Under the Knife

by Arnold van de Laar, Laproscopic surgeon

  Eunuchs were a powerful and privileged group at the court and in the harems of kings, sultans and emperors in Asia, Arabia and Byzantium, the eastern Roman Empire. They were often influential men with high social status as diplomats, treasurers, civil servants or generals. Apparently, castrated men were appreciated for a number of positive qualities. They were seen as loyal, trustworthy, refined, astute, conciliatory and gifted with a talent for organisation. Traditionally, Mohammed’s grave could only be guarded by eunuchs. Political power in China was even dominated by eunuchs for twenty-three dynasties and under the Ming emperors the country was ruled by 100,000 castrated public officials. The last surviving eunuch in the Forbidden City in China, Sun Yaoting, died in 1996.

  In the severe version of castration, penis and scrotum were removed with one simple, decisive slash of the knife. An object – a goose feather, for example, or a special plug made of tin – was then inserted into the freshly transected urethra to keep it open. The operation was not performed by surgeons: in North Africa, slave traders did it themselves at the trading posts for black slaves from the Sudan destined for Ottoman sultans. They stemmed the flow of blood from the gaping wound with glowing hot desert sand. The blood poured out of the erectile tissues of the penis and the arteries of the testicles. If it did not stop in a day, the slave would bleed to death. If he survived until the next day, it was very likely that he would develop a life-threatening infection in the following weeks, when the wound should normally have been healing. It was a cruel selection process, determined more by coincidence and the cleanliness of the knife and bandages than the victim’s strength and will to survive. But a slave who survived the ordeal was immediately worth several times the price he would have fetched otherwise.

  In the Imperial City in Peking, the operation was performed by specialised castrators. Taking hold of the victim’s genitals in their left hand and holding a curved knife behind them with their right hand, they asked the man (or, in the case of a minor, the father) whether the castration really should take place and, on hearing the word ‘yes’, they would pull the knife towards them, cutting the penis and scrotum off in one stroke. They then tended to the wound with oiled paper and allowed the victim to walk around the room for a couple of hours. The patient was not permitted to drink anything for three days, so as not to have to urinate. The castrator would preserve the genitals in vinegar in a labelled jar, to serve as a kind of lifelong guarantee for the imperial eunuch.

  In the seventh century, Byzantine surgeon Paul of Aegina described two methods of castration that surgeons could apply to minimise the damage. At the same time, Aegina admitted that the operation went completely against the basic principle of surgery. Rather than restoring the natural order, it actually distorted it irrevocably. Moreover, castration was officially outlawed by the state and the church, and anyone performing it could be punished either by being castrated himself or by being eaten by wild animals. Nevertheless, writes Aegina, prominent figures frequently forced surgeons to perform castrations against their will, and the fact that Aegina describes this operation, which was so dangerous for both patient and surgeon, in his textbook probably means that too many castrations ended badly because they were not performed correctly.

  According to Aegina, the first method was to castrate young boys by putting them in a warm bath and slowly squeezing their testicles until you could no longer feel them. This was a risky undertaking – you could never be completely certain that the victim’s libido might not manifest itself to some degree during adolescence. In the second method, the patient had to stand on a platform with his legs apart whereby a vertical incision would be made on both sides of the scrotum, as far as the testicles. The surgeon would then pull the scrotum down forcefully until the testicles popped out. He would then only have to peel away the shell surrounding them, remove them and tie off the spermatic chord.

  These more selective castrations, which Aegina intended for real surgeons, thus spared the penis. A surgical clamp with the same intention has also been found on the bed of the River Thames, dating from the time of the Romans when the city was known as Londinium. It looks like a kind of elongated nutcracker, ornately decorated and with two serrated surfaces that come together when the forceps are closed. There is, however, a gap on the upper side. It may be a Roman castration clamp that can be placed on the scrotum without crushing the penis, allowing the scrotum to be easily removed with a knife. The clamp would then keep the blood vessels closed off to stem the bleeding.

  Castrations were quite commonplace in the history of the Roman emperors. In the ninth century, Byzantine emperor Michael II not only overthrew his predecessor Leo V, but also had Leo’s four sons castrated in order to bring the dynasty of his rival to an end. One of them died from loss of blood, another was allegedly struck dumb. Two Roman emperors fell in love with men and had them castrated by a surgeon so that they could marry them: Nero with a man called Sporus and Heliogabalus with a charioteer called Hierocles.

  These three different methods produced three different kinds of eunuch. The Byzantine Romans called them castrati (no penis or scrotum), spadones (without testicles but with a penis) and thlibiae (with crushed testicles). By practising castration on a large scale, the Byzantines and the Chinese created a separate social class of eunuchs within their societies. The eunuch class was intended to act as a safe but efficient buffer between the male ruler and all other men with ambitions in the kingdom, and between the ruler and his women. But it was not only about politics and securing power and lineage. By surrounding themselves with a large group of eunuchs, the leaders also preserved the mystery of the court. In Christian Byzantium, it represented a literal extension of the biblical creation legend of Adam and Eve. That story already described an operation – the surgical removal of one of Adam’s ribs to create the female sex – but the Byzantines went a step further and created another sex from Adam, again with an operation: a sexless gender in between male and female. These were the angels, who had undeniably male characteristics, but never grew beards. In that sense, they were consistent in the practice of their faith: it was not only the Christian emperors who surrounded themselves with hosts of sexless beings; their God did the same.

  A castration is a primal operation – simple, dangerous and with serious consequences. Anyone could do it: a father could castrate his son, a victor his vanquished enemy, a man could even castrate himself. After all, ultimately it was simply a matter of cutting off an appendage, just as Abraham had removed his own foreskin. It was as easy as an executioner chopping off hands, ears or a nose, or cutting out a tongue. Such operations require three decisive surgical actions: localisation (deciding where and what to cut), incision (making the cut) and haemostasis (stopping the bleeding). By comparison, even a simple modern-day operation like removing a small fatty lump requires at least six surgical actions: localisation, incision, dissection (dividing, searching and separating) resection (removing or extracting), haemostasis and suture, (closing the wound). More complex operations (such as removing a rib) entail more steps. Highly complex procedures like removing the oesophagus, rectum or pancreas require around a hundred decisive surgical actions to bring them to a successful conclusion. And yet, the greatest difference between common-or-garden operations, like castration, and a real surgical procedure is not the number of actions required. It is dissection.

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  Gills

  As our bodies develop in the womb, the embryo again passes through the same phases that we experienced in our evolution from single-cell beings to humans. Sometime in the first few weeks of the pregnancy, we are briefly creatures with gills, like fish, five on each side of our head. The gills then close up again and grow together, eventually forming the face and neck. If something goes wrong at this stage in the development of the embryo, the child is left with a defect, a scar or a cleft lip or palate. These are congenital disorders that can only be corrected surgically. A cleft palate is known medically as palatoschisis, a cleft lip (or h
arelip) as cheiloschisis and a cleft lip, jaw and palate, which can extend as far as the eye socket and eyelid, as cheilognathopalatoschisis. Similar problems can also occur elsewhere, such as in spina bifida (when the tube of the embryonic nervous system does not close completely) or hypospadias (incomplete development of the urethra). Structures evolve from the five gill arches that you would not expect to be related to either fish or gills. The first arch gives rise to the middle ear – two of the three middle ear bones (auditory ossicles) and the Eustachian tube. The second forms the third auditory ossicle (the stapes), the hyoid bone (tongue bone) and the pharyngeal tonsil (adenoid). The parathyroid glands and the thymus are formed from the third and fourth gill arch and the fourth and fifth develop into the thyroid gland and the larynx (with the vocal cords). So anyone who thinks we were created from anything else is simply wrong – we started off as fish.

  * * *

  Dissection, a Latin word meaning ‘cut away from each other’, embraces all surgical techniques to search for and find the right surgical plane. Surgery is all about planes. Our bodies are made up of a large number of anatomical layers that remain intact from the very beginning – during the development of the embryo – through to adulthood, but can be separated from each other by dissection. The important thing is to recognise the different layers, to stay in the right plane between them and to know what important structures are to be found in which layer. Dissection is thus the practice of separating different layers and structures, recognising them and cutting through them, while leaving the rest intact.

  With operations involving only one incision, dissection is not necessary. But the second method proposed by Paul of Aegina, peeling the testicles out of their shells and then removing them, required a form of dissection – a testicle is surrounded by no fewer than four layers – and you needed a surgeon with experience and skill to do that. But given the enormous number of castrations that took place throughout the history of humankind, most of which were not carried out by skilled surgeons, there must still have been hordes of surgeons performing the procedure. And those surgeons had the blood of many innocent young men on their hands – literally and figuratively.

  A castration has major consequences, depending on the technique used and the age at which the production of the male hormone testosterone is interrupted. Testosterone is produced by the testicles from puberty onwards. First of all, cutting off a penis caused two opposing problems in the urethra, or what was left of it. The scar had the tendency to close up the hole in the urethra, making it increasingly difficult to urinate, but the operation also affected the working of the sphincter, so that the patient could no longer retain his urine. This combination of incontinence and narrowing of the urethra meant that eunuchs lost urine during the whole day, drip by drip. In both China and the Ottoman Empire, they used a metal rod with a string or a knob on the end, which they inserted in the urethra to close it off and also to stop the opening from narrowing. The shift in the eunuchs’ hormone balance made their bones grow more rapidly, so that they suffered osteoporosis at a young age, which caused spontaneous compression of the vertebrae. They lost body hair, their breast tissue increased and their voices became weaker. All in all, a eunuch could be recognised by the sour smell of urine, a heavy build with a typically crooked posture, a smooth face and a sing-song voice. This bizarre operation also had its advantages: eunuchs tended to live longer than average, though that may have been more a consequence of their protected and privileged position in society, where they enjoyed better living conditions than their contemporaries.

  The fact that castration can prevent young boys’ singing voices from breaking in puberty has led to a fascinating chapter in the history of surgical emasculation. In the eighteenth century, castrati – castrated male sopranos – were an absolute sensation in Europe. They were the megastars of Italian opera, whose soprano voices set many a female heart beating faster. The biggest idol of all was Carlo Broschi, known in his young years as il ragazzo (‘the young boy’) and later under his stage name as Farinelli. He was castrated as a child because he had such a beautiful voice. He sang in Rome, Vienna, London, Paris and Madrid and at the pinnacle of his career his voice range extended from the A below the middle C to the D above the high C. In Spain, his voice had such a soothing effect on the king, who was tormented by depressive melancholy, that he offered Farinelli a position as a minister. He spent many years of his life, like the Chinese nightingale in Hans Christian Andersen’s fairy tale, singing to the king evening after evening, and died in Italy in 1782 at the age of seventy-eight.

  Farinelli did not, of course, owe his success purely to being castrated: he had been born with a wonderful voice. It is alarming to think how many hundreds or thousands of young boys with ambitious parents were castrated in those times in the hope of achieving similar success, but who proved not to have the required talent.

  Castrati were immensely popular in the baroque era, but had been a common feature of opera and religious music long before, and would remain so long after. For many centuries, women were forbidden to perform in public, and castrati played the female roles in opera. As women were also not permitted to sing in church, castrati were illustrious members of the papal choir in the Sistine Chapel in Rome and so castration for the purpose of preserving the voice was not banned in Italy until 1870 – though in the Vatican castration continued for more than thirty years after that and castrati were still singing in the papal choir until the beginning of the twentieth century. One of them was Alessandro Moreschi, the first and last castrato whose voice has been preserved on a gramophone record. Moreschi died in 1922.

  The libido also becomes weaker after castration, which was of course usually the intention. For that reason, castration was used until not so long ago to ‘cure’ people of what was considered to be perverted sexual preferences. A well-known victim was Alan Turing, who cracked the Enigma code and invented the computer during the Second World War, but was sentenced to undergo chemical castration by a judge in 1952 because of his homosexuality.

  Castrations are still performed today. Every year, the testicles of tens of thousands of men worldwide are surgically removed as part of the treatment for prostate cancer. The male hormone testosterone stimulates the growth of prostate cancer cells and stopping production of the hormone through castration can help slow down the spread of the cancer. Unlike all the other reasons used in history to castrate men, the treatment of cancer is of course a good reason to consider undergoing such a severe operation. Furthermore, prostate cancer – and therefore the need to perform a castration to combat it – usually occurs at a later age, after the patient has passed the reproductive phase of his life.

  19

  Lung Cancer

  Thoracotomy at Home: King George VI

  ON 23 SEPTEMBER 1951, after many days of preparation, English surgeon Clement Price-Thomas gave up his free Sunday morning to perform an operation that was, for a number of reasons, remarkable. Not only because it was a pneumectomy, an operation to remove an entire lung, or because the patient was the British King George VI – father of the current queen, Elizabeth II. It was also notable for the fact that the venue was the patient’s own home: an operating room, just like the one the surgeon usually worked in at Westminster Hospital, had been set up in one of the rooms at Buckingham Palace.

  George VI had lung cancer. In June of that year, he had withdrawn from public life, officially stating that it was due to a bout of flu. But the real diagnosis was not specified by name; the press release spoke only of ‘structural changes’ in the lung. In the 2010 film The King’s Speech, it is suggested that George VI’s doctors advised him to inhale cigarette smoke to help relieve his stutter. Inhaling smoke was something of a fad that had originated around the beginning of the century. For a long time – and thus still in 1951 – it was not considered to be harmful. Both the king and his surgeon were chain-smokers and there is a good chance that they even had a quick cigarette before the operation.

&
nbsp; Tobacco first came to Europe in the sixteenth century. It was chewed, sniffed or smoked in a pipe. It was a very successful product and soon became a part of daily life. It even found its way into surgical terminology. The triangular hollow on the back of the hand that appears at the base of the thumb when you spread your fingers is known as the anatomical snuffbox, and is important in traumatology because pain in the snuffbox when pressure is applied can mean that the underlying bone, the scaphoid, is broken. Dutch surgeons must have been particularly fond of tobacco. A surgical suture placed around a structure or opening in the body to pull it closed is known throughout the world as a ‘purse string’, but in the Netherlands it is called a ‘tobacco-pouch suture’. Calcified hardening of the small, elongated arteries in the lower leg as the result of diabetes is known very appropriately in Dutch as ‘pipe-stem hardening’, after the long, slim pipes made of white clay used to smoke tobacco.

  Cigars became popular in the nineteenth century, while cigarettes became widespread in the twentieth century. Until then, tobacco consumed by sniffing, chewing or smoking a pipe or cigar never penetrated further into the body than the mouth, nose or throat. For four centuries, this led to many forms of cancer, but they were limited to the upper parts of the airways. Chewing tobacco, for example, caused cancer of the lips and tongue, and smoking cigars, of the throat. In the seventeenth century, there are records of several cases of tumours in the mouth, for example in the books of the Amsterdam chirurgeons Job van Meekren and Nicolaes Tulp, and a specific case of ‘bastard flesh (cancer) and decay of the palate, fortuitously removed with the knife and glowing branding irons’ recorded by Frederik Ruysch. Sigmund Freud, the psychoanalyst who was known for always having a cigar in his mouth, died of mouth cancer in 1939. The much-loved German emperor Friedrich III, also a cigar-smoker, died a miserable death of throat cancer in 1888. But lung cancer had always been a rarity, almost non-existent. Cancer from other parts of the body would sometimes spread to the lungs, but primary lung tumours, that is originating in the lung tissue itself, hardly occurred. A thesis published in 1912 listed all cases of lung cancer in the world recorded up to that date. There were less than 400. And then suddenly, out of nowhere, the figures for lung cancer increased explosively between 1920 and 1960 and it became a ‘normal’ disease. Lung cancer eventually became the most common cause of death from cancer, with more than a million fatalities worldwide every year. Initially, no one had any idea where these tumours came from.