Under the Knife

by Arnold van de Laar, Laproscopic surgeon

  7

  Fracture

  Dr Democedes and the Greek Method: King Darius

  IN ONE OF the most exciting books of all time, The Histories – written more than 2,400 years ago – Herodotus tells a story that was then already a century old. It is about a man who, at the age of about thirty-three, fell from his horse while hunting and dislocated his ankle, leaving his foot incorrectly positioned below his leg.

  Little is said about the circumstances of the accident, but much about what followed. A doctor pulled the foot back into place. In medical terms, that is known as reposition. That caused the man so much pain, however, that he asked another doctor for a second opinion. The latter’s advice was clear and simple – rest. Apparently the ankle recovered fully, as he conducted one military campaign after the other until he was finally defeated during a battle near Marathon in Greece. He was none other than Darius the Great, King of Persia, builder of the world’s very first asphalted highway and founder of the city of Persepolis. He called himself ‘the King of Kings’.

  The first doctor – the one who had caused him so much pain – was an Egyptian physician in service to the king. At that time, Egyptians were considered the best doctors. In actual fact, there was nothing wrong with his treatment, despite Darius not being satisfied with it. It would have been a big mistake not to pull the crooked ankle back straight again. A displaced foot has to be realigned with the the lower leg as soon as possible. Until that happens, the foot receives too little blood and starts to die off. But you needed guts to pull on the dislocated ankle of Darius. After all, as a doctor in Persia you had to comply with the thousand-year-old laws of King Hammurabi of Babylon. Known as the Code of Hammurabi, they have been preserved for posterity on a large pillar of black basalt more than two metres high, which can now be seen in the Louvre in Paris.

  The code was based on the rules of trade and surgeons would enter into an agreement with their clients: if the treatment was successful, they were paid. If not, they received nothing. If it went wrong, they were called to account – an eye for an eye, a tooth for a tooth – just like everyone else. Article 197 of the code states that if a man should break the bone of another, one of his bones should also be broken – unless the bone in question belonged to a slave. Then, under article 199, it was sufficient to pay half the value of the slave or – under article 198 – one gold mina if it were a freed slave. Article 218 says that if a patient died at the hands of a surgeon, the surgeon’s own hands were to be cut off. It may have been less lucrative to treat slaves, but it was much safer; under article 219, if a slave died during treatment, you could replace him with a slave of equal value – and keep your hands.

  The code has nothing to say about the doctor–patient relationship in the case of kings. Article 202 does state that a man who strikes someone of a higher rank or status shall receive sixty strokes with an oxtail whip in public. King Darius was, of course, above the law. He was so enraged by the pain from his foot that he ordered all his Egyptian physicians to be crucified.

  The second doctor who told Darius to rest was none other than Democedes of Croton, famed throughout Greece but at the time a prisoner of Darius. Democedes had been personal physician to Polycrates, the ruler of Samos, but had been captured along with the entourage of Polycrates. He was not noticed until Darius urgently needed a doctor for a second opinion.

  According to Herodotus, Democedes treated Darius’s ankle the Greek way, meaning ‘with a gentle hand’. The historian speaks as though Democedes knew exactly what he was doing, while all the other (non-Greek) doctors did not. His method must have been a great success, as Darius recovered completely and showered him with gifts and he was appointed as a slave to the Persian court. It is likely however, that Democedes did little more than examine the patient and conclude that the foot (thanks to his Egyptian colleague) was sufficiently straight and vital. All he had to do was reassure the king and prescribe him rest – that is to say, to be patient – and let the healing power of the body work its magic. Sometimes good care is that simple.

  Except, of course, that the story is most likely untrue. Herodotus had every reason to boast about the Greeks and their healing skills. He was himself a Greek and, at the time he wrote this story about the Greek slave who had saved the Persian king, Athens had just been destroyed by the Persians in the Second Persian War. Darius had begun the First Persian War, but was defeated at the Battle of Marathon in 490 AD. His son Xerxes then started a second campaign against Greece and, although it was the greatest military campaign ever seen in history, the Greeks again refused to succumb. Herodotus did his utmost to remain as objective as possible about the Persians but, nevertheless, this story about Darius’s ankle must be interpreted as Greek propaganda in the aftermath of the two Persian wars. With today’s surgical knowledge, it is difficult to believe that the dislocated ankle of such an important historic figure could have left no traces in records. And to heal an ankle joint without a lasting functional impairment or chronic pain calls for a precision that cannot have been possible in those times.

  The ankle is comprised of the talus, the uppermost bone in the foot, which fits neatly as a tenon into the ankle mortise of the lower leg. The ankle mortise is a rectangular socket of bones, formed on the inner and upper side by the tibia (shinbone) and on the outer side by the fibula (the calf bone). The foot fits into this structure so snugly that, in the event of a trauma to the ankle, it can only move out of position if the bones of the ankle mortise break. If the broken bones are then not replaced in exactly the same place – to the millimetre – and the talus therefore no longer hinges precisely in the ankle mortise, this will cause wear and tear, leading to degenerative joint disease. That is especially problematic in the ankle, as the joint bears the full weight of the body with every step and the forces are even greater when running and jumping. Severe fractures of the ankle joint are therefore notorious for leading to chronic functional impairment, pain and disability. None of these appear to have occurred in the case of King Darius.

  A precise repositioning of the fractured bones, in such a way that the ankle joint is exactly restored, only really became possible with the invention of the plaster cast in 1851, by Dutch army surgeon Antonius Mathijsen, the discovery of X-rays by Wilhelm Conrad Röntgen in 1895, and the development of a completely new operational technique by the Arbeitsgemeinschaft für Osteosynthesefragen (AO Foundation) in Switzerland in 1958. Today, the treatment almost always involves an operation whereby, using X-rays, the broken pieces are held firmly in place with metal plates and screws. This method is known as osteosynthesis, literally ‘joining the bone together’. It is usually a very fiddly job getting all the small pieces of bone to fit back together exactly and then fixing them with screws. In the case of an ankle, this can take a good hour, from the first incision to the final stitch.

  If Darius’s ankle was not broken, is it possible that his foot could have been displaced without a fracture to the ankle fork? He would then have suffered a luxation of the joint, more commonly referred to as a dislocation. A pure dislocation of the ankle is extremely rare and requires exceptionally strong bones. We can assume, however that Darius did not have strong bones, a conclusion that can be drawn from a scientific experiment conducted by Herodotus himself – without him being aware of it.

  * * *

  Traumatology, surgery and orthopaedics

  Traumatology – the treatment of injuries and wounds caused by accidents – is a typical surgical activity. It becomes very important in war. A good army surgeon was worth his weight in gold to a king, as a patched-up soldier can fight again. In peacetime, traumatology was fuelled by crime, and traffic and accidents at work. Fixing fractures and caring for gaping wounds was the job of the surgeon, who ‘healed’ – that is, made things whole again. For a long time, in peacetime, traumatology was performed by barbers. They happened to have a perfect treatment chair, a wash basin and a clean blade to hand. After a successful operation, the barber would hang the bl
ood-spattered white bandages outside on a stick, as a sign of his trade. This is the origin of the red-and-white stick you still see hanging outside barber’s shops today. Orthopaedics originally had nothing to do with surgery and did not involve the use of knives, blades or scalpels. The word comes from the Greek orthos, meaning straight, and paidion (child), and the focus lay on fitting children with braces and splints to correct deformities of the bones. Today orthopaedists treat all kinds of abnormalities of the bones and joints, not only among children and no longer without using a scalpel. With the advent of joint replacement surgery, orthopaedics has become a fully fledged surgical discipline.

  * * *

  The historian had been to Egypt as a tourist and had visited the site in the desert where the first battle had taken place between the Persians, led by King Cambyses, Darius’s mad predecessor, and the Egyptians, under the leadership of Pharaoh Psamtik. The Persians had won, but only after severe losses on both sides. As was customary, after the battle (or rather, the slaughter), the bodies had been separated and piled up. Herodotus had stood and looked at the piles of skeletons and, in a sudden fit of touristic vandalism, threw rocks at them. He observed that it was possible to make a hole in the skulls of the Persians with only a small stone, while those of the Egyptians refused to break even if you hammered away at them with a sizeable rock. Herodotus attributed the difference to the sun, which shone down on the heads of the bare-headed Egyptians for their whole lives, while the Persians always wore felt hats or carried parasols (you do indeed get strong bones from the sun, but not for the reason Herodotus thought – it comes from the vitamin D engendered by sunlight).

  If we could examine Darius’s skeleton, we could measure the strength of his bones. We might even be able to find traces of a fractured ankle, if he had one. Just as a wound in the skin always leaves a scar, a wound to a bone – in other words, a fracture – also leaves its traces many years later, at least in adults. That is because bone, like skin, is living tissue.

  Bone consists of cells supplied with blood by small blood vessels that criss-cross the thick calcium layers. That is why, if a bone breaks, it will bleed. The calcium, however, gets in the way of the healing process. That problem is solved by osteoclasts (literally, ‘bone-demolishers’), special cells that clear the area around the wound by eating away a few millimetres of bone tissue on either side of the fracture. After the osteoclasts have done their work, it is the turn of the osteoblasts (‘bone builders’), cells that produce connective tissue to fill the gap. Because this is a process that takes up more space than the gap allows, a lump is created at the site of the fracture. This lump, known as a callus, contains young bone cells called osteocytes, which deposit calcium, so that the fresh callus becomes stronger. It takes around two months for the callus to bridge the fracture sufficiently. The young bone then gradually matures until there is eventually no difference in structure from the rest of the bone. But the callus remains as a scar.

  Unfortunately, we cannot conduct a post-mortem on Darius to see if there is a callus on his ankle. The Persians did adopt the practice of mummification from the Egyptians but, although Darius’s tomb has been found, hewn out of a rock in Naqš-e-Rostām in present-day Iran, his mummy is no longer in it. Exactly what happened to his foot during the hunt that day will forever remain a mystery.

  What does Herodotus tell us about the fate of Democedes? He proved not only to have a ‘gentle hand’ but also to be a gentle man, showing great solidarity with his Egyptian colleagues, as he persuaded Darius to spare their lives. He suffered terribly from homesickness and was afraid that he would never return to Greece now the king was so pleased with him. But when Queen Atossa developed an abscess in her breast and Democedes successfully cut it open, he asked the king to reward him by allowing him to return to Greece. Darius made him part of a spying mission to prepare for the imminent invasion of Greece. He was to serve as guide and interpreter for a group of scouts. Democedes, however, took advantage of the opportunity to escape. Back in his birthplace of Croton, he married the daughter of Milon the wrestler. So ended a brilliant career that had started in Aegina, where he was paid 60 mina (1 talent) a year in the service of the state. He later received 100 mina in Athens and a year later 120 as physician to Polycrates on Samos – a salary that roughly corresponds to that of a modern surgeon, if you take the price of bread then and now for comparison. Due to an unfortunate change of course in his career he found himself working for Darius the Great. Although he was the most famous doctor of his time, in the history books he would be completely overshadowed by another Greek doctor, who also spoke of the gentle hand and of solidarity among colleagues: Hippocrates.

  And of course the Code of Hammurabi has failed to withstand the ravages of time. Hammurabi had warned that anyone who changed his laws would be inflicted with ‘high fever and severe wounds that cannot be healed’ by the goddess Nin-karak and struck down by the inexorable curse of the supreme god Bel. Despite the warning, the duty to provide a result (‘no cure, no pay’) was replaced. In modern medical law, the patient is no longer a client who buys a product. That has been changed to a duty to provide a best effort (‘duty of care’). Surgeons no longer commit themselves to achieve a result but to do their best to achieve it. This protects the surgeon, because sometimes the result may not be possible. In the case of harm, too, the onus of guilt is shifted from the result to the intention: surgeons who do their best to prevent harm cannot be called to account for any harm caused.

  This distinction between anyone who harms another with a knife and a surgeon who treats someone using a scalpel has been laid down in modern law. The concepts of competence and authority determine who is guilty and who is not. A qualified surgeon is authorised but, as long as he practises his profession, he must ensure that his competence remains up to scratch, by accumulating experience, taking refresher courses, and achieving good results.

  8

  Varicose Veins

  Lucy and Modern-Day Surgery: Australopithecus afarensis

  OUR BODIES ARE made up of components that, after billions of years of trial and error, have become closely related to each other at macroscopic, cellular and molecu-lar level. To understand them, you need knowledge of several natural sciences, including biology, biochemistry and genetics. They are so complex that it is easy to overlook the fact that many of those components work surprisingly simply. The venous valves in our veins, which prevent the blood from flowing in the reverse direction, are a good example. The explanation of how they work may seem a little technical, but with some knowledge of gravity and pressure, they are easy to understand.

  On the inside of each of our legs, a long vein runs just below the skin, from the ankle right up to the groin. This is the great saphenous vein, or GSV for short (one origin of the word ‘saphenous’ is saphon, the Latin for ‘cable’). Together with a number of smaller veins, the GSV comes out in the groin in a short, curved section of vein resembling a shepherd’s crook, called the saphenous arch. In the saphenous arch, there is a small valve. This is nothing out of the ordinary, as all veins below this point have valves, to stop the blood from flowing back downwards under the influence of gravity. Strangely enough, however, there is not a single valve to be found in the long stretch of veins above the saphenous arch, from the groin to the heart. In an adult human, during the day, that one small valve in the saphenous arch therefore has to resist the pressure of a column of liquid some 50 centimetres long. That is five times greater than the pressure on any of the other valves in our veins. A lot to expect from a valve that is otherwise completely normal, not especially strong or built to withstand such high pressure. As a result, the small valve in the saphenous arch can sometimes malfunction. It no longer stops the backflow of blood and starts to ‘leak’. This can cause varicose veins.

  Varicose veins are abnormally enlarged subcutaneous veins through which the blood flows upwards too slowly, does not flow at all, or even flows back downwards. They are not only unsightly, but can
also cause problems, such as pain, itching and eczema in the surrounding skin. They usually start with a leaking valve, often the valve in the saphenous arch, as that is most under pressure. If the valve fails, the pressure is relocated downwards to the following valve, around ten centimetres lower down the leg. This valve then has to cope with the column of liquid, which is now ten centimetres longer. If that valve also fails, there is even more pressure on the next one. In this way, the pressure steadily rises and the GSV will gradually blow up like an elongated balloon. Eventually, all the valves will leak and the GSV, normally no thicker than half a centimetre, will enlarge to form varicose veins, which can in some places grow to the size of a bunch of grapes.

  So the cause for varicose veins is that one small valve in the saphenous arch is too weak for the job it is supposed to do because, for some mysterious reason, there are no valves in the large veins above it. The obvious question is: why? The answer is staggeringly simple.

  To find it, we have to go back 3.2 million years, to Lucy, a twenty-five-year-old Australopithecus afarensis. Lucy and the other members of her species were among the first of our ancestors to walk on two legs. Lucy, by walking upright, is at the root of half of modern-day surgical practice. Parts of her skeleton were found in Ethiopia in 1974 by paleoanthropologists Donald Johanson and Tom Gray. They called her after the Beatles’ song ‘Lucy in the Sky with Diamonds’, which was playing on the radio when they were digging. Lucy is currently to be seen in the national museum in Addis Ababa and replicas can be found in museums all around the world.

  Let us assume that Lucy’s mother still walked on all four legs. That meant that the liquid column in the major veins between her groin and heart was horizontal. And because no pressure builds up in a horizontal liquid column, Lucy’s ancestors did not suffer from varicose veins. Valves in the major veins ‘above’ the saphenous arch would have been pointless for the simple reason that they were not above it.