Under the Knife

by Arnold van de Laar, Laproscopic surgeon

  Pus then forms around the appendix. At first, the pus can be contained by the surrounding intestines, but in the next stage the appendix dies off locally and bursts. Faeces and intestinal gases are then released into the abdominal cavity. The patient experiences a sudden increase in the pain in the lower right of the abdomen, which then spreads throughout the whole abdomen and becomes so severe that it is no longer possible to say exactly where it is coming from. This is the stage of life-threatening peritonitis.

  The total picture that fits in with peritonitis is typically that of an ‘irritated abdomen’. The abdominal muscles are tense, the abdomen is hard and every movement is painful. It is not only painful when the abdomen is touched, but even more so when it is released – this is known as ‘rebound tenderness’. The patient’s face is pale, anxious and tense, with sunken eyes and cheeks. The intestines in the abdomen respond to the inflammation by stopping their normal movements. Through a stethoscope, the abdomen is unnaturally quiet. All of these symptoms are so typical of peritonitis that it can be diagnosed in a couple of seconds, with a quick look at the patient (face and position), a few questions (where does it hurt and where and when did it start?), pressing the abdomen once (hard and painful when pressure is applied and released) and listening with the stethoscope (no audible intestinal movements). In the final stage, the patient experiences septic shock caused by blood poisoning; the peritoneum has a large surface area, allowing a mass release of bacteria into the bloodstream. That leads to general poisoning of the body, causing high fever and affecting all organs, with death as the result.

  Peritonitis is an acute surgical emergency. The surgeon has to repair or remove the cause as soon as possible and rinse the abdominal cavity. This should be done at the earliest stage possible, preferably before the onset of septic shock or, even better, before the stage of general peritonitis, but the best time is while the problem is still restricted to the affected organ, the tiny appendix. Acute appendicitis is therefore already a surgical emergency.

  In 1889, American surgeon Charles McBurney described these principles for operating on appendicitis, namely the sooner the operation is performed, the greater the chances of a full recovery, and that it is sufficient to remove the inflamed organ as long as peritonitis has not yet developed. This linked McBurney irrevocably to appendicitis. The spot on the abdomen where the most pain usually occurs is known as McBurney’s point and the incision in the abdominal wall to perform the appendectomy is also named after him. Every surgeon knows immediately what the problem is if a colleague says that a patient has ‘tenderness at McBurney’s point’.

  A classical operation for appendicitis proceeds as follows. The patient lies on his back, the surgeon standing to his right and the assistant to the left. The surgeon makes a small, diagonal incision in the lower right of the abdomen, at McBurney’s point, which is exactly two-thirds of the way down an imaginary line between the navel and the bony projection of the iliac crest, the outer edge of the pelvis. There, beneath the skin and the subcutaneous tissue, are three abdominal muscles on top of each other. At exactly this point in the abdominal wall, these muscles can be passed without cutting them, by manoeuvring between the muscle fibres, as though you are opening three pairs of curtains. Below the third muscle is the peritoneum. You have to take hold of this carefully and open it up, making sure you do not damage the intestines. If you are lucky, you can now see the appendix but, usually, it is hidden away somewhere in the depths of the abdomen. You can feel around for it with your finger, free it carefully and pull it outwards. Using a small clamp and an absorbable thread, you first divide and tie off the blood vessel feeding the appendix. You then do the same with the appendix itself. You can now close the peritoneum, move the muscles back in place, and close the aponeurosis, the flat tendon of the outermost of the three abdominal muscles. Lastly, you close the subcutaneous tissue and the skin. The whole business takes about twenty minutes. Today, however, the appendix is no longer removed using the classical procedure. Now, a laparoscopic appendectomy is preferred, using keyhole surgery via the navel and two very small incisions.

  Houdini’s symptoms were typical of appendicitis – fever and pain in the lower right of the abdomen. The doctor who was only permitted to examine him in his dressing room in Detroit after the show encountered a seriously sick man with an irritated lower right abdomen. The symptoms were so obvious that the doctors did not even consider the punch in the stomach that Gordon Whitehead had given Houdini three days previously. The diagnosis was confirmed during the operation – they found a perforated appendix and the consequential peritonitis. And yet, it was the punches to the stomach that were the focus of attention later. Other cases of alleged ‘traumatic appendicitis’ – that is, caused by a direct blow, fall or other trauma to the abdomen – were cited. No causal link has, however, ever been found between trauma and appendicitis, and the fact that these two events occurred within days of each other must be seen as coincidence. Nevertheless, the cause of appendicitis is by no means always clear. We do not know why some people contract appendicitis at a certain moment, while others never do.

  In the case of Houdini, it was apparently important to find a cause. The three students were extensively interrogated by the police and the punch delivered by poor Gordon Whitehead was established as the clear cause of death. It may have also been significant that Houdini, given his not entirely danger-free profession, had taken out life insurance that included an accident clause. The clause stated that his wife and lifelong assistant Bess Weisz would receive a double pay-out – 500,000 dollars – if Houdini died as the result of an accident while performing a stunt. While a punch in the stomach to demonstrate his strength could be considered as such, an everyday disease like appendicitis of course could not. Fortunately, Whitehead was not prosecuted for grievous bodily harm or manslaughter, as Price and Smilovitz were able to testify that Houdini had given him permission to punch him.

  Among the audience at Houdini’s last performance in the Garrick Theater in Detroit on 24 October 1926 was a man called Harry Rickles. He later recalled that the show had been a disappointment. It had started more than half an hour late and Houdini did not look well. He made mistakes, so that the audience could see through his tricks, and he had to be supported by his assistant several times. But when Rickles read that the escape artist had performed with a burst appendix, from which he died several days later, he realised that Houdini had given his life to perform for his admirers right up to the last minute.

  10

  Narcosis

  L’anaesthésie à la reine: Queen Victoria

  VICTORIA OF HANOVER was Queen of the United Kingdom and Empress of India. The sun never set on her empire: her children and grandchildren belonged to many of the royal families of Europe and the era in which she reigned was even named after her. She married her cousin Prince Albert of Saxe-Coburg and Gotha and together they seemed like the dream couple, considered the most in-love of all couples in British royal history. Less well known is that they fought constantly, sometimes coming to blows, and it was often the same issue that repeatedly soured the mood in Buckingham Palace. Victoria could not bear the insufferable pain that accompanied what she called the ‘animalistic’ experience of giving birth. She would become so enraged that Prince Albert finally threatened to leave her if she hit him just once more. Queen Victoria may have been a strong woman, but she felt these assaults on her spirits and her nerves were intolerably sordid. And, although the births of her first seven children had all passed off without problems, she had experienced them as an indescribable trauma. Each was followed by a post-natal depression of at least a year, which ran seamlessly into her next pregnancy. In 1853, Victoria was pregnant again and was again becoming hysterical about the impending drama. Albert decided that this could go on no longer and called in a doctor named John Snow. It was time for anaesthesia.

  The technique of putting a patient to sleep, or inducing complete unconsciousness is known as general anaesthesia
or narcosis (Greek ‘sleep’). The first operation performed under general anaesthesia had, at that time, been performed seven years earlier, on 16 October 1846, at the Massachusetts General Hospital in Boston, United States. A dentist called William Morton had anaesthetised a patient called Edward Abbott, by getting him to inhale ether, diethyl ether to be exact. Abbott had a tumour in his neck that had to be removed. While he was asleep, a surgeon called John Warren cut the tumour out. Everything went well, the patient had felt nothing and simply woke up after the operation. Warren was very impressed, uttering the historic, if understated, words ‘Gentlemen, this is no humbug.’ It was a turning point in the history of surgery.

  Ever since the invention of sharp tools, anyone wishing to help someone else by cutting them open had to contend with the patient thrashing around during the operation. Being cut open is not only painful, but the patient is afraid, above all of not surviving the ordeal. Surgeons therefore always had to be quick, not only to keep the duration of the pain as short as possible, but also because there was little opportunity to take your time while the patient was being held down by your assistants or other helpers. It was therefore a matter of ‘the faster, the better’. London surgeon Robert Liston would always start his operations by calling out to his audience: ‘Time me, gentlemen, time me!’ If you had not completed your work before the patient wrested himself free from the helpers who were pinning him down to the table, the consequences were disastrous. The victim would still be bleeding profusely and, with all the thrashing around and the panic, blood would be spraying in all directions. That would cause the unfortunate patient to become even more terrified and frantic, making it much more difficult to hold him down. This gave rise to a very specific dress code. Until around a hundred and fifty years ago, surgeons would always wear a black coat when operating. That made it less obvious that it was covered in blood and they did not have to wash it so often. Some surgeons used to boast that their coats were so stiff from all the blood that they could stand upright on their own.

  So you had to be quick, otherwise it would end badly. Speed meant safety. And that called for short, deep and accurate incisions – in the right place, and passing through as many layers of tissue as possible with one cut. The flow of blood was therefore always stemmed at the end, ‘on the way back’, by tying off the tissue layers with thread, searing them closed with a branding iron or simply applying a very tight bandage. This method was effective, but not very secure. It left no time to examine closely what you were doing and there was little time or space for unexpected circumstances. So, that was what operations were like until 16 October 1846: quick and bloody – and standardised, with no time for specifics.

  Administering a general anaesthetic was therefore considered a waste of time for a quick surgeon and, in Europe, it took a long time for it to become regular surgical practice. Many surgeons were openly opposed to what they saw as dangerous and unnecessary nonsense. Anaesthesia was known in England as ‘Yankee humbug’ only good for quacks who were not good enough to operate quickly. But that was to change, thanks to the temper of Queen Victoria. After she had dared to try anaesthesia and had benefited so tremendously from it, no one could dismiss it any longer. It was exactly the boost that this new, unknown, but welcome discovery needed to convince the public at large.

  John Snow was a farmer’s son and amateur anaesthetist who had written a book about ether and chloroform and designed a special mask to administer chloroform slowly and in controlled doses. In 1847, a year after the first ether anaesthesia was performed in Boston, James Young Simpson performed the first chloroform anaesthesia in Edinburgh. What John Snow did in 1853 was thus nothing new, but it was rare. Did Victoria know that Snow was not actually an expert, or that he didn’t know the risks of what he was going to do to her, or her unborn child? Snow’s heart must have been pounding as he climbed the stairs to the royal bedrooms in the palace. It was evening and the corridors, reception rooms and stairways were illuminated by gaslight. The staff would have been nervous. The cabinet was on stand-by, the people waited in suspense and there, beyond the antechambers and yet more doors, Snow would have heard the queen moaning. No doubt, Snow would have wondered whether the queen was able to receive him, a complete stranger, a commoner, calmly and with respect. When he entered, he would have positioned himself at the head of the bed and, not permitted to use the dosing mask he himself had designed, laid a clean handkerchief over Her Majesty’s nose and mouth. Using a pipette, he would have dripped a few droplets of chloroform from a bottle onto the handkerchief. He would certainly also have inhaled a little of the chloroform – that is unavoidable – so he would have turned his head to the side now and again to breathe deeply clean air.

  * * *

  Anaesthesiology

  Today, anaesthesiology is rightly a full-scale discipline in itself. The days of a few drops of ether on a handkerchief are long over. Three kinds of medicine are used in modern general anaesthesia. A narcotic reduces consciousness, causing sleep (narcosis) and forgetfulness (amnesia). As the narcotic does not completely repress physical reactions to the pain of the operation – such as increased heartbeat and blood pressure, goose bumps and sweating – powerful painkillers (analgesics) are also administered. These are often opium derivatives. Anaesthesia means literally ‘without feeling’. To repress the tensing of the muscles in response to manipulation during the operation, a muscle relaxant is often included in the cocktail. These are derived from curare, the poison that Amazonian Indians use for their arrows. This combination of three medicines results in a relaxed, sleeping patient with no physical reactions to the operation. The anaesthetist uses a ventilator, a respiration machine to take over the patient’s breathing, inserting a tracheal tube into the windpipe (trachea) via the nose or mouth (intubation). While the patient is under general anaesthetic, the heartbeat, oxygen content in the blood, and carbon dioxide content in the exhaled air, are continually monitored via a blood pressure band and electrodes on the chest and finger. During the operation, the anaesthetist checks a lot more, including the blood count, urine production, blood-sugar level and blood coagulation. The stage of putting the patient to sleep is known as ‘induction’, and the waking stage as ‘emergence’.

  * * *

  Snow recorded every detail. He administered the chloroform to the queen, drop by drop, until she indicated that she felt no more pain, noting that the chloroform had no impact on the contractions, which remained just as severe. From twenty minutes past midnight on 7 April 1853, he gave Victoria fifteen drops of chloroform on the handkerchief with every contraction. ‘Her Majesty expressed great relief from the application,’ he wrote, ‘the pains being trifling during the uterine contractions, and whilst between the periods of contraction there was complete ease.’ The queen was not for one moment stupefied by the chloroform, and remained conscious throughout the birth. The child was born 53 minutes later, at 1.13 in the morning. The placenta followed a few minutes later, and the queen was delighted, ‘… expressing herself much gratified with the effect of chloroform’. She herself described it as ‘… that blessed chloroform, soothing and delightful beyond measure’. The newborn prince was christened Leopold; he was their eighth child and fourth son.

  Albert was over the moon, though their delight didn’t last long: shortly afterwards, the queen fell into her usual post-natal depression, the worst she had ever experienced. The medical journal the Lancet published a damning comment and biblical scholars were outraged as the Scriptures state that women must endure pain when giving birth. But the news came as a bombshell to the wider public throughout Europe. In France, the use of chloroform became immensely popular and was given the catchy name ‘l’anaesthésie à la reine’. Patients no longer wished to be operated on without anaesthesia and surgeons were forced to comply with their demands.

  Within a few decades, the days of the old, quick surgery were over and a new order emerged. Thanks to anaesthetics, surgeons now had time to work more precisely, and they w
ere no longer distracted by their patients thrashing around and screaming in pain. Operations became precise, meticulous and dry, with no noise, and no blood spattering everywhere. Incisions were careful and exact. Tissue was no longer cut through in one go, but layer for layer, with the flow of blood being stemmed before the following layer was cut open – ‘on the way’ rather than at the end. And with new heroes like Friedrich Trendelenburg, Theodor Billroth and Richard von Volkmann, surgery became a precision science. Black surgery coats were replaced by white ones.

  One of the great new names was the American William Halsted. An innovator in treating inguinal hernias and breast cancer, Halsted had introduced rubber gloves in surgery and with a number of colleagues he had put together a working group to develop local anaesthesia, a wonderful new invention. The procedure, which entailed injecting an anaesthetic drug around a nerve, allowed the patient to remain awake, but to feel nothing in the anaesthetised, numb area. The group met regularly to practise on each other and enjoyed wonderful evenings together. Halsted became not only a pioneer of local anaesthesia, but – because the drug they used was cocaine – he also became an addict. Cocaine has long since been replaced in local anaesthesia by derivative drugs that have the same effect locally, but without the stimulating side effects.