Under the Knife

by Arnold van de Laar, Laproscopic surgeon

  Shepard was grounded and given a desk job at NASA, where he soon gained a reputation as the most bad-tempered official at the agency. As his colleagues made one space voyage after another, Shepard heard of a new, experimental operation that might be able to help him. The surgeon was fully convinced that it would work.

  A few months before Neil Armstrong flew to the Moon, Shepard was operated on in Los Angeles by ear, nose and throat specialist William House. House inserted a tiny silicone tube through the petrous part of the temporal bone and into the inner ear to drain the excess endolymph fluid. This procedure is known as an endolymphatic shunt. Theoretically, this would reduce the pressure in the vestibular system. The details of this procedure are not very relevant here. What is important is that, after the operation, Shepard no longer suffered from his attacks.

  NASA’s doctors examined him and passed him for flight duty. In May 1969, aged forty-five, Shepard was reinstated as an astronaut and began training for the Apollo 13 mission. But because of his age, he needed longer to get fit for the voyage to the Moon and so he was moved back one mission. A lucky decision for him, with hindsight, as Apollo 13 experienced trouble during the flight (the immortal words ‘Houston, we have a problem’ were uttered by the astronaut who replaced him). But, on 31 January 1971, Alan B. Shepard finally got his flight to the Moon. As commander of Apollo 14, he was even responsible for the most demanding task of the whole mission: landing the lunar module Antares on the Fra Mauro Highlands on 5 February 1971. It would prove to be the most precise lunar landing of all the Apollo missions.

  It was essential for the astronauts to perform this manoeuvre standing up, so that they could feel the movements of the module in the Moon’s weak gravity with their own sense of balance. Just how remarkable it was that Shepard did this faultlessly emerged more than ten years later, when it was shown that the outcome of the endolymphatic shunt was based entirely on a placebo effect.

  This was demonstrated by the following experiment: A group of patients with Ménière’s disease were tested for an operation. Lots were drawn. An important part of the endolymphatic shunt procedure is the removal of the mastoid bone, the knob of bone that you can feel as a hard lump behind your ear, another part of the temporal bone. Removing it gives the surgeon access to the minuscule cavities of the inner ear. Half of the patients in the group underwent a full endolymphatic shunt operation, while the others only had their mastoid bones removed – a procedure that would have no effect on their symptoms. It was not possible to see or feel on the outside who had undergone which procedure. They were then all tested over a period of three years with neither the patients nor the doctors who tested them knowing who had had which operation. This is known as a double-blind experiment or, in full, a double-blind, randomised placebo-controlled test. The results showed that more than two-thirds of the patients displayed an improvement of their symptoms, irrespective of whether they had undergone the real or the fake operation.

  It is difficult to say to what extent the placebo effect contributes to the success of surgery in general. It is probably more significant than we think. Fortunately, thanks to double-blind, randomised placebo-controlled testing, operations like that performed on Alan B. Shepard, which have purely a placebo effect, are performed less and less frequently. In the past, however, the outcomes of operations were not systematically recorded and the scientific publication of surgical results was usually limited to descriptions of successful individual cases rather than presenting average figures for large groups of patients. Surgeons performed operations if they had seen that earlier results had been favourable,

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  Location and direction in the body

  An exact anatomical indication of location and direction is essential for good communication between doctors. To do that, they use a whole arsenal of Latin and Greek terms. It is these terms that make surgical jargon so incomprehensible to the layman. Anterior and ventral (towards the venter, belly) both refer to the front, posterior and dorsal (towards the dorsum, back) to the back. Cranial means upwards (towards the cranium, head), caudal means downwards (towards the cauda, tail). Lateral means to the side, medial to the middle. The eyes are thus lateral to the nose, medial to the ears and cranial to the mouth. Combinations are also possible, such as anteromedial or posterocaudal. Proximal and distal mean closer or further away from the core of the body, respectively. So the elbow is distal from the shoulder, but proximal to the wrist. Superior and supra- mean above, while inferior, sub- and infra- mean below. Intra- is in, inter- is between, para- is next to, juxta- is near to, endo- means inside, exo- and extra- outside, retro- behind, per- and trans- through or via, and peri- around. Central and peripheral speak for themselves, median means on the midline. Volar and palmar both mean on the palm side of the hand, i.e. anterior if the thumb points laterally. The sole of the foot is plantar. The thumb side of the hand is radial, the little finger side is ulnar and the back of the hand is dorsal, as is the top of the foot. The sagittal plane divides the body into left and right halves – the plane in which an arrow strikes you (sagitta is Latin for arrow). The frontal plane divides the body into front and back and the axial or transverse plane into a top and bottom half. In medicine, surgery and anatomy left and right are always from the patient’s point of view (else you have to specify whether you look at the patient from the front or from the back).

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  but did not critically study the results for all other patients who had undergone the same procedure. This was the reason why, for many centuries, a pure placebo procedure – bloodletting – was the most commonly performed surgical operation.

  Bloodletting was used as a cure-all for practically everything: wound infections, fever and even, counter-intuitively, severe bleeding. Although a large number of patients died not despite, but because of, bloodletting, it must have had a beneficial effect for some, or it would have been abandoned much earlier. However, that benefit must have been a purely placebo effect, as there is absolutely no demonstrable evidence of bloodletting being beneficial in medical terms. In other words, if Alan B. Shepard and his surgeon had believed in bloodletting, Shepard could just as easily have gone to the Moon after being bled as by undergoing the much more complex operation on his inner ear.

  It was usually the job of the surgeon or barber – the men with the knives – who performed bloodletting. The tradition must have originated thousands of years ago with exorcism rituals, where medicine men would drive out evil spirits (diseases) by cutting the victim open. The ancient Greeks practised libation: a sacrifice offered by spilling red wine on the ground. Bloodletting was thus comparable to making a sacrifice. And since loss of blood could cause the victim to faint, they seemed to be in a trance or surrendering to the gods. Superstitious belief in evil spirits continued to be an important component of bloodletting until well into the Middle Ages but, in the centuries that followed, surgeons preferred a more rational explanation: it was a matter of ridding the body of blood ‘corrupted’ by disease or infection. One way of doing this was to place a tourniquet around the upper arm and tapping blood off through an incision in the elbow. (This is where the expression ‘bad blood’ comes from.)

  The special knife used for bloodletting was called a fleam. It was designed so that it would not cut too deep. The favourite place to make an incision was in the fold of the elbow, because of the vein there just below the surface. Unfortunately, not much deeper than the vein, is the main artery to the arm. So, if the surgeon cut even slightly too deep, the bloodletting would turn into a bloodbath. The aponeurosis (flat tendon, or fascia) that happens to pass between these two blood vessels offers at least some protection, and was therefore also referred to as the fascie grâce à Dieu, the ‘praise be to God’ fascia.

  A healthy body can replenish about one session of bloodletting a day with new blood but, after a week, the body’s iron reserves will be almost depleted. In the history of medicine the fashion for bloodletting is not one to look upon with any plea
sure. We can of course forgive old doctors and healers for not being able to cure diseases and heal wounds through a lack of knowledge and understanding, but intentionally inflicting fatal wounds because you don’t know a better alternative is absurd. Bloodletting continued until the end of the nineteenth century, when it quietly died out, perhaps because, as more and more real treatments were found for a growing variety of diseases and ailments, doctors and surgeons no longer believed in its beneficial properties and its placebo effect became less effective.

  After bloodletting had been abandoned, however, more operations were developed that we would now consider as pure placebo procedures. In the nineteenth century, at an advanced age, French physiologist Charles-Édouard Brown-Séquard injected himself with a potion concocted from the testicles of guinea pigs and announced that it had a rejuvenating effect. With such experiments, he laid the basis for endocrinology, a branch of medical science that deals with hormones, and surgeons started implanting patients with slivers of animal testicles for their rejuvenative properties, with surprisingly beneficial effects. But many more recent operations rely to a greater or lesser extent on a placebo effect, including removing the uvula to relieve sleeping problems or varicose veins in patients with restless legs, hernia operations to alleviate chronic back pain, anti-reflux surgery for people with chest pains, implanting spinal electrodes for chronic pain, operating on the blood vessels in the penis to cure impotence, laparoscopic groin hernia operations on athletes with pain in the groin, brain operations on Parkinson’s patients, and operating on tennis elbow.

  When operations are performed to alleviate inexplicable chronic symptoms, a beneficial result is more often due to a placebo effect than a real solution to the problem. The medical term for symptoms for which no clear cause can be found is e causa ignota or e.c.i., Latin for ‘of unknown cause’. Chronic abdominal pains are a good example of a problem treated by a wide variety of operations, even when they are e.c.i. One suspicious fact is that these procedures seem to work best when they are new. They tend to come in fits and starts, as fashionable fads. New simply seems better than old, and innovations usually imply promises. In the 1960s and 1970s, for example, it was popular to remove healthy appendices to treat chronic abdominal pains e.c.i. In the 1980s and 1990s it was believed that these inexplicable complaints could be relieved by severing adhesions in the abdominal cavity. For exactly the same symptoms, it is nowadays fashionable to cut through superficial nerves in the abdominal wall, and no one operates any more to sever adhesions or remove a healthy appendix.

  Surgeons have a tendency to attribute the observed beneficial effects of their treatment almost exclusively to their own actions. ‘The patient came to me with a problem,’ they might say. ‘I applied a treatment that I was certain would help. The patient went home satisfied with no more symptoms. That was a good result of my work. But that was to be expected, of course.’ This way of thinking and working based on overconfidence in one’s own actions is known as self-serving bias. A surgeon should actually ask himself after every operation whether the patient no longer suffers from the symptoms because of the operation, or in spite of it. Perhaps the symptoms would have gone away by themselves? Perhaps the symptoms return later, but the patient does not come back to the surgeon? The only genuine way to determine the value of a treatment is to distance oneself from the one-to-one relationship between patient and surgeon.

  The true value of a surgical procedure can only be determined objectively with large groups of patients all undergoing the same operation for the same problem, preferably conducted by different surgeons in different hospitals. In modern surgery, this value is then adopted in national or international guidelines based on such results. The guidelines have to be reviewed regularly, as new insights can be acquired from new results from new groups of patients.

  If specific operations prove to be placebo procedures, it is not worth continuing to perform them, even though many patients benefit from them, because they are unnecessarily expensive and generate unnecessary expectations. Moreover, in many cases, they do not work at all or only temporarily, and if they do seem to work, it may be that the symptoms would have disappeared anyway. Many chronic symptoms come and go with a rhythm that cannot always be explained. And, of course, it is not a good thing to deceive patients with a treatment that is not a real treatment. Every operation – including a placebo – runs the risk of complications and it is not acceptable to use a fake procedure that happens to be in trend.

  But even when procedures are exposed as placebo, it can take time for them to go out of fashion. This is the case with arthroscopy (keyhole surgery) on patients suffering from gonarthrosis (osteoarthritis of the knee), which was exposed as a placebo operation in 2002. The operation has become very popular based on patients’ responses to it, though in fact very little is done to the knee, besides inspecting, rinsing and cleaning it a little.

  To test this, Bruce Moseley, an orthopaedic surgeon in Houston in the United States, performed a fake arthroscopy of the knee on a large group of patients. Moseley made three small incisions in the skin and, in full view of the patient, played around with a wide range of instruments and spilled rinsing fluid on the floor to make it all look as real as possible. The results were astounding. Arthroscopic rinsing of a worn knee joint, laboriously scraping wear and tear from the cartilage and neatly smoothing a damaged meniscus proved to have just as much effect on the pain and as little effect on the functioning of the joint as pretending to do so. And yet, keyhole surgery to the knee continues to be the most commonly performed orthopaedic procedure in the world. Hobbling to a private orthopaedic clinic to have your worn-out knee looked at now seems little different from taking a good slug of Lourdes water, lighting a candle at the statue of the Virgin in ’s-Hertogenbosch, or going to the barber to be bled. All you have to do is believe in it.

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  Twelve men have stood on the Moon – Neil Armstrong, Buzz Aldrin, Pete Conrad, Alan Bean, Alan B. Shepard, Edgar Mitchell, David Scott, James Irwin, John Young, Charles Duke, Harrison Schmitt and Eugene Cernan. Of them all, Shepard was the oldest. Imagine that, despite his endolymphatic-shunt operation, he had experienced symptoms of his disease while he was up there. He could have choked if he had vomited while wearing his helmet. After the drama of Apollo 13, that would have meant a definite end to the lunar missions. It is not known if he suffered symptoms of Ménière’s disease after returning to earth. Shepard died of leukaemia in 1998.

  21

  Umbilical Hernia

  The Miserable Death of a Stout Lady: Queen Caroline

  THE ANCIENT GREEK philosophers hit the nail on the head with their ideas about how the world works. From the very beginning, they encompassed the whole of science in one simple principle: nothing is certain, everything changes, all the time. In the sixth century BC, Heraclitus expressed this idea in the phrase panta rhei, ‘everything flows’. If you look at a river for a second time, it is still the same river, but the water is different.

  Living beings, too, are flowing rivers that are continually changing, without altering their form. No one knows that better than a doctor. For a patient with symptoms that you cannot explain, there is no better cure than to wait. As most ailments will simply go away by themselves, your doctor has good reason to bide his time and ask you to come back after a few days. There is also no better way of making a diagnosis than waiting to see which way the problems ‘flow’. The secret is, of course, to know when it is the right moment to stop waiting and start treating the patient.

  Waiting is also a valuable instrument in surgery, both in making a diagnosis and in improving the patient’s state of health. This is reflected in the three different approaches that a surgeon can adopt in treating a patient: conservative (treating without surgical intervention), expectative (watchful waiting without treating) and invasive (intervening surgically in the flow of events). Waiting is often a wise course of action if you know what you are doing, but it can be difficult to persua
de the suffering patient, a concerned family, and colleagues who think they know better, why you don’t seem to be doing anything. Doing nothing is, after all, not what many people expect a surgeon to do. But a well-thought-out decision to wait calls for just as much nerve as taking action, and whether a surgeon is a good doctor or not depends not on taking prompt surgical steps, but on the result. That is why a good surgeon knows the course followed by every disease and disorder, so that he does not wait too long, nor intervene too soon.

  The course of a wound infection is a few days; if there is no pus by then, then no pus will develop. The course of cancer is a number of months; if there is no tumour by then, there was no tumour in the first place. The course of a leaking intestinal anastomosis (where two parts of the intestine have been joined together surgically) is ten days; if it has not leaked by then, it will not leak at all. The course of a fully blocked artery in the leg is six hours; if the leg has not died off by then, it will survive. You can safely leave an ileus (an obstruction in the small intestine) for several days before it ruptures, but if you discover a colon obstruction (a blockage in the large intestine), you have no time to sleep on it. However, a blockage in any intestine with strangulation of the bowel is life-threatening within a few hours because the intestinal wall will die from lack of blood supply.