Under the Knife

by Arnold van de Laar, Laproscopic surgeon

  Until modern times, cancer was rare. This is perhaps because people died earlier from other causes, whereas cancer typically develops at a later age. The reason why cells that have functioned perfectly normally suddenly turn malignant has been clarified for several forms of cancer by developments in genetics. A clear external cause can only be identified in limited types of cancer. John Hill was the first to find a clear link, in 1761, between long-term use of snuff and cancer of the nasal cavity. In 1775, Percival Pott noted that the strikingly high incidence of scrotal cancer among English chimney sweeps must have something to do with soot. Later, a connection was also found between bladder cancer and working with solvents used in paint, but the cause of the explosive number of cases of lung cancer long remained a mystery. A link with cigarette smoking had already been suspected in the 1930s, but it was not demonstrated conclusively until a number of large-scale patient surveys were conducted in the 1950s. Even then, it took a depressingly long time for the message to get through to doctors and surgeons. No one wanted to believe it.

  With hindsight, graphs show very clearly that the increase in lung cancer ran completely parallel to the rise in cigarette consumption, with a delay of around twenty years. The full scale of the damage from inhaling smoke only became visible after the cigarette had become an integral part of modern culture and the daily life of millions of people. And it wasn’t just movie stars and musicians: up to the 1970s it was still perfectly normal for a doctor to smoke in his consulting room, or for children to treat their schoolmates to sweet cigarettes on their birthdays, or their teachers to real ones.

  Smoking can also give rise to other kinds of cancer in the body, such as breast cancer, pancreatic cancer and skin cancer. In addition, it can cause lung emphysema and chronic bronchitis, and is the main cause of cardiovascular diseases. There is no profession (other than that of cigarette manufacturer) that benefits as much from this bad habit as surgery. Most patients of vascular surgeons are smokers (hardened arteries caused by smoking lead to intermittent claudication, strokes and impotence), as are those of cardiac surgeons (smoking-related hardening of the arteries causes heart attacks) and of oncological surgeons (smoking causes a wide variety of cancers). Pulmonary (lung) surgery in particular has become prominent thanks to the cigarette.

  Lung surgery is an exceptional challenge, because the lung is an exceptional organ. The lungs are located, separately from each other, in a hermetically sealed part of the thorax (chest). To get at the lungs, the chest has to be cut open between two ribs. This operation is known as a thoracotomy, an incision in the chest. For that reason pulmonary surgery is also known as thoracic surgery.

  The distance between two ribs is less than two centimetres. To perform an operation on the lung in the chest cavity, that small gap has to be widened far enough to get both hands through. That is why, during a thoracotomy, the patient lies on his side and the operating table is tilted downwards at both ends so that the shoulders and the pelvis are lower than the ribs. This is known as ‘breaking’ the table. The skin is then cut open along the line of a rib. A number of muscles of the back, the chest and the shoulder girdle then have to be moved or loosened to make the ribs visible. The chest cavity is usually opened between the fourth and fifth ribs using a special rib spreader inserted between the two ribs, which are slowly pushed apart until the gap is around twenty centimetres wide. The break in the operating table helps to open the chest cavity. You can then see the lung in the chest cavity and, on the left, the pericardium, the sac holding the beating heart.

  Breathing exposes our lungs permanently to the outside world. As a result they contain large quantities of external material and pathogens, which affects their appearance. A young lung is light-pink and soft, while the lung of an old smoker is black, hard and grainy. It also means that operating on the lungs makes infections more likely. The lungs are unique organs in the body that have their own circulatory system. They are supplied with blood from the right half of the heart, rather than the left and the blood pressure in the arteries in the lungs is five times lower than in the rest of the body. That is necessary because the delicate alveoli in the lungs could not withstand the high blood pressure. The arteries of the lung consequently have much thinner walls, making them more fragile and meaning that surgical sutures can easily rip.

  The airways, too, are not easy to deal with. These rigid tubes are strong enough to resist the permanent fluctuations caused by inhaling and exhaling and are kept open by rings of cartilage, which makes it difficult to close a bronchus (airway) with a suture. To make sure the stitches were airtight, the thread used to be soaked in paraffin. Today, stapling machines are used. Even so, considerable pressure can be exerted on these sutures when patients cough following their operations. The lungs are thus like sponges that contain air. They cannot keep themselves open but are sucked open by negative pressure in the chest and so after an operation that negative pressure has to be restored by inserting a chest tube, a plastic suction tube, between the ribs. Removing a whole lung (a pneumectomy), however, leaves a hollow space where the pressure should not be negative. The empty chest cavity has to gradually fill itself with fluid and then scar tissue. In the meantime, infections or an air leak can lead to serious complications.

  * * *

  Smoking

  Nothing is as unhealthy as smoking. Smokers find that difficult to accept. ‘You can also be killed crossing the road’ is one of the most often-heard excuses when they visit the doctor. That may be so, but the 28,000 Europeans who were killed on the roads in 2015 are a drop in the ocean compared with the 700,000 who died that year from smoking. About a quarter of all people in the world smoke. Half of them will die from their habit and half of those even before they reach retirement age. ‘My grandpa has smoked for his whole life and he hasn’t got lung cancer’ is the second most common excuse. That may also be true, but smoking causes many more health problems than lung cancer alone. There is a good chance that, after smoking all his life, grandpa will die of a stroke, a heart attack, emphysema, pancreatic cancer, an aortic aneurysm or gangrene in the legs – all diseases caused by smoking. Impotence, facial wrinkles, gum infections and stomach ulcers will not kill you, but they are all smoking-related. Chronic infections of the middle ear among children almost always occur only if the parents smoke. Smoking during pregnancy stunts the child’s development. And, to top it all, smoking is an important risk factor in post-operative complications, no matter what they are. So if you have to undergo an operation and are afraid of the risks, don’t light up a cigarette to deal with the stress. Stop smoking.

  * * *

  Another problem with removing a whole lung is that, from one moment to the next, the entire circulatory system has to flow through only one lung, rather than two. That doubles the resistance of the blood flow, suddenly increasing the load on the heart. The first successful resection of a whole lung was not performed until 1931 when Rudolf Nissen (the surgeon who would later operate on Einstein) operated on an eleven-year-old girl. At the first attempt, she suffered a cardiac arrest but, on a second attempt, her heart proved able to withstand the sudden changes in circulation. Before this heroic feat, resections had been performed on part of a lung (in cases of tuberculosis, for example) but they were less risky, because there was always sufficient lung tissue left to fill up the chest cavity.

  Two years after Nissen, in 1933, the first successful pneumectomy for lung cancer was performed in St Louis in the United States. The surgeon, Evarts Graham, would later play a different role in the cigarette story. Graham was also a smoker, as was his patient, Dr James Gilmore, a forty-eight-year-old gynaecologist. Cancer had been diagnosed in Gilmore’s left lung by means of a bronchoscopy, an internal examination of the airways, which, at that time, was performed by pushing a straight rigid tube through the patient’s mouth and down the windpipe. Gilmore weighed up his chances: they didn’t seem promising. Until then, Graham had only performed a pneumectomy on test animals. The operation was therefor
e a dangerous experiment, but dying from lung cancer would be very unpleasant. Before the operation, Gilmore got his dentist to remove his gold fillings and used them to buy a plot in a cemetery. The evening before the operation, a resident physician came to Gilmore’s bedside and urged him to leave the hospital. But the operation went ahead. The thoracotomy went surprisingly well and the tumour was clearly visible. Graham applied a clamp to the artery feeding the lung for a minute and a half to see if the heart could deal with the extra pressure. There were no serious problems, so he tied off the artery, then the veins and the primary bronchus. The lung was now free.

  Graham was alarmed at the enormous space left after he had lifted the large organ out of the chest cavity and so he spent a further hour removing a number of ribs in order to somewhat collapse the ribcage. That strangely distorted the shape of the chest, but did reduce the size of the cavity. Gilmore stayed in the hospital for seventy-five days and had to be operated on again twice because of infections. Nevertheless he made a full recovery and resumed his work as a gynaecologist without problems, but with only one lung.

  Gilmore was incredibly lucky. Lung cancer is a lethal disease that has usually spread by the time it is diagnosed. Even if treatment is possible, there is still a very high probability that the cancer will recur in the years following. In the case of Dr Gilmore, the lung cancer was apparently discovered at an early stage, because it never returned after the operation. He lived for another forty years (and carried on smoking until his death).

  The operation on King George VI in Buckingham Palace also went well, though little is known about how the king responded to the operation or his recovery. His Christmas message on the radio that year was apparently weak and compiled from various fragments recorded in advance. The king only lived for another four months after this pneumectomy, dying of a cardiac arrest in his sleep. He was fifty-six years old. His daughter and successor, Elizabeth, was on a visit to Kenya. She came home to be the Queen of England.

  The resection of his right lung was not the only operation George VI underwent in his life. In 1917, he had been operated on for a peptic ulcer (stomach ulcer) and in 1949 on hardened arteries (arteriosclerosis) in the legs. All three diseases – arteriosclerosis, a peptic ulcer and lung cancer – are smoking related. As is, of course, a cardiac arrest, which the king ultimately died of.

  Indeed, smoking-related illnesses are not uncommon for the royal family. George VI’s father George V and his grandfather Edward VII were both heavy smokers as well and both died of emphysema. They, too, had been operated on at the palace, Edward for appendicitis on the day of his coronation and George for an abscess next to a lung. George VI’s second daughter, Princess Margaret, smoked from her teenage years and contracted lung cancer in 1985, and she was successfully operated on. She died in 2002 of a stroke, also smoking-related despite the fact that she had stopped some years previously. The mother of George VI, Queen Mary, died in 1953, a year after her son, of the same disease: lung cancer. George’s brother Edward also smoked. As mentioned earlier, he was operated on in Houston in December 1964 by surgeon Michael DeBakey for an aortic aneurysm and was later diagnosed with throat cancer – needless to say, both are also smoking-related.

  Royal surgeon Clement Price-Thomas was knighted by his own patient. The surgeon carried on smoking – and contracted lung cancer. He was operated on by doctors Charles Drew and Peter Jones, who had assisted him at Buckingham Palace and were now surgeons themselves. They performed a lobectomy, removal of part of the lung, and with success: Price-Thomas lived on for many years in good health.

  Surgeon Evarts Graham in St Louis thought the idea that lung cancer was related to smoking ridiculous. To prove that he was right, he studied 684 of his lung cancer patients but he discovered the complete opposite. This groundbreaking study, published in 1950, showed an irrefutable link between cancer and smoking, demonstrating for the first time that smoking has a carcinogenic effect. In the years that followed, however, sales of cigarettes continued to rise. For Graham, who had smoked his whole life, the realisation of the harm he was doing to his body came too late. He contracted lung cancer himself and died in 1957. His patient James Gilmore visited him as he lay on his deathbed. Despite his one lung and deformed chest, Gilmore was as fit as a fiddle. The annual turnover of tobacco manufacturer Philip Morris in that year was 20 billion dollars.

  20

  Placebo

  The Fifth Man on the Moon: Alan Shepard

  IN THE MIDDLE Ages, anyone who wanted to add a little lustre to their funeral could hire a group of monks to come and sing Psalm 114. The final sentence in particular gave extra drama to the final farewell: ‘I shall please the Lord in the land of the living’. It wasn’t cheap, but it assured you a long-remembered send-off. The singers themselves, of course, had nothing to do with the deceased. Their lamenting was all pretence. They were essentially fake-mourners, commercial clerics who were referred to mockingly by the word they sang most dramatically of all: placebo, Latin for ‘I shall please’.

  A placebo is something that is not actually active in treating a medical problem, but, if presented as such, can cause a beneficial effect. A well-known example is homeopathy, in which mixtures containing no active ingredients are prescribed for certain ailments or diseases. Placebos do not always have to be potions or pills. Well-intended acupuncture needles or osteopathic manipulations are forms of ‘treatment’ that, in reality, are not that at all. Therefore a placebo itself does not have any beneficial effect, but believing in it does. The mechanism driving that effect is purely psychological and contains elements of expectation, recognition, attention and suggestion. For some time, it was assumed that placebos had a valuable role to play in medical treatment, but this has since been proved to be untrue and that their functional impact is very limited. The result of a placebo treatment can thus often be beneficial, but is mostly not useful. In homeopathy, for example, doctor and patient often maintain a long-term relationship. It does not end in a cure, but is perpetuated by the repeated prescription of remedies that do not work, allowing the symptoms to persist. The great disadvantage of this is that the patient becomes increasingly labelled as a chronic sufferer, making the step back to a normal, healthy life more and more difficult.

  The placebo effect is nothing new. The walls of the Lady Chapel in the Cathedral of St John in the Dutch city of ’s-Hertogenbosch are adorned with votive offerings in silver or wax, in the form of small legs or arms, donated by grateful patients who have been cured of their diseases and ailments throughout the centuries. In the cave at Lourdes, where the Virgin Mary is alleged to have appeared to a young shepherdess, hang the crutches of cripples who found they could walk again.

  The placebo effect conforms to a number of rules. First, the patient must be convinced that it will work. He or she must therefore not know (or want to know) that the treatment is fake. The effect will be stronger if the person administering it also believes that it will work. And it will work even better if administered with a certain degree of pomp and circumstance. A surgical procedure therefore has all the potential to be a powerful placebo. After all, neither patient nor surgeon would dare to run the risk of complications if they are not convinced that the operation will be a success. And, of course, surgery is quite a lot more dramatic than a pill or a drink.

  The placebo effect is weaker among patients who derive considerable satisfaction from their bad health, for example people who thrive on the sympathy and attention they receive because of it. Conversely, the effect can be reinforced among patients who would benefit more than average from a successful treatment.

  No one could ever have expected to gain so much from being cured as Alan B. Shepard when he consented to an operation in 1969. Shepard was lined up to undergo the ultimate adventure when he contracted a disease that threatened to make him completely unsuitable for a once-in-a-lifetime opportunity.

  Shepard was thirty-seven when he became the first American to go into space. Although the flight
lasted only fifteen minutes and his Mercury spacecraft followed a sub-orbital ballistic trajectory, Shepard was briefly a hero, at least in the United States. The mission had actually been just too late – twenty-three days earlier, the Russian Yuri Gagarin had become the first man in space and had orbited the earth for more than an hour – but Shepard’s flight heralded the start of a much greater adventure: the journey to the Moon.

  The Mercury missions were followed by the Gemini capsule and the Apollo project. Of the original seven Mercury astronauts, six played a role in the long series of missions that led to the Moon. John Glenn was the first American to orbit the earth, Scott Carpenter the second, Gordon Cooper was the first to spend a night in space, Gus Grissom the first to be killed during the lunar space programme, Walter Schirra the first to fly the Apollo and Deke Slayton the last.

  Only Alan Shepard came no further. He was found unfit for medical reasons, as he was suffering from a form of Ménière’s disease – idiopathic vestibular dysfunction, to be precise. Idiopathic means a disease without a clearly identifiable cause, and vestibular refers to the system in the inner ear that regulates our sense of balance. The disease causes spontaneous attacks of vertigo and tinnitus. Shepard could suddenly hear a buzzing sound in his left ear and would feel as if everything around him was spinning. This was followed by nausea, like seasickness, which was sometimes so bad that he had to vomit. He took a medicine called Diamox to combat the disease, believed to be caused by excess pressure of the endolymph fluid in the semicircular canals of the vestibular system in the inner ear. Diamox is a diuretic, a pill that promotes the excretion of water, which could have reduced the excess fluid in the inner ear, but unfortunately in Shepard’s case it did not work. An unexpected attack of dizziness, vomiting and loss of balance could naturally be catastrophic to a test pilot who spends hundreds of hours in a jet plane. Or a space rocket.