Under the Knife
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It is no longer always necessary to perform a tracheotomy to alleviate an acute breathing problem. It was replaced by intubation – the insertion of a breathing tube into the windpipe via the mouth – around the beginning of the twentieth century. The breathing tube is one of the most successful life-saving devices in modern medicine. It is a simple, disposable plastic tube, flexible, about 1 centimetre in diameter and 30 centimetres long. There is a small balloon around the end, which is blown up once the tube has passed between the vocal cords and into the windpipe. That creates an airtight seal between the lungs and the respiratory machine to which the tube can be connected. This method is not only used to alleviate breathing problems, but also for respiration during general anaesthesia for operations. Effective intubation with a breathing tube in the patient’s windpipe has become a basic condition of every large-scale operation. In the rare cases that intubation is not successful and the patient threatens to suffocate, a tracheotomy can always be used as a last resort.
The events of Friday 22 November 1963 would pursue Malcolm Perry for the rest of his life. He had been a surgeon for just two months when the dramatic events unfolded and he had a very busy few days. But it was far from over: Perry was called immediately to the operating theatre to operate on Governor Connally, and two days later he was there again, with his hands in Lee Harvey Oswald’s abdomen, trying to stop arterial haemorrhaging.
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Wound Healing
The Royal Prepuce: Abraham and King Louis XVI
AN OLD MAN hears a voice. He picks up a stone and strikes his penis to remove the prepuce, the foreskin. Then he does the same to his son and slaves. The men must have found the operation too painful as, shortly afterwards, it is decreed that circumcision is best not performed on adults but on male babies, on the eighth day after their birth.
The old man was Abraham. This story is told in chapter 17 of the Book of Genesis. Why he would do something so remarkable to himself can be explained not only historically, sociologically, anthropologically and theologically, but also surgically. At that moment, the old man had not successfully fathered a child for the past thirteen years. Throughout this whole chapter from Genesis it is clear that Abraham and his wife, Sarah, now both quite elderly, would still like to have a child of their own, but are having no luck. Could Abraham’s foreskin have something to do with that?
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There is an illness that can make sexual intercourse quite painful for a male: phimosis, a constriction of the foreskin caused by a chronic infection between the foreskin and the glans. The people of Abraham lived in the desert somewhere between Ur and the Mediterranean Sea. It was very dry and dust clouded up with every step they made. The robes they wore in those days were open from below and they wore nothing underneath them, so the dust could go everywhere. Moreover, they had little understanding of hygiene. Genesis repeatedly speaks of people washing themselves with water, but that is limited to the feet. Water was scarce in the desert and needed for cattle. So there was probably not enough to wash yourself daily. It is therefore not surprising that the tradition of circumcision mainly prevailed – and still does – among people who lived in the desert, not only in central Asia – as with Abraham, the Jews and the Muslims – but also among the Aboriginals in Australia and various African peoples.
Phimosis primarily becomes a problem during an erection, as the glans is obstructed and the foreskin may tear. The movements associated with sexual intercourse exacerbate the symptoms, making it increasingly difficult to bring the act to a satisfactory conclusion. Can this make a man so desperate, especially if he passionately wants to found a long lineage, that he is willing to remove the most logical cause of the problem – his foreskin – by striking it with a stone? Don’t most surgical operations have similar origins? If you are sick to death of a pustule or an abscess and the pain is keeping you from sleeping, you cut it open. If the persistent throbbing, thumping pain of an infected tooth is becoming unbearable, you rip it out. If a bladder stone is driving you to distraction, you cut it out. If your foreskin is spoiling your attempts at procreation, you strike it off with a stone. In any case, shortly after this surgical operation, Abraham’s wish is fulfilled. In Genesis 21, Sarah gives birth to a son, Isaac.
What generally happens after circumcision is the theme of a Bible story that reaches its climax in Genesis 34, verses 24 and 25. We are now three generations further. The sons of Jacob promise not to avenge the defiling of their sister Dinah by a man called Shichem, a Hivite, if all male Hivites allow themselves to be circumcised. The Hivites, who were probably in the minority, are more than happy that this will put an end to the matter and agree. But they make the terrible mistake of all being circumcised at the same time. That is not smart, as Jacob’s sons are clearly better informed of the normal post-operative course than the Hivites. The same things happen after every operation – including a circumcision – with the same symptoms occurring.
During a surgical operation, the nerve fibres in the skin are stimulated directly. That means that the operation is immediately very painful. Not much later, after the knife – or stone – has been put aside, the initial pain ebbs away almost completely. The body has now started the healing process. In the first phase, the damage caused to the tissues is repaired by means of an inflammation. This is performed by special cells, called macrophages (‘big eaters’), which clear away all the debris. As a result of this inflammation, some three hours after the operation, the tissue begins to swell, causing pain again, but this time less severe. The wound is a little swollen, a little red and a little warm. In hygienic conditions, that’s as far as it goes. The inflammation disappears after a few days, and the pain with it. Cells known as fibroblasts (‘fibre-makers’) are now carried to the area of the wound and start to make connective tissue, ultimately forming the scar. This is called healing by primary intention (per primam in Latin) and usually lasts eight to fourteen days, depending on the depth of the wound.
However, in less hygienic circumstances, such as those described in the book of Genesis, bacteria in the wound will benefit from the damaged tissues, multiplying and attracting a second wave of inflammation cells. White blood cells, or leucocytes, try to destroy the bacteria. This leads to the formation of pus – a soup of harmful bacteria, dead leucocytes and damaged tissue. The wound becomes crimson, swollen and hot. In such circumstances, after an initial phase in which the pain is mild and bearable, there will be a new wave of excruciating pain, typically on the second day after the operation. Because, in biblical times, the day of an event was also counted, the second day after an operation was described as the third day (just as Christ is described as having risen on the third day, while Easter Sunday is actually the second day after Good Friday).
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Inflammation
Inflammation is our body’s reaction to something that should not be there. It is a varied and complex reaction performed by various kinds of cells, releasing a large number of substances, all of which either cause another reaction or serve as a signal for other cells. Through this complex process, an inflammation reaction can take various forms, depending on its cause. A sprained ankle, toothache, eczema, diarrhoea, AIDS, a smoker’s cough, warts, an infected wound, the rejection of a transplanted kidney, hay fever, a malfunctioning thyroid gland, dandruff, typhoid, asthma, clogged-up arteries and mosquito bites are all forms of inflammation where a different aspect of the reaction comes to the fore. The local symptoms of inflammation can be summarised in five indications: rubor (redness), calor (heat), dolor (pain), tumor (swelling) and functio laesa (loss of function). Two kinds of cells are essential to an inflammation: macrophages (large cells called in to clear away the debris resulting from damaged cells) and lymphocytes (small cells that can recognise components of a foreign substance and manufacture antibodies to fight them). An allergy is an inflammatory reaction to a foreign substance that gets out of hand. An attack by intruders (a virus, bacteria or parasite) invokes an inflammation tha
t we call an infection. If inflammation cells mistakenly see parts of our own bodies as foreign, the result is an autoimmune disease. An example is rheumatism, where parts of the joints are attacked by inflammation.
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That is why all the Hivites were in bed in terrible pain on the third day after their circumcision. With sharp surgical insight, Simeon and Levi – two of Jacob’s sons – had counted on that. They sneaked into the city with their swords drawn and slaughtered their defenceless patients in cold blood.
What happens to the operation wounds of patients who survive beyond the third day? As long as the wound is open and not too dirty and the tissue is not too badly damaged, the body is capable of fighting the infection. The pus can drip out of the wound and the bacteria are driven away from the healthy tissue, allowing the wound to heal. Until the mid-nineteenth century, surgical wounds were therefore always left open, because wound infections were inevitable. This is known as healing by secondary intention (per secundam). The wound gradually fills with granulating tissue and the skin grows over the wound from the edges until it is completely closed. Secondary healing can take a few weeks to several months, depending on the size of the wound.
In any case, we can conclude from both of these Bible stories that circumcision – at least at an adult age and in less than clean circumstances – is not a painless experience. It is not surprising that, several centuries later, the head of public relations of a young new religion pulled out all the stops to have circumcision removed as one of the requirements for men wishing to join the club. If St Paul had not put this point high on the agenda, Christendom would never have progressed much further than a Jewish splinter group. No adult Roman or Greek would have considered having himself circumcised. In the second century AD, the Roman emperor Hadrian (the one who had a wall named after him in Britain) issued a decree banning the practice. This led to two reactions, both politically and surgically: one progressive, the other reactionary.
Until then, circumcision had entailed cutting off only that part of the foreskin that could be pulled past the glans. This was known as the mashuk method. Partly in response to Hadrian’s decree, Simon bar Kochba led the third Jewish rebellion against the Roman occupiers and propagated, by way of provocation, the periah method, fully exposing the glans. That entailed removing the rest of the foreskin by cutting around the base of the glans (this is the origin of the word circumcise, meaning ‘to cut around’). Many of Bar Kochba’s supporters had themselves re-circumcised during the revolt and full circumcision became the standard method.
Just as re-circumcision was a political statement, the reverse operation was also available to those with less fervent political views. Anyone who had been circumcised but did not want to join the Jewish revolt could have their foreskin repaired and remain an obedient citizen of the Roman Empire. The operation, known as epispasm, was apparently performed with some regularity, since the Roman encyclopaedist Celsus described it as early as the first century in his book De Medicina. It was an ingenious and, according to Celsus, not even very painful method of reconstructing the foreskin.
All you needed to perform it was a knife and a toothpick. An incision was made around the base of the penis. The skin was then slid forwards over the shaft like a sheath, so that the end could be pulled over the glans to form, as it were, a new foreskin. The skin would be held in place by the wooden stick until the gaping circular wound around the base was completed healed. It was an ingenious operation because the patient’s urine did not come into contact with the open wound: an excellent example of the optimal use of secondary healing in times of limited hygiene.
Several centuries later, a new religion emerged in the same region. Although, these days, circumcision seems irrevocably linked to Islam, there is no mention of it in the Koran and it is not considered an obligation for Muslims. It is more a tradition. The thinking is that a father wishes his sons to look the same as he does.
In the dark ages that followed, Western civilisation lost its way. While philosophers in antiquity spent their time thinking about noble questions like the essence of being, the ideal form of state and ethics, the great medieval thinkers concerned themselves with the issue of the foreskin. If Jesus genuinely ascended to heaven in physical form on Ascension Day, what happened to the foreskin that had been cut off when he was child? Did it, as the Greek scholar Leo Allatius claimed, make the journey to heaven independently?
Although the Vatican took no official standpoint on this issue, tour operators avant la lettre were keen to take advantage of the possibility that the holy foreskin was still somewhere on earth. Claiming to possess a sacred relic was an assured source of income for a town or village. Pilgrims were Europe’s first tourists and tourism was a lucrative business, even back then. Cologne had the three kings, Constantinople the hand of John the Baptist, Trier the holy robe and Bruges the holy blood, while the sacred cross was splintered across the whole continent. After the small town of Charroux in France claimed to possess the foreskin of Christ, this mother of all relics turned up in a dozen other places in Europe. Even Antwerp had it. The last remaining foreskin was stolen from the small Italian village of Calcata in 1983.
Legend has it that the French royal family is directly descended via Charlemagne from Jesus of Nazareth, and therefore from Abraham as well. Christ’s last royal descendant was therefore Louis XVI. It can be argued that Louis’s foreskin played a decisive role in the advent of the French Revolution, which – as is well known – was to cost him his life. Louis also probably suffered from phimosis.
On 16 May 1770, the young Louis Auguste, the dauphin of France, was married to the Austrian archduchess Marie-Antoinette. They were both still children; he was fifteen years old and she was fourteen. On his wedding night, he fell asleep and early the next morning went hunting. His grandfather King Louis XV, the nobles at the royal court, and all the citizens of France were concerned that young Louis’s love life seemed unable to get off the ground. Marie-Antoinette was beautiful and willing, but had married the only Louis in the French dynasty who was not lusty and hot-blooded. Her Louis was apparently a listless and impotent boy who seemed unable to move beyond puberty. There was a rumour that the prince had a disorder of the genitals that prevented him from engaging in sexual intercourse and it was openly speculated that a simple operation might be required to remove the obstacle. Two months after Louis’s marriage, he was examined by Dr Germain Pichault de La Martinière, who found no abnormalities that might warrant an operation.
When young Louis had still not fulfilled his marital obligations after two years, his grandfather summoned him so that he could inspect the prince’s private parts in person. Louis explained that the sexual act caused him pain, making him afraid to continue. The king observed what he had already suspected, an abnormality of the penis, but did not go into any further detail. He referred his grandson to Dr Joseph-Marie-François de Lassone. Lassone examined the dauphin in 1773 and made an official statement that, on the contrary, Louis’s sexual organs were well formed. He concluded that the prince’s impotence was more likely caused by the ignorance and awkwardness of the young couple. It was, however, widely believed that Louis had an overly tight foreskin that restricted his natural desires.
In 1774, the old king died and the impotent prince became King Louis XVI. That made the problem more urgent. The non-existent sex life of the young royal couple became a public matter discussed and gossiped about at court and in the city. France was buzzing with rhymes, jokes and songs about the king’s assumed phimosis. On 15 January 1776, Louis XVI finally consulted a surgeon, Jacques-Louis Moreau, in the Hôtel-Dieu in Paris. Marie-Antoinette later wrote to her mother that the surgeon had given the same advice as all the other doctors: that the problem would right itself without an operation. Louis just had to keep trying.
Moreau was right, as his colleague Lassone had been. We now know that phimosis at a young age is often cured by spontaneous nocturnal erections and sexual activity, and that an op
eration is only necessary in the most serious cases. Unfortunately, there are no further details of the findings of this eighteenth-century surgeon, but the fact that the king went to a hospital to consult a surgeon rather than just calling a doctor to visit him at home, suggests that there was something seriously wrong with him; that his foreskin probably was at least a little constricted. But it seems that Louis did nothing.
In 1777, Marie-Antoinette’s brother came to visit with his entourage to try to sort out the matter. He apparently gave his brother-in-law a good talking to and put Lassone back on the job. This time there was no official report, but it did produce results. A few weeks later, in August of the same year, Louis and Marie-Antoinette were delighted. This time, it seemed to have worked. Dr Lassone was asked to confirm it officially: after seven years, the marriage had been consummated and the encounter in the royal bed had lasted an hour and a quarter. Marie-Antoinette wrote to her mother about the intense pleasure it had given her. The following year, she was pregnant and on 19 December 1778, she gave birth to their daughter, Marie-Thérèse.