prevents the blood from clotting. This anticoagulant is so effective that even when the leech is removed, the wound will continue to bleed for another three to four hours. Leeches were particularly useful for bleeding sensitive areas of the body, such as the gums or around the eyes. American leeches were said to have a less irritating bite than British ones. The received wisdom was that leeches should be kept in a tub of river water with some peat or turf. It was best to rinse them before application.

  For the modern physician who wanted to keep up with cutting-edge medical advances, scarifiers were the answer. These vicious contraptions resembled the mechanism of a clock and were marketed as the 'mechanical leech'. This 'new and modern' device contained a row of blades. When it was placed against the skin and a button was depressed, the blades sprang out to puncture the surface and induce bleeding.

  The cases where bloodletting appeared to be effective were probably attributable to the placebo effect – the patient's belief in the treatment.* At least with bloodletting, patients were getting something for their money. However, by the 1860s evidence was mounting that the procedure was not only useless, but was probably doing more harm than good, particularly when advances in human physiology showed that bloodletting reduced the concentration of red blood cells. These contain haemoglobin, the protein complex that carries oxygen.