Under the Knife
Page 24
Oswald was not a simple man. He had served in the US Army and had lived in the Soviet Union for several years. Was he a disturbed loner, or did his past suggest secret government activities? Right up to his murder, he himself insisted that he had been framed. He was twenty-four when he died.
But imagine that Perry and his colleagues had been able to save Oswald. They would have kept him in a medically induced coma to improve his chances of survival and, even after that, he would have spent months in intensive care. He might even have needed a number of further operations. He would have been a mental and physical wreck. If he had not succumbed to some complication or other and had eventually left the hospital alive, he would probably have needed a further year’s convalescence before he could once again become more or less the same Lee Harvey Oswald as before the shooting. And for what? He would probably have been found guilty anyway and sentenced to death.
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Retroperitoneum
Both lungs and the heart are located in a more of less separate cavity, the former in the left and right chest (or thoracic) cavity, and the heart in the pericardium. The largest cavity in our bodies is the abdominal cavity, which contains the stomach, the small intestine, the large intestine (colon) with the appendix and the greater omentum (epiploon), the liver and the gall bladder, the spleen, the womb and the ovaries. The remaining organs in the torso are embedded in fatty or connective tissue, and are therefore not ‘loose’ in a cavity. They are the oesophagus, the thymus, the major blood vessels, the pancreas, the kidneys, the adrenal glands, the prostate, the bladder and the rectum. The abdomen can be divided into two compartments: the abdominal cavity at the front, and behind it, the retroperitoneum. Located between the abdomen and the back, the retroperitoneum is difficult to get to during surgery. It is deep down in the torso and all the organs in the abdominal cavity are in front of it. And, because the organs in the retroperitoneum are surrounded by fatty and connective tissue, searching for them is like rummaging around in a lucky dip. The retroperitoneum can be accessed through the abdomen of a patient lying on their back, where it then forms the ‘floor’ of the abdominal cavity. But it can also be accessed from the side, with the patient lying on their side. This is known as a lumbotomy, literally ‘an incision in the flank’ and is the classic way of accessing the kidneys and the ureters.
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24
Prosthesis
Une belle épaule de la belle époque: The Baker Jules Pedoux
SURGERY HAS ALWAYS been about dexterity, but it has also gradually become increasingly dependent on technology. Today, technology is indispensable even for routine operations. The technological revolution in surgery started a century and a half ago and was driven by a small number of hopelessly optimistic surgeons.
Western civilisation had never taken such a great leap forward as at the end of the nineteenth century. The Industrial Revolution was the culmination of the Renaissance, the Enlightenment and many other revolutions that preceded it. It was a period of new ideas, philosophies, discoveries and inventions. There was a widespread sense of optimism. The future belonged to technology. Nowhere was this optimism of the new age as prevalent as in France. There, the new emphasis that emerged in the nineteenth century did not lead to prudishness and grey industrial cities as in England, or to wild lawlessness as in America, but to daring, enjoyment and grandeur. It was the belle époque. And the centre of this ‘beautiful era’ was of course Paris. Paris had splendid avenues and boulevards, railway stations like palaces, museums, parks and fountains. It was a dazzling city, the city of Maxim’s, the Moulin Rouge and the Folies Bergère, of Toulouse-Lautrec, Sarah Bernhardt and the cancan. The most renowned surgeon in this renowned city was Jules-Émile Péan. In 1893, after building his career in the Hôpital Saint Louis, he set up his own hospital on the Rue de la Santé and gave it the less-than-modest name Hôpital International.
The nouveau riche who were having the time of their lives in Paris were, however, in stark contrast to the hard-working labourers in the poor outer districts. Strangely enough, this class distinction was expressed in two chronic infectious diseases that affected all layers of the population: tuberculosis for the poor and syphilis for the decadent ‘happy few’. Both diseases were ubiquitous and were partly responsible for the relatively short life expectancy of forty to fifty years of age. For that reason, most people in the nineteenth century did not live long enough to suffer from diseases that typically affect the elderly and which became commonplace in the twentieth century. Osteoarthritis (wear and tear on the joints), for example, was not very common – joints were more commonly affected by tuberculosis or syphilis.
Jules-Émile Péan described a specific case of a shoulder affected by tuberculosis, together with his typical, hopelessly optimistic nineteenth-century solution to the problem. With the assistance of a handy dentist, he replaced the shoulder with a new, mechanical joint. The patient was a poor wretch from the banlieues, a thirty-seven-year-old baker called Jules Pedoux, who had probably contracted tuberculosis as a small boy since there are often decades between the first infection with tuberculosis – which always starts in the lungs – and the development of secondary localisations of the infection elsewhere in the body, such as in the vertebrae or other bones.
Péan’s shoulder prosthesis is one of the many wondrous French inventions of the belle époque, on a par with the highest artificial construction in the world (Gustave Eiffel’s iron tower), cinematography (the Lumière brothers’ film), and the velocipede (Pierre Michaux’s bicycle). Amazingly, the artificial shoulder lasted for two years.
Tuberculosis is a disease that, just like syphilis and leprosy, gradually affects the body’s tissues and can lead to disfigurement and deformity. They are chronic infections, in other words the symptoms are not usually sudden and severe, but develop slowly, gnawing away at the tissues. That is because they are caused by a specific kind of bacteria – leprosy and tuberculosis by mycobacteria and syphilis by spirochetes – that invoke a different reaction in the body than most other bacterial infections.
Tuberculosis bacilli attract immune cells that form small clumps of tissue, granulomas, which the bacteria gradually destroy. The bacilli are not very aggressive, but extremely persistent, so that the destructive effect in the long term is much greater than with other infections. They slowly spread through the whole body and remain in hiding for many years. Without tuberculostatics – antibiotics that specifically combat tuberculosis bacilli – they would never leave the affected tissues. Typical symptoms of tuberculosis are nocturnal sweating and slow emaciation. Tuberculosis does not attack local tissues acutely and severely with pus and a red, painful and warm abscess; the local reaction is much slower, but by no means less severe. It results in the gradual destruction of the affected tissues, which are transformed into a cheese-like substance. A tuberculosis abscess is thus known as a ‘cold abscess’.
When Jules Pedoux reported to Péan’s hospital, he was very sick and emaciated and had a large cold abscess in his left upper arm. There was probably not much to be seen on the outside, but if you had taken hold of the arm, you would have clearly felt a fluid mass deep below the skin. Every movement of the shoulder must have been painful and his hand was probably congested and swollen, and therefore as difficult to use as the upper arm. Péan initially thought that the only way to save the man’s life was by disarticulation, amputation of the entire arm by separating it from the shoulder joint. The baker steadfastly refused, preferring to die than live with only one arm. After all, he needed both arms to make his living. Péan took up the challenge, probably against his better judgement. He performed an operation, restricting himself to nettoyage (‘cleaning up’) of the cold abscess. He exposed the bone with a long incision in the upper arm from the top of the shoulder. The upper part of the bone, including the rounded head, was completely affected. Péan cleared away all the Camembert-like bone tissue. The periosteum (the membrane covering the outer surface of the bone), the cap
sule of the shoulder joint, and the socket all seemed to be intact, leaving a well-defined cavity. After this first operation on 11 March 1893, the patient recovered within a few days and his arm survived.
Péan was familiar with temporary implants of platinum in the faces of patients whose noses and jaws had been deformed by syphilis and tuberculosis. He asked a dentist, a Dr Michaels, to build a mechanical shoulder joint for his patient that would be as inert as possible and guarantee the function of the shoulder joint. Michaels came up with an ingenious contraption that, at least in theory, fulfilled both requirements. He made a rubber ball that he boiled in paraffin for twenty-four hours to harden it. There were two grooves in the surface of the ball, at right angles to each other, in which two platinum rings could move. The horizontal ring was fixed to the shoulder socket of the shoulder blade with two small screws. This enabled the arm to move inwards and outwards (exorotation and endorotation). The movement of the vertical ring enabled the arm to be lifted (abduction). This second ring was fixed to a platinum tube that would replace the top section of the upper arm.
Péan implanted the prosthesis shortly after the first operation, reopening the same incision. It fitted well in the now vacant cavity and he stitched the platinum tube in tightly using catgut thread. Leaving a rubber drain in the arm, he sewed up the skin with horsehair stitches. In his report on the patient’s progress, Péan wrote that everything proceeded very well. After twelve days, Pedoux was able to walk around again and was discharged after gaining ‘35 pounds’ in weight. Péan was not more specific about how long Pedoux was in hospital – a few months, half a year perhaps? Although he does describe having to drain an abscess in the wound on four occasions. There is no mention at all of how well the arm functioned, which was after all what the whole operation was for. After Pedoux was discharged, Péan did not see his patient at all for another year. This is in itself remarkable – that a renowned surgeon would allow a simple baker to walk off with an upper arm full of platinum (though this precious metal was not considered very valuable at that time).
Why was he so optimistic about this shoulder prosthesis? Louis Pasteur had already proved thirty years earlier that bacteria were responsible for causing diseases and, ten years earlier, Robert Koch had discovered the bacillus that caused tuberculosis. And yet, Péan could not have known much about the mechanism the human body employs to defend itself against intruding bacteria. We now know that an effective local defence response is only possible in healthy tissues. No matter how well Péan had been able to clean the tissues surrounding the cold abscess, the foreign materials – the rubber ball and the platinum tube – offered bacteria somewhere they could survive out of reach of the body’s immune system. The whole undertaking was thus doomed to failure from the start – as would become clear a year later.
In 1897, Péan published a report on the follow-up to the operation. About two years after the surgeon had fitted the prosthesis, Pedoux came back because he was suffering from a fistula, a hole in the upper arm, which continually leaked pus. Péan had the arm X-rayed – a completely new innovation that had just been invented in Germany. He does not report what he saw on the X-ray, but he decided to remove the prosthesis. He cut the arm open again in the same place and saw that an ossified mantle had formed around the prosthesis. The scar tissue of the original cold abscess had festered and had been transformed into bone tissue. It was a complete mess, but nevertheless seemed strong enough to ensure that the arm could retain its length, even without the prosthesis. Péan removed the prosthesis, which had probably worked itself loose from all the attachment points anyway. He closed the wound up again and the patient began the recovery process. Again, Péan gave no information about the function of the shoulder or the arm, or whether he had solved the problem of the fistula. Nevertheless, he proudly presented his account of the case to the Académie de Médicine.
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Osteoarthritis
Our bones do not normally come into contact with each other. Their ends, in our joints, are covered with a special kind of tissue, cartilage. Cartilage is the ultimate non-stick material. It is many times smoother than polytetrafluoroethylene (PTFE), better known as Teflon and the smoothest synthetic material ever produced. That makes cartilage an almost irreplaceable tissue in our bodies. Unfortunately, it is also one of the few tissues that cannot heal. Cartilage cells, known as chondrocytes, live without a blood supply. They consequently receive little oxygen and nutrients and have an exceptionally low metabolism. Once cartilage has formed in childhood, the cartilage cells hardly grow or develop any further. Unlike most of the other tissues in our bodies, cartilage is therefore almost unable to regenerate. Dead cartilage cells are not replaced by new ones and, because of the absence of blood vessels, it is almost impossible for scar tissue to form if cartilage is damaged. Wear and tear on cartilage tissue is therefore practically irreversible. It also leads to wear and tear of the joint, which is known as osteoarthritis. It can develop later in life in the weight-bearing joints (knees, hips and ankles) or at a younger age after a fracture or other injury to a joint. Typical symptoms of osteoarthritis are stiffness in the joint, especially in the mornings, and pain at the start of a movement. At a more advanced stage, it can also cause pain at rest and progressive loss of function in the joint. Both problems can only be treated by full or partial replacement of the joint. Metal and Teflon are usually used for artificial joints.
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Although Péan of course grossly overestimated the success of his treatment, he was certainly ahead of his time. He was, however, not the first surgeon to replace a joint. In 1890 the German Themistocles Glück already had no less than fourteen total joint replacements to his name, including knees, wrists and elbows, all made of ivory. He had even had the various parts of the joints made in different sizes so that he could find the right fit for both sides of the joint during the operation and assemble the two ivory components together on the spot. But Glück, too, had no luck. His patients also suffered from tuberculosis and, like Péan, he did not understand that treating joints affected by bacteria was not the right choice for a pioneer in prosthetics. As we now know, an artificial joint has to be fitted in absolutely sterile conditions. Every bacterium that finds its way onto the prosthesis during the operation will irrevocably lead to the whole thing becoming infected, which can only be treated by removing it again.
When tuberculosis and syphilis were repressed by the discovery of tuberculostatics and antibiotics and people lived longer, a group of patients emerged with a disease that can be treated with artificial joints. Osteoarthritis is wear and tear of a joint, without infection, caused by many years of excess load on the joint. It mostly occurs later in life. Osteoarthritis is ideal for joint replacement. A combination of rubber and ivory proved not to be hard enough. Ivory and wood were tried out, but these natural materials dissolved in the body. Platinum became far too expensive and steel was liable to rust. In 1938, vitallium was introduced in prosthetic surgery. Vitallium is a metallic alloy of cobalt, chromium and molybdenum and is extremely strong and resistant to wear, does not rust, and cannot invoke an allergic reaction. Modern implants are made of titanium or complex alloys combined with Teflon.
Today, following Glück, artificial joints are supplied in various sizes for both sides of the joint and are measured up and assembled during the operation. The individual components are joined to the patient’s bone with screws or epoxy cement that is applied as a paste and then hardens. The most common joint replacements are hips, knees and shoulders. The purpose of these operations is firstly to relieve the pain caused by osteoarthritis and secondly to stop the deterioration of the joint function.
With today’s knowledge, Péan’s prosthesis operation seems to have been completely pointless. The pain was already alleviated by the first operation, which cleaned up the cold abscess. The prosthesis most likely made no difference in that respect. On the contrary, the contraption must have felt uncomfortable, to say the least, among all the m
uscles of the arm. The third operation showed an advanced degree of ossification in the upper arm. That can only mean that Pedoux must have all but completely lost the use of his shoulder. He could probably hardly move his arm at all and his shoulder may have been frozen. But that would also have happened without Péan’s prosthesis. All in all, the contraption did little good, but also little harm.
Péan did leave us with another useful invention. He is responsible for the basic design of nearly all modern surgical clamps and needle holders. It comprises two opposing metal handles for the thumb and index finger, each with a toothed projection. The teeth can be interlocked like a ratchet to hold the clamp shut. Péan was also the first surgeon to remove a spleen, and to make an almost successful attempt to remove part of a stomach. A year after his last report on the baker and his shoulder, Péan contracted pneumonia. He died at the age of sixty-seven. What happened to Jules Pedoux is unknown.
And Michaels’s and Péan’s surgical masterpiece? Péan initially kept it but, one way or another, Jules Pedoux’s artificial shoulder ended up in the hands of an obscure American dentist. He took it with him back to the United States, where it can now be seen in the Smithsonian Institute in Washington DC.
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The body can deal remarkably well with foreign materials, as long as no bacteria can get at them. The story of the baker and the history of joint prostheses indeed shows that the acceptance of foreign materials by the body depends on the absence of infection. If bacteria attach to something foreign in our bodies, they are apparently beyond reach of the immune system. Prosthetic material will therefore only be accepted if it is fitted under absolutely sterile conditions. That applies not only to artificial joints, but also to the synthetic textile used to repair hernias, metal clips and staples, pacemakers, synthetic arteries, screws and metal plates for fractured bones, synthetic lenses for the eye, artificial ossicles for the middle ear, drainage systems in the brain, metal stents in blood vessels, mechanical valves in the heart and silicone breast implants.