Varicose veins are therefore as old as the modern human. The first report of varicose veins is from Egypt and is more than 3,500 years old. The earliest illustration dates from the golden age of Athens, and Hippocrates was the first to treat them with bandages. The Roman Celsus described the removing of varicose veins by making an incision and drawing them out with a blunt hook. According to Plutarch, consul Gaius Marius, the uncle of Julius Caesar, was more affected by the pain of this operation than by the result, and refused to allow his second leg to be operated on. Pliny tells us that this tough-guy statesman was the only one to undergo the operation standing up, refusing to be bound to the operating table. Tough indeed, but also a little foolish as, because of the higher pressure in the vertical liquid column, much more blood spurts out of the open varicose veins during the operation than if the patient is lying down.
The valves in the veins were not described until after the Middle Ages. Even so, that does not mean they were understood. Ambroise Paré was the first surgeon to think of tying off the GSV with a ligature high in the upper leg. We now know that doing this cannot cause any real harm, as there are plenty of veins to take over the work of the GSV – but did Paré know that?
In 1890, German surgeon Friedrich Trendelenburg described the high ligature in greater detail and was the first to display some insight into varicose veins being caused by the leaking of the venous valves and the increased hydraulic pressure. This marked the step to functional treatment. The position of the patient on their back, with the operating table tilted with the head down and the feet up, is named after him. In the Trendelenburg position, the hydraulic pressure is reversed, becoming negative in the legs and positive in the heart. The increase in pressure in the heart is favourable for patients in shock and the low pressure in the legs is better for performing varicose vein operations.
At the end of the nineteenth century, Australian surgeon Jerry Moore perfected the methods of Paré and Trendelenburg. He understood that you should not tie off the GSV as high as possible, but go one step further and tie off the saphenous arch. This became the standard method in modern times, and is known as a crossectomy, after the French for a shepherd’s crook, crosse. The procedure not only allows the existing, visible varicose veins to be treated, but also prevents the problem from reoccurring.
In the twentieth century, the crossectomy was combined with ‘stripping’, a method by which the GSV can be removed subcutaneously completely and in one go. This was – and remained until around 2005 – the standard procedure for treating varicose veins, the whole operation taking no more than fifteen minutes per leg. Theodor Billroth, one of the greatest names in the whole history of surgery, was vehemently opposed to varicose vein operations, without bothering to explain why.
And then came Sven Ivar Seldinger, a Swedish radiologist who turned the whole of vascular surgery on its head. In 1953, he invented a method that made it possible to treat blood vessels endovascularly – from the inside. Thanks to the Seldinger method, in 1964 another radiologist called Charles Dotter invented percutaneous angioplasty, a brilliantly simple idea for the treatment of narrowed arteries by stretching the blood vessel from the inside with a small balloon. In the twenty-first century, the Seldinger method is used to treat not only arteries, but also varicose veins. The GSV can be seared from the inside with laser or microwave treatment to seal it off. And all without the need for a scalpel.
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Circulation
The heart consists of two halves. The right half pumps blood from the body to the lungs under slight pressure. The lungs are delicate and cannot withstand high pressures. The left half of the heart pumps the blood from the lungs to the rest of the body. Here, the blood pressure is much higher. Arteries transport the oxygen-rich, bright-red blood from the heart to the furthest edges of the body. Veins collect the blood from the whole body and carry it back to the heart. The workings of the heart and the blood vessels – the circulation – was a complete mystery until 1628, when the Englishman William Harvey spent several hours looking at the beating heart of a dying deer, which he had cut open while it was still alive. He described his findings in a treatise entitled Exercitatio Anatomica the Motu Cordis et Sanguinis in Animalibus. No one had ever understood the body’s circulatory system before mainly because, after death, blood coagulates, so that the blood vessels of a corpse seem to mainly contain air. The return of the blood to the heart occurs through a combination of the movement of the limbs and the valves in the veins. This is known as the skeletal-muscle pump. The suction power of the chest also helps this process. When we breathe in, negative pressure is created in the chest cavity, drawing blood up out of the abdomen and the limbs. The veins of the digestive system and the spleen are an exception in the circulation system. Known as portal veins, they transport the blood to the liver, rather than back to the heart.
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Lucy brought humankind even more problems. If she did not happen to have three small blood vessels in her rectum that kept her anus watertight (the haemorrhoidal veins), she would probably have changed her mind after her first few steps and gone back to walking on four legs. The act of defecation has never succeeded in adapting: we still have to bend our hips at 90 degrees to do it. The fact that this now requires much greater pressure leads to typical human problems like haemorrhoids, prolapses and constipation.
Another regular feature in the daily work of a surgeon that we have Lucy to thank for is the inguinal canal. This is a weak spot at the bottom of the abdominal wall, exactly where it should be at its strongest. Gravity continually forces the contents of the abdomen against the inside of this weak spot. That can lead to a hole, known as an inguinal or groin hernia, an opening that evolution seems to have forgotten. But if we imagine ourselves on four legs again, the inguinal canal then appears to be higher than the centre of gravity of the abdomen, not lower. So no problem for our four-legged friends, but a real design flaw for us bipeds. Because we walk upright, modern men have a 25 per cent chance of developing a groin hernia in their lifetimes. And that means plenty of work for the surgeon.
The transition from quadruped to biped also meant of course that the hips and knees had to bear twice as much weight. And the intervertebral discs, which separate the individual vertebrae in the spine, went from supporting practically nothing (horizontally) to carrying half the body weight (vertically). This excessive load on the knees, hips and back led to the development of a sister discipline of surgery – orthopaedics. Orthopaedic surgeons spend a large part of their time replacing overburdened hips and knees with prostheses and removing hernias in the back.
The most conspicuous fault can be seen in the arteries running to the legs. They still make a 90-degree bend characteristic of quadrupeds, deep down at the back of the pelvis. This bend was necessary because the hind legs of an animal are at right angles to the trunk. Since we spent most of the time we were evolving from primitive land animals to humans walking on four legs, natural selection has made the 90-degree bend in our arteries wide, spacious and gradual. That causes the least possible turbulence in this stretch of the circulation system, which is important for our survival, as turbulence in the arteries can cause damage to the artery wall. Because we now walk upright, however, after making the gentle, gradual bend of the quadruped, the leg arteries now have to bend back another 90-degrees in the groin. This is not a smooth curve, but a sharp kink that has not adapted and does cause turbulence. That leads to hardening of the arteries (arteriosclerosis), resulting in narrowing of the blood vessels near the kink. And that is why hardening of the arteries in humans is most common in the groin. If the arteries gradually become narrower, the legs receive insufficient oxygen-rich blood at the moment that they need it most – during exercise. That causes pain when walking, which disappears immediately again when standing still. This condition is known medically as intermittent claudication (from the Latin claudicare, ‘to limp’), but in Dutch it is appropriately called ‘window-shopping legs’, referring to t
he fact that the pain of walking down the street will subside every time you stop to look in a shop window. Eventually, the legs can die off, causing gangrene. This is not something quadrupeds have to worry about.
And so we have accumulated quite a list of complaints treated by modern-day surgeons that can be traced back to Lucy. Varicose veins, haemorrhoids, groin hernias and narrowing of the arteries account for perhaps half the work of the average surgical practice. In other words, a large part of the work of the surgeon consists of patching up what went wrong when Lucy decided to walk on two legs. Incidentally, Lucy was given a second name, in Ethiopian – Dinqines, which means ‘you are amazing’. Surgeons can agree with that.
9
Peritonitis
The Death of an Escape Artist: Harry Houdini
WHEN ERIK WEISZ died on 31 October 1926, it was world news. On this side of the Atlantic, it was a time of guarded optimism. But there was also poverty and unrest, and two as yet unknown men called Adolf Hitler and Benito Mussolini were preparing themselves for a leading role in global politics. It was the year Claude Monet died and Marilyn Monroe was born. Europe looked jealously at America, where everything seemed possible and where these years – until the Great Crash of 1929 – were known as the Roaring Twenties. It was the era of the Charleston and Prohibition, of Rockefeller and Al Capone.
Like Charlie Chaplin, Stan Laurel and Oliver Hardy, Erik Weisz typified the spirit of that wonderful time in America. Almost no one knew his real name but his stage name is still – almost a century later – known around the world and has become synonymous with the art that he developed. Erik Weisz was the world-famous Harry Houdini, the escape artist who had himself buttoned up into a straitjacket and hoisted up in the air by his feet, wrapped in chains and sealed in a wooden chest and then thrown overboard in New York harbour, handcuffed and shut in a milk churn full of beer. And he always emerged unharmed, even after being buried alive in a bronze coffin. Many will think that his death was as spectacular as his life, that he drowned while performing his legendary Chinese Water Torture Cell act – handcuffed, upside down and underwater, on stage, in front of a packed theatre. But nothing is further from the truth.
Houdini ornamented his spectacular escape acts with Spiritism and classical circus tricks. He was a juggler, an acrobat and a strong-man. He claimed, for example, that his abdominal muscles could withstand any blow and challenged everyone to try it out. For a long time, it was assumed that his death had been caused by one of these hefty punches in his stomach, but we know now that it had nothing to do with his stunts and was largely down to his stubborn refusal to go to a doctor.
Gordon Whitehead, Jacques Price and Sam Smilovitz were three Canadian students. They visited Houdini in his dressing room in the theatre in Montreal on 22 October 1926, the morning after his performance. Houdini lay on a divan to pose for Smilovitz, who wanted to draw a portrait of him. Whitehead asked him if it was true that he could withstand any blow to his stomach and whether he could give it a try. Houdini agreed and the student immediately started to punch him. He hit Houdini several times extremely hard in his right lower abdomen. The two other young men later stated that the escape artist was clearly not ready for their friend’s rapid attack. They saw that he had only been able to tense his abdominal muscles sufficiently after the third blow and they noticed that, as the tough escape artist – who had been so magnificently indestructible on the stage the previous night – lay there on the divan, he seemed to be suffering unexpected terrible pain from the few well-aimed punches.
Houdini left the following day, after his evening show, taking the train to Detroit, the next stop on his tour. He was not feeling well and sent a telegram ahead asking to see a doctor when he arrived. But once he got to the city, he had no time to be examined and started the final performance of his life with a high fever. He may have performed his underwater escape act, which entailed him holding his breath for several minutes – a fantastic achievement considering that, after the show, a doctor had no hesitation in concluding that he needed to be operated on immediately. The audience thus had no idea just what an incredible stuntman they were watching up there on the stage.
The surgeon at the hospital in Detroit made his diagnosis with a simple physical examination. Laying his hand on Houdini’s abdomen, he declared that the escape artist was suffering from an everyday complaint – appendicitis – but which was only just then starting to be understood. It had only been correctly described for the first time forty years earlier (when Houdini was twelve years old) by Reginald Fitz in Boston. That is remarkable for a life-threatening illness that must have been affecting people for thousands of years. There is no mention of it in ancient Mesopotamian, Egyptian, Greek or Roman medical texts, while it must have been prevalent in these old civilisations, where knowledge of medicine was already quite advanced. It was first described by Giovanni Battista Morgagni, an eighteenth-century anatomist, but he too was unable to put his finger on the correct cause of its lethal consequences. Only in 1887 did it become clear that this illness did not have to end in the death of the patient, when Dr Thomas Morton in Philadelphia conducted the first successful operation to treat it.
Houdini should therefore have simply gone to hospital in Montreal, where he could have been saved by an operation. Was he too stubborn, too vain, too money-driven, or simply afraid of doctors? He probably thought ‘the show must go on’. Consequently, he was not operated on until three days later in Detroit. The surgeon discovered peritonitis, which develops from the bursting of the appendix. Houdini’s abdominal cavity was completely infected with pus. Four days later his abdomen had to be opened up again to be rinsed out. But the situation did not improve and there were at that time no antibiotics to fight the infection.
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Medical terms
Medical complaints and diseases are indicated by words ending in -osis. Arthrosis is therefore a complaint affecting a joint (arthron) (caused by wear and tear). Words ending in -itis indicate an inflammation: arthritis is an inflamed joint. Not all inflammations are infections. They are only referred to as infections if they are caused by propagating pathogens, such as bacteria, viruses and other parasites. The prefix a or an means ‘without’ and ec or ex mean ‘out’. Apnoea means ‘without breathing’ and a tumourectomy means cutting out a tumour. Haem(at)o is related to blood. Haematuria is blood in the urine, haemoptysis is the act of coughing up blood. A tumour (Latin for ‘swelling’) is indicated by the ending -oma. It can be an accumulation of fluid; a haematoma, for example, is a collection of blood. But tumours can also be made of solid tissue. A lipoma is a tumour consisting of fatty tissue. Tumours can be malignant or benign. Malignant tumours are cancerous and their names end with carcinoma (cancer of the skin, mucous membrane or gland tissue) or sarcoma (cancer of other tissues, such as bone or muscle). Benign tumours are not cancerous. The result of a test is positive if it confirms the diagnosis or if it reveals a disorder. A positive result is therefore often negative for a patient. Furthermore, no tests are 100 per cent reliable. A result can thus sometimes be falsely positive or negative. The ending -genic indicates a cause. If something is carcinogenic, it can give you cancer.
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Harry Houdini died two days later, at the age of fifty-two. He was buried in Queens, New York, amid a whirl of public attention, in the same bronze coffin he had used for his escape acts. Erik Weisz, juggler, stuntman, Spiritist and, above all, escape artist – known around the world as The Great Houdini – died of a banal, everyday complaint: appendicitis.
Appendicitis is a very common disease. More than 8 per cent of men and almost 7 per cent of women contract appendicitis at some time in their lives. It can occur at any age and is the most common cause of acute abdominal pain. The appendix – more correctly the vermiform (‘worm-shaped’) appendix – is a blind-ended intestinal tube starting from the great bowel near the junction with the small bowel, located in the right lower quadrant of the abdomen. It is less than a centimetre
in diameter and some ten centimetres long.
Doctors knew about the small organ for a long time, but it had never occurred to anyone that such a small thing could have such disastrous consequences. It is because it is so small that, once it is inflamed, it can burst quite quickly. The contents of the intestines are then released into the abdomen, which causes peritonitis, inflammation of the entire peritoneum, the lining of the abdominal cavity. And that is why the link was never made between that small appendix and the fatal consequences of an abdominal inflammation. Before surgeons dared to open up a living patient’s abdomen with any degree of success in the nineteenth century, they only saw the final state of the appendix in the body of the deceased. During the autopsy, amid the debris of full-scale peritonitis, no one had ever noticed the rupture of that tiny, worm-shaped appendage.
Appendicitis generates a typical series of symptoms that reflect the successive stages of the disease, starting with the inflammation of the appendix itself. This causes a vague organic pain in the centre of the upper abdomen. Within a day, the inflammation expands around the appendix and starts to irritate the peritoneum in the area where it is located, on the right side of the lower abdomen. This local pain is much more acute and pronounced than the vague organic pain. Typically, patients with appendicitis describe the pain as moving downwards from the centre to the lower right of the abdomen, increasing in severity as it does so. The local irritation of the peritoneum also causes fever, loss of appetite (anorexia) and, above all, pain during movement. Patients can no longer tolerate being touched or making sudden movements, and prefer to lie still, flat on their backs with their legs pulled up. For a normal person in this stage of the disease, it would seem impossible to remain standing in front of a theatre full of people, not to mention allow themselves to be tied up, hung upside down and immersed in the Chinese Water Torture Cell as Houdini did.
Under the Knife Page 9