Under the Knife

by Arnold van de Laar, Laproscopic surgeon

  Sisi was the victim of the ‘propaganda of the deed’, a bizarre philosophy associated with anarchism. In that respect, she was in good company: between 1881 and 1913, a series of public figures – including the Russian Tsar Alexander II, the Italian King Umberto I, the French President Sadi Carnot, the Greek King George I and the American President William McKinley were assassinated by anarchists. Luigi Lucheni was given a life sentence and committed suicide in his cell in 1910. His head was saved, in the interests of science. It was not until 2000 that it was decided that this rogue’s head was of little scientific interest and it was buried in the Vienna Central Cemetery, where Beethoven and Billroth also enjoy eternal rest. As was customary among deceased imperial and royal Habsburgs, Sisi’s body was interred in the Capuchin Crypt in Vienna. Unlike the deceased members of her in-laws’ family, however, her intestines were not interred separately in the crypt beneath St Stephen’s Cathedral and her pierced heart was not placed in a silver goblet in the Augustinian Church. Luigi’s file can be seen in the Sisi Museum in the Hofburg palace complex. The dress – with the hole made by the file – is on display at the national museum in Budapest. But without the corset.

  5

  Obesity

  Popes: From Peter to Francis

  A REMARKABLE MEDICAL conclusion can be drawn from the long list of 305 popes and antipopes that have graced Roman Catholic history to the present day. Their five year survival rate after being ordained was only 54 per cent. One in five did not even survive their first year. Being elected as pope therefore has a rather sombre prognosis, though some were so old when they took high office that it is no surprise they did not keep it for long. Clement XII was the oldest, elected in 1730 at the age of seventy-nine, yet he was pope for ten years. In 1975, Pope Paul VI set the maximum age at which a cardinal could still be elected pope at eighty years old. Benedict XVI was only two years short of this upper limit when he was elected in 2005.

  A common cause of death among popes in the past was malaria, which was prevalent in the marshes around Rome. It mainly affected those from outside Italy, who were not accustomed to the local climate and the mosquitoes that thrived in it.

  The death of a pope was often kept under wraps – and not only in the distant past. The details of the death of sixty-five-year-old Pope John Paul I in 1978, only thirty-three days after he was elected, are still shrouded in mystery. Still relatively young for a pope, he was found dead in his bed one morning. A post-mortem was never carried out and the accusations of foul play flew back and forth in the Italian and Vatican banking world. Only nine popes have held the pontificate for a shorter time. Sisinnius died after twenty days in 708 and Theodore II lasted for three weeks in 897. Leo V managed a whole month in 903, Celestine IV only seventeen days in 1241, Pius III twenty-six days in 1503, Marcellus II twenty-two days in 1555, Urban VII twelve days in 1590 and Leo XI twenty-seven days in 1605. Boniface VI, pope in the turbulent ninth century, died after only fifteen days, allegedly after ‘an attack of gout’. He may, however, have been poisoned by his successor Stephen VI, the malignant pope who dug up the corpse of Boniface’s predecessor in 896 to bring it to trial. In 752, Stephen II did not even make it to his ordination, dying three days after being elected. The only Englishman to occupy the papal throne, Adrian IV, died within five years, choking on a fly in his wine in 1159. His namesake Adrian VI from Utrecht – the only Dutch pope in Roman Catholic history – survived twelve months in Rome, dying there in 1523.

  From a surgical point of view, the medical histories of a number of popes are worth mentioning. In 1404, Boniface IX is alleged to have died of stones, possibly in his gall bladder, after being ill for two days. Alexander VIII succumbed in 1691 to the effects of gangrene in his leg. Pius VII, who had the misfortune to be pope during the time of Napoleon Bonaparte, died forty-five days after falling in his bedroom and fracturing his hip. At the end of the last century, in his apartment in the Vatican, Paul VI underwent a secret operation on his prostate via the urethra. The equipment purchased especially for the operation was later donated to a missionary hospital in a developing country. In 2009, Benedict XVI broke his wrist while on holiday, but that could be treated with a simple forearm plaster. He later had two small operations to implant a pacemaker to correct heart arrhythmia. And Jorge Bergoglio, the current pope Francis, had the upper lobe of his right lung removed at the age of twenty- one to treat bronchiectasis, dilations of the airways caused in the lung tissue following pneumonia.

  There was also a pope who was a surgeon himself. Pope John XXI was a professor of medicine in his home country of Portugal before being elected to the pontificate in 1276. He must therefore also have been active as a surgeon. During his term of office, he continued his study of philosophy and medicine in Italy. He wrote a book on the medical and surgical sciences, a standard work in medieval times, with the dramatic title Thesaurus Pauperum, the ‘treasure chest for the poor’. It was a kind of almanac, intended to make the achievements in healthcare available to the common folk, so that they could also benefit from them (if they could read, of course). Doctors had anxiously protected their knowledge for many centuries, for fear that their patients would no longer pay for their services. And perhaps also not to be caught out, as that knowledge actually did not amount to much. The pope’s book was thus mainly an extensive collection of home remedies and old wives’ tales. It offered cures for all kinds of complaints, surgical operations and recipes for preparing medicines. He even described several forms of contraception and ways to abort a foetus. Anyone who claims that contraception and abortion are incompatible with the prevailing views of the Vatican should take a look at this book by Pope John XXI.

  But all that rummaging around in old books was considered suspect. As a bona fide medieval professor, John must have familiarised himself with alchemy and have messed around with alembics and astrolabes which would have aroused suspicion, especially in the thirteenth century, that the Pope was not what he seemed. Rumours soon began that this strange (foreign!) professor was actually a magician. Pope John XXI would be irrevocably punished by God, as in the spring of 1277, the ceiling of his workroom suddenly fell on his head. As he lay there, buried beneath rubble and piles of heavy manuscripts, he allegedly just about managed to utter ‘My book! Who shall finish my book?’ Seriously hurt, he succumbed to his injuries six days later to widespread agreement that this was a deserved punishment for messing around with black magic.

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  Operations and obesity

  Bariatric surgery is the branch of gastrointestinal surgery concerned with obesity. The word ‘bariatric’ comes from the Greek baros (weight) and iater (doctor). It is a form of functional surgery and makes use of two kinds of operations. One reduces the size of the stomach, so that the patient eats less. This can be achieved by a gastric bypass, gastric banding or a sleeve gastrectomy. The second kind of operation, an intestinal bypass, reduces the functioning of the intestines so that less food is digested. There are also combinations of both methods. The gastric bypass, which has been conducted since 1969, is the most effective operation to reduce the size of the stomach. We now know that these operations can treat much more than obesity. They can also cure diabetes type 2, obstructive sleep apnoea syndrome (OSAS), high blood pressure and high cholesterol. Obesity is a known risk factor in all operations; the more overweight the patient, the more complications can occur. It is therefore to be expected that complications occur more often in bariatric surgery than with other forms of surgery. It has, however, become considerably safer since the introduction of laparoscopic (keyhole) surgery. Bariatric surgery is not a luxury – obesity is a serious threat to the patient’s health and, to date, it is the only treatment for obesity that can give the patient high expectations of sustained weight loss.

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  A common weakness among popes throughout the centuries was gluttony. It is alleged, for example, that Pope Martin IV died in 1285 after gorging himself on Lake Bolsena eels fed with milk. Pope In
nocent VIII was also immensely fat and slept the whole day. On top of that, he was certainly not a pleasant man. He was the pope who instigated the horrific witch-hunts that led to thousands of innocent women being burned alive. He eventually became so obese that he could no longer move and had to be breastfed by young women. You can imagine that the doctor who gave this advice had little trouble in retaining his post with the Holy See. For some incomprehensible reason, it was then decided to postpone the approaching end of this pope’s worthless life by giving him a blood transfusion. Three healthy young Roman boys each gave their blood for a ducat, but it was to no avail. The pope and his three blood donors died and the story goes that the coins had to be wrenched from the balled fists of the young men.

  Whether this was a blood transfusion as we now know it is not clear. Perhaps they simply gave the pope the blood to drink, let the boys bleed to death, and then the patient died anyway. But even if it was a vein-to-vein transfusion, the deaths of all four can be easily explained. After all, blood groups were not discovered until four hundred years later, in 1900, by Karl Landsteiner. There is little chance that Innocent had the rare blood group AB-positive, which would have protected him against an incorrect transfusion, while the chances that all three of the young men were O-negative, so that the pope could have successfully used their blood no matter what type he had, are even smaller.

  Obesity, falling asleep during the day and an unpleasant humour are, in religious terms, a combination of three of the seven deadly sins – gula (gluttony), acedia (sloth) and ira (wrath) – but are compatible, in medical terms, with obstructive sleep apnoea syndrome (OSAS). OSAS is a sleeping sickness caused mostly by obesity whereby, at night, the breathing stops repeatedly for a short time (apnoea). This is usually accompanied by snoring. Because of this disruption of their nightly rest, sufferers are unable to sleep deeply enough to enter the necessary REM phase. That makes them sleepy, bad-tempered and remarkably lethargic during the day. They will also often feel hungry, exacerbating their obesity and therefore their sleeping problems. Charles Dickens described a character with exactly these symptoms in his 1837 novel The Pickwick Papers. Consequently, OSAS is also sometimes referred to as Pickwick syndrome.

  Today OSAS can be treated effectively with a laparoscopic gastric bypass, a stomach-reducing operation that can break the vicious circle of lethargy, obesity and insomnia. It could have made a lot of difference in the case of Innocent VIII, as a fit, contented and effective world leader was exactly what the doctor ordered in those dark ages. If Innocent VIII did indeed suffer from OSAS, his death must be considered a genuine medical failure. Obstructive sleep apnoea syndrome can cause a chronic shortage of oxygen, stimulating the production of red blood cells. This results in an excessively high level of these cells in the blood rather than anaemia, meaning that you should definitely not give the patient a transfusion. Whatever the real cause may have been, Innocent’s death in 1492 marked a fitting end to the dark Middle Ages.

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  In contrast to Innocent VIII, his grandson Giovanni di Lorenzo de’ Medici, lord of Florence, represented the colourful highpoint in the history of the papacy. Giovanni, alias Pope Leo X, is reputed to have said when elected to the pontificate at the age of thirty-seven, ‘since God has given us the papacy, let us enjoy it’. During his seven years in the office, he managed to work his way through 5 million ducats (the equivalent of hundreds of millions of euros!). He raised the money by selling indulgences to poor sinners and clerical positions to the highest bidders, and spent it on orgies, parties, art and an opulent lifestyle.

  Like a number of other well-known figures from the Renaissance Leo X was homosexual. He suffered continually from fistula and fissures of the anus. That could be seen from the expression on his face when he rode through Rome on a snow-white horse with unprecedented pomp and circumstance on the day of his ordination as pope. His alleged lover was twenty-six-year-old Cardinal Alfonso Petrucci. Apparently, in 1516, the pope had had enough of Alfonso and came up with a scarcely credible story to rid himself of the young man. The pope was to undergo surgery on his anus by a surgeon called Vercelli. He claimed that Alfonso had bribed the surgeon to inject poison into his holiness’s rear end during the operation – at least this is what the unfortunate Vercelli had confessed during his interrogation in the torture chamber. The surgeon was quartered, but that was only a triviality. Cardinal Alfonso was found guilty and condemned to death. The pope had his former boyfriend strangled with a red silk cord.

  It was not so surprising that the Florentine pope had such a low regard for surgeons. Florence was a proverbial hotbed of sodomy. For many years, surgeons were obliged to report the anal complaints of their male patients to the city magistrates so that they – the patients – could be prosecuted.

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  Julius III was one of the most shamelessly gluttonous popes of all. Ironically, in the last few months of his life, he suffered from increasing problems with swallowing. Eventually he could not eat at all and, in 1555, he starved to death. These symptoms closely resemble those of cancer of the stomach or oesophagus. Malignant tumours where the oesophagus enters the stomach display typical symptoms and the prognosis is grim. The main problem is dysphagia, a medical term for difficulty with swallowing. While the growth is still small, it will cause problems with swallowing solid food, especially food like meat that is difficult to chew. The patient develops horror carnis, Latin for ‘fear of meat’. Food gets stuck in the oesophagus, giving the sufferer bad breath, foetor ex ore (Latin for ‘a smell from the mouth’). Swallowing becomes increasingly difficult and, within a few months, it is only possible to ingest liquid food. The rapidly growing cancerous tumour requires increasing energy and uses up the body’s reserves of protein and fat. Exactly when the patient needs more nutrition, he is no longer able to eat. He becomes emaciated, and develops cachexia – severe malnutrition – which ultimately leads to death.

  Four hundred years later, Angelo Roncalli became the kind-hearted and widely loved Pope John XXIII, who tried to steer the Catholic Church into the modern age in the 1960s by convening the Second Vatican Council. He, too, was seriously overweight. So much so in fact that they were unable to find anything to fit him when he was due to appear on the balcony of St Peter’s after his election. He therefore had to wear a robe with the back cut open. The cheering crowd on the square noticed nothing out of the ordinary. This pontiff also succumbed to stomach cancer.

  A tumour in the stomach does not usually cause problems with swallowing until a later stage, because the oesophagus is not affected. Yet horror carnis, the fear of meat, is typically one of the first symptoms of stomach cancer. In the stomach, the tumour is attacked by gastric juices. That causes an ulcer, which generates pain in the upper abdomen. The ulcer on the tumour can bleed, slowly, causing anaemia, or suddenly, leading to haematemesis (vomiting blood) and melena, a medical term for faeces that are coloured black due to blood in the intestines.

  As the tumour becomes larger, the patient will – as with oesophageal cancer – find it increasingly difficult to eat. Undigested food will be vomited out, leading eventually to fatal cachexia. Pope John XXIII did not reach this stage. He was diagnosed with stomach cancer after undergoing a stomach X-ray to investigate the symptoms of anaemia. The diagnosis was kept secret as long as possible. More than two thousand bishops from around the world attended the Council. John was the centre of attention, while he must have continually suffered from pain and stomach problems. He experienced repeated stomach haemorrhaging and was hospitalised on several occasions. He died in 1963, at the age of eighty-one, from a perforated stomach. The ulcer in his tumour had eaten through the stomach wall.

  If the stomach perforates, the contents of the stomach and gastric acid can enter the abdominal cavity and the patient feels a sudden, acute pain in the upper abdomen, like a stab wound. The peritonitis that always follows is a life-threatening condition that can only be treated with an emergency operation. The hole in the stomac
h must be closed or a piece of the stomach removed, and the abdominal cavity thoroughly rinsed with water. It was decided, however, not to perform this operation on the old pope. Medically and ethically, that was a wise decision. There was already no hope of recovery and this saved him from a miserable death from cachexia. Pope John XXIII survived another nine days with the peritonitis resulting from the stomach perforation. His body was laid to rest in an altar in St Peter’s Basilica, embalmed in a glass coffin.