Under the Knife

by Arnold van de Laar, Laproscopic surgeon

  Eighteenth-century surgeon John Ranby waited too long before treating the symptoms of Queen Caroline, wife of George II. Subsequently, he failed to observe a favourable development in the course of her illness and believed that he had to take action after all. That cost his patient her life. But, because neither he nor anyone else in the eighteenth century had any idea at all what was wrong with the queen, no one blamed him and he was even knighted because he had eventually stuck his scalpel in her navel. Better late than never, they must have thought.

  Queen Caroline called him a ‘blockhead’. John Ranby had been a member of the Company of Barber-Surgeons in London and, when a separate Company of Surgeons was set up in 1745, he became its first Master. This was the first association of real surgeons and would later become the prestigious Royal College of Surgeons. Ranby was an inelegant, oafish man who, despite being well respected by the upper-class elite, would mark up few successes in his surgical life.

  Caroline of Brandenburg-Ansbach was of noble descent. She married George Augustus, the eldest son of George Louis, the Prince-Elector of Hanover, later George I of Great Britain. When Queen Anne died in 1714, the distant Hanoverian branch of the English royal family was the only one that still had Protestant progeny. So George senior was put on a boat to England, together with his son and daughter-in-law Caroline, to become king. On their arrival, the German family suddenly found themselves at the centre of the highly fashionable English periwig era, which was to be named the ‘Georgian Age’ after them.

  The royal family spoke French to each other and, in public, incomprehensible English with a heavy German accent. The two Georges, both notorious pile-sufferers, were boorish, dull and moody. The princess, on the other hand, was completely the opposite. Interesting, charming, witty and very beautiful, Caroline and her ladies-in-waiting became the high point of glamour and style. The mantua was in fashion, a grotesque dress with enormous side-extensions on both hips supported by whalebone stiffeners, so wide that the ladies could not pass through an open door without turning sideways. They would also wear a very high wig on their heads, painted their necks and faces bright white with a thick layer of toxic lead pigment, completing the picture with a black beauty spot above the corner of the mouth. They would then be stuffed – wig, dress and all – into a one-person sedan chair carried by two lackeys and rushed around London from one ball to the next. When she was older, however, Caroline no longer fitted into her sedan chair, or her dress for that matter.

  George I died of a stroke in the summer of 1727 in the coach to Osnabrück. He had spent all night on the toilet in the Dutch town of Delden, where he had developed indigestion after eating too many strawberries during a stop en route to Hanover. The new King George II and his consort, Queen Caroline, had waited thirteen years for the throne. In all those years of luxury and idleness, the once so beautiful Caroline had become hopelessly obese. Although her true size was never shown in portraits and the fame of her enormous breasts was ultimately greater than they were in reality, once Caroline finally became queen, she was so immense that she could no longer turn over in bed without the aid of her servants. Her husband, the king, took a mistress – his wife’s head lady-in-waiting no less – but no matter how unhappy this made the queen, she continued to love him, and he her.

  Caroline was probably not ashamed of her gluttony or her body. Normal citizens could buy tickets to watch the royal couple eat their meals on Sundays. People could see the queen, with her immensely obese body, gorge herself. But she carried a secret that only her husband knew about. As a result of all that excess weight and a series of pregnancies, after the birth of her youngest daughter, Princess Louise, a swelling had developed in the centre of her abdomen. She skilfully concealed this bulge beneath her clothing. It was an umbilical hernia that had eventually grown to an ‘immense size’. No one knows just how large it was but, especially with people who are overweight, an umbilical hernia can be enormous, as large as a water melon, for example. Some can become so big that, sagging under their own weight, they hang down to the knees like an elongated sac.

  * * *

  Acid

  A large number of systems in our bodies necessarily have to be able to work together for us to survive. Our metabolism, respiration, blood coagulation, immunological resistance, digestion, the production of body fluids and hormones by the glands, the absorption of nutrients, the elimination of toxic waste, the circulatory system of the blood, the working of the muscles, thinking, cell division and tissue growth, water management, the distribution of minerals, and a whole range of other functions all need each other to continue to work properly. For that to happen, our bodies must create a constant environment in which all these systems can operate optimally. Our body temperature has to be maintained at 37ºC and the ideal acidity level of the body (pH) is 7.4 (a little less acid than pure water). Our metabolism and respiration produce acidic waste by burning calories, including lactic acid and carbon dioxide (CO2). Excess acid is removed from the blood by the kidneys and through exhalation. Toxins produced by dead tissue and bacteria are also acidic. A patient suffering from a serious infection or whose cells are dying off will start to breathe more rapidly to compensate for the excess of acid being produced by expelling (exhaling) more carbon dioxide. If the patient is too exhausted to expel any more CO2, the level of acid in the blood will rise to a critical level. This is known as acidosis. It has an immediate detrimental effect on all of the body’s systems. As these systems fail, the pH level in the body will fall even further – a downward spiral that ends in death.

  * * *

  An umbilical hernia occurs when the intestines or internal organs protrude (or herniate) from the abdominal cavity through the navel (umbilicus) in the muscles of the abdominal wall. The navel opening is left after birth and is normally less than half a centimetre in diameter, small enough to withstand the pressure in the abdomen. If, however, the contents of the abdomen expand for a long period, for example due to excess fatty tissue or multiple pregnancies, the umbilical opening can weaken and stretch. Consequently the abdominal content can be pushed through the enlarged opening; over time, more and more abdominal content can be pushed out.

  If the umbilical opening continues to widen, the protruding intestines retain sufficient space in the hernia not to be constricted. The bulge is then merely inconvenient and only painful when pressure in the abdomen suddenly rises, for example during coughing, sneezing, laughing or straining. When the patient lies on her back, gravity will decrease the pressure in the hernia so that the intestines can fall back to their original position in the abdomen and the swelling will disappear until the patient stands up again. This is known as spontaneous reduction. But even a spontaneously reducing umbilical hernia will never go away of its own accord. Sooner or later, more abdominal tissue will find its way into the hernia. The symptoms will then worsen and the swelling will no longer disappear when the patient lies on their back. The hernia is then no longer reducible. If more abdominal content is forced into the hernia, it can become constricted. That will cause sudden severe pain and vomiting. Also the tissue in the hernia will die if nothing is done to reduce the pressure in the umbilical opening. The hernia is then incarcerated, from the Latin incarcerare meaning ‘to imprison’, and its contents are strangulated. The outcome of an incarcerated hernia depends on what kind of tissue is strangulated, the surgeon who addresses the problem and, especially, at what point he does that.

  In the summer of 1737, Caroline had severe pain in the abdomen twice, but both times it passed away on its own. On the morning of Wednesday 9 November, she again experienced extreme pain, which would persist until she died, eleven days later. What happened in and around the queen’s bedroom in those days was recorded in great detail in the memoirs of Lord John Hervey, Vice Chamberlain and a personal friend of the royal couple. The queen’s pain was acute and unbearable, and was accompanied by vomiting. And yet she insisted on appearing in the drawing room that evening as usual. During the night
, she continued to retch, could not lie still, and the mint water and herbal bitters administered to her did not stay down. Royal surgeon John Ranby was summoned, and he took austere measures: he gave Caroline usquebaugh (whisky) to drink and immediately bled her twelve ounces.

  The following day was a busy one for Ranby. He started by letting more blood from the queen, as she was still not feeling any better. Then he had to attend to Caroline’s daughter Caroline, who had spent so long sobbing at her mother’s bedside that she had a nosebleed. Ranby was in no doubt about how to treat the distressed young lady. He bled her, too – twice for good measure. Meanwhile, the queen was plagued by all kinds of doctors administering all kinds of treatments. They raised blisters on her legs, made her drink elixirs and rinsed her bowel, despite the fact that no one knew what was wrong with her. They attributed it all to ‘gout of the stomach’. One of the doctors was slapped by the king for suggesting that the queen might not recover.

  On the Friday morning, the queen was bled again, but the pain continued and she vomited everything she tried to eat or drink. On the Saturday, the king could no longer keep up the pretence and revealed his wife’s secret. Much against her will, he told Ranby about the umbilical hernia that she had concealed for more than thirteen years. Only then – the fourth day of her illness – was the patient examined. Ranby felt the swelling on her abdomen and immediately summoned two fellow surgeons, a court surgeon called Busier, who was nearly ninety, and the much younger John Shipton, surgeon of the city. While the three physicians tended to the queen, George II started to organise his wife’s estate. The situation was finally being taken seriously.

  Busier suggested an extensive operation, cutting the umbilical opening deep down in the hernia so that the strangulated bowels could be pushed back into the abdomen. This showed that the aged surgeon still possessed a sharp surgical mind, but he was clearly way ahead of his time, as Ranby opposed the suggestion and Shipton agreed with the latter’s advice to wait a little longer. The patient’s pain increased as the day wore on, however, and in the early evening Ranby proposed the incomprehensible compromise of making an incision, but no deeper than the skin. Around six o’clock, the three eighteenth-century specialists performed the operation by candlelight, standing around the bed of the brave queen. She was accustomed to sleeping on five mattresses. This must have made the operation very taxing on the backs of the three surgeons, who not only had to bend over the pile of mattresses but also over the enormous bulk of their patient. Ranby’s jacket was soaked with sweat. Like three medical students letting themselves go on a corpse in the dissecting room, they cut open the skin of the bulging umbilicus and tried to push the now visible contents back into the queen’s abdomen. These must have been the most painful moments in the queen’s life, but their efforts were in vain. The result was even more miserable: the most prominent woman in the country now not only had a strangulated umbilical hernia but also a large, gaping wound.

  Although the three surgeons were concerned – and with very good reason – about how this horrific situation would ultimately end, they overlooked the clear sign of the favourable course of the queen’s illness. If the bowel really had been incarcerated, Caroline would never have survived those five long days. The dead intestinal wall would have allowed the toxic waste of the mortified cells, the digestive fluids and the contents of the intestines into the blood within a few hours. That would have caused a disastrous biochemical chain reaction during which the increased acidity would cause havoc in all of the systems in her body in no time. She would certainly have died within two days at the most. But on Sunday 13 November, she was still very much alive, awake and responding to those around her bed. There must therefore have been something else trapped in her umbilical opening.

  Especially in cases of obesity, there is a large structure hanging in front of the intestines in the abdominal cavity, known as the greater omentum or epiploon. That is normally a thin membrane between the abdominal wall and the bowels, but in severely obese people enormous quantities of fatty tissue accumulate in it. What was trapped in the queen’s umbilical hernia was therefore more likely to be her greater omentum than her intestines. The difference is that, though a strangulated omentum is painful, it is less dangerous because the mortified fat cells make the victim less sick than a dead, rotting bowel.

  On Sunday, the day after the operation, the surgeons tended to the painful wound. Because they could now see better in daylight than in the candlelight of the previous evening, they suddenly noticed the mortified fat tissue deep in the hernia. In those days, any mortification in a wound was normally taken to be a sure sign that the patient would die a quick death from gangrene. So, although the queen felt no worse than the day before and there were no other signs of her imminent demise, the three surgeons believed that she now had no longer than a few hours to live. The king was called to take his leave of her. He was inconsolable. He promised to always stay faithful to his beloved wife, even after her death, despite her exhortations to marry again. Sobbing and snivelling, George II uttered the historic words ‘Non, j’aurai des maîtresses’ (‘No, I shall have mistresses), to which Caroline replied, sighing, ‘Ah! Mon Dieu! Cela n’empêche pas’ (‘My God, that won’t make any difference!’).

  The surgeons returned to their work. As they cut away dead tissue, they again failed to notice the favourable sign that no faeces came out of the wound, meaning that what they were cutting away was not intestine. Vice Chamberlain Lord Hervey became increasingly agitated by the shameless indifference with which the surgeons dealt with the emotions of the patient and her loved ones. Only a few hours previously, they had announced that the queen was nearing her end, and now that had not happened the three men were acting as though nothing was wrong. The mortifying tissue in her umbilical hernia had little immediate effect on the queen and, in the days that followed, she received both the prime minister and the archbishop. She was, however, becoming weaker. She could still not keep any food down and had to vomit constantly. The surgeons operated on her every day, tended to the wound, cut away dead tissue, sticking their fingers in it and fathoming it with probes, all of course without any form of anaesthetic. During one of these procedures, the aged Busier had held the candle a little too close to his head and his wig had caught fire. The newspapers published every horrific detail and Caroline’s case was publicly debated, in Hervey’s words, ‘as if she had been dissected before [the palace] gate’.

  The situation did not really take a turn for the worse until Thursday 17 November when the bowels must have punctured. The vomiting increased and a large quantity of faeces suddenly started flowing out of the wound. As the ordure gushed out of the queen’s belly, soaking her sheets and pouring over the floor of her bedroom, the windows were thrown open because of the stench. And yet she lasted another three long days, dying at ten o’clock in the evening on Sunday 20 November 1737 in the filthiest and most miserable of circumstances. She was fifty-four years old.

  How would the queen’s symptoms have been explained with our present-day knowledge? The most important clue is the abnormal course of her illness. From the beginning, she suffered from an ileus, a blockage in the small intestine. That is compatible with strangulation of the intestine in an incarcerated umbilical hernia. But, as the hole in the intestine only occurred after eight days, it could not have been caused by strangulation, because that would have led to disaster after only a few hours. Perhaps the ileus had gone on for too long, the pressure had risen too high and the small intestine had burst like a balloon. It is, however, more likely to have been caused by the three surgeons rummaging around in the depths of the queen’s abdomen. During their daily operations, they could have easily made a hole in the bowel, which was already under pressure. The fact that the queen was constantly vomiting strongly suggests a blockage of the intestine. Her small intestine was thus pinched together, perhaps by being trapped in the umbilical opening together with the greater omentum, but without being strangulated. The blockage co
uld also have originated deeper in the abdomen, if the omentum had been pulling on the intestine.

  In any case, at a time when surgeons often did more harm than good, the only correct treatment would have been to push the hernia back into the abdomen without operating. Ranby should not have waited to do that, but have insisted from the first day on examining the sick woman and not bleeding her without first assessing the situation. He should then have exerted gentle pressure on the swelling with flat hands for at least half an hour to try to push the umbilical bulge, at least partially, back into the abdomen. He did not even have to do that to save the mortifying content of the hernia, as that was clearly not threatening the queen’s life, but only to relieve the obstruction in the small intestine. Once he had cut into it, however, all hope was lost.

  * * *

  Fourteen years later, on 19 December 1751, history repeated itself in Denmark. Princess Louise, one of Caroline’s daughters, married the Danish king and became a queen. Like her mother, Louise was obese. At the age of twenty-seven, while pregnant, she too developed an incarcerated umbilical hernia. And again a surgeon made a futile attempt to save her. In the same gruesome circumstances as her mother, she lost both her young life and her child.

  Despite this debacle at the beginning of his career, John Ranby had a very high opinion of himself. He described his most glorious moments as a sergeant-surgeon in the English army in the years that followed in his book The Method of Treating Gunshot Wounds, published in 1744. One of his heroic deeds was the treatment of Prince William, the youngest son of King George II and the late Queen Caroline, also known as ‘The Butcher’. William fought alongside his father against the French at the Battle of Dettingen in 1743, during the War of the Austrian Succession. It was the last time in English history that the king personally led his troops on the battlefield. William was hit by a musket ball that went right through his calf, creating a wound ‘as large as a chicken’s egg’. Ranby immediately rushed to help the prince, who was bleeding profusely, and drew his knife. Today, a sensible surgeon would cut open the soldier’s trouser leg to assess the wound, use the trouser leg to make a robust pressure bandage to stem the flow of blood, and remove the victim from the tumult of the battle as quickly as possible. But Ranby used his knife for something else. He made an incision in the fallen prince’s arm to bleed him, there, in the middle of the battlefield, with musket balls flying around their ears. He drained more than half a litre of blood, as though the victim was not already losing enough blood from his leg. In the field hospital, he tended to the wound with a dressing of bread and milk and bled the prince twice more for good measure. Despite all this, the young man survived, much to the honour and relief of the surgeon. Later on Ranby would be less fortunate with his absurd style of treatment. He had caused Robert Walpole, the British prime minister, to bleed while trying to remove a bladder stone through the urethra. Here, too, he could think of nothing better than to draw more blood from the patient, who was already bleeding to death.