Under the Knife

by Arnold van de Laar, Laproscopic surgeon

  Sutures are an exception. They cannot always be left behind in the body, which is why absorbable thread is mostly used. If there are bacteria on the sutures, instead of opening up the patient again to retrieve the thread from deep inside the body you can just wait. Once the suture has dissolved, the bacteria will usually give up. Since Roman times, thread made of dried sheep or goat gut was used to stitch up wounds. Péan also mentioned using gut in his report.

  25

  Stroke

  The Neck of Vladimir Ilyich Uljanov: Lenin

  ‘AS FOR YOU, Ilyich,’ a simple peasant had once predicted, ‘you’ll die of a stroke.’

  ‘Why?’ Ilyich had asked.

  ‘It’s that terribly short neck of yours,’ the peasant had explained.

  When Vladimir Ilyich Uljanov told this anecdote about himself, he was fifty-two years old and recovering from his second stroke. A few months later, he had another one and, within a year, he was dead. In the many photographs of him, he does have a notably short neck and, in all the thousands of statues of him that used to stand in squares in almost every town and city to the east of the Iron Curtain, his head does seem to be sitting right on top of the collar of his shirt. Nevertheless, a short neck does not heighten the risk of a stroke. So why, after April 1922, did this relatively young man suffer one cerebral infarction after another?

  Vladimir Ilyich Uljanov is better known under his revolutionary pseudonym Lenin, leader of the Russian Bolsheviks and of the October Revolution, and father of the Soviet Union. The Soviet media published only praise and positive news on the leaders of the state. When Lenin had his first stroke in May 1922, it reported that he had suffered a stomach infection after eating a rotten fish. The leader had allegedly made a rapid recovery and the months of convalescence that followed were officially referred to as a holiday. However, the stroke could not be kept secret for long and there was much speculation about what had caused it. One suggestion linked the stroke to something that had happened not long previously – Lenin had recently undergone an operation on his neck. That link is indeed striking if you know how a stroke is caused.

  The official medical term for a stroke is a cerebrovascular accident (CVA), which means an event affecting the blood vessels in the brain. Worldwide, more than 10 million people a year suffer a stroke. There are two kinds of stroke, a cerebral infarction (ischaemic stroke) and a cerebral haemorrhage (haemorrhagic stroke). A cerebral infarction happens when a blood vessel in the brain becomes blocked. The cause, however, lies outside the brain. If a blood clot forms in the arteries in the neck and then breaks loose, it will flow upwards into the head with the blood and, somewhere deep in the brain, block a small blood vessel. This is known as an embolism and the blood clot as an embolus. In the case of a cerebral haemorrhage, a small blood vessel in the brain bursts of its own accord, flooding the surrounding brain cells with blood. In both cases, the brain tissue is damaged, leading to a sudden loss of brain functions. The lost functions can sometimes recover fully or partially. If the symptoms have completely disappeared within a day, the stroke is referred to as a transient ischaemic attack (TIA), literally a short-lived attack caused by a shortage of oxygen. A TIA can be an indication of a pending real stroke.

  The loss of function often takes the form of paralysis of an arm or leg, a drooping mouth, or problems with speaking or comprehending language. Because all connections between the brain and the rest of the body cross sides, a stroke in the left half of the brain will produce symptoms in the right side of the body, and vice versa. Paralysis in an arm and a leg on the same side of the body is known as hemiparesis, literally ‘half paralysed’. The parts of the brain that are responsible for speech, comprehending and initiating language are usually in the same half of the brain as that controlling your dominant hand (the one you naturally write with). With people who are naturally right-handed, the area of the brain involved with language is usually in the left half.

  A left-sided cerebral infarction can therefore cause a combination of right-sided paralysis and aphasia, the medical term for loss of speech. The embolism originates in the left common carotid artery, the major artery in the neck that feeds the left half of the brain. Lenin was right-handed, and suffered a stroke that caused right-sided paralysis and loss of speech while he was still recovering from an alleged operation on the left side of his neck. That certainly sounded suspicious. Had a surgeon caused his stroke?

  What was the reason for the operation? Many of the details of Lenin’s health are probably censored, and cult- and myth-forming have added much that is not always true but, between the lines, the Soviet leader did appear to have suffered from a genuine mental disorder. What is clear is that he struggled with headaches, mood changes, a fiery temperament, obsessions, nightmares, and insomnia. Prescriptions have been found in the secret archives in the Kremlin for painkillers and sedatives sent from Germany, including potassium bromide and barbitone, old-fashioned remedies which, if taken excessively or for too long, can cause side effects that are worse than the original complaint.

  Lenin was a man who always knew better. Apparently that also applied to the health of his party comrades, as he had made a habit of determining – together with other members of the politburo, the highest party committee – when a comrade was in need of rest. A comrade would then be sent, for his own good and whether he liked it or not, to a health resort or, in the worst case scenario, a psychiatric institution, without a doctor ever being consulted. Now Lenin’s own health was on the politburo’s agenda. He had changed from an intelligent and impassioned visionary into a cruel and neurotic dictator, and his symptoms were getting worse. In 1921, the other members of the politburo, including Trotsky and Stalin, sent him to his country mansion in Gorki, about an hour’s journey to the south of Moscow.

  All kinds of doctors visited him and came up with a wide variety of diagnoses. Some of them, including Ivan Pavlov (of Pavlov’s dogs fame), claimed that Lenin was suffering from syphilis. Others concluded that it was a purely psychological disorder, such as chronic depression, or ‘neurasthenia’ – similar to what we would today call ‘burnout’. But German medical consultant Professor Georg Klemperer came up with something completely different. He suggested that Lenin’s problems were caused by lead poisoning resulting from two bullets that, for many years, had been lodged in his neck.

  Some years earlier, several attempts had been made on Lenin’s life. In January 1918, his car had been shot at in St Petersburg (which would later be renamed Leningrad), but he was not injured. On 30 August of the same year, a month and a half after the tsar and his entire family had been killed under Lenin’s orders, he was severely wounded when a young woman shot at him from close range in Moscow. Fanya Kaplan, twenty-eight, fired three times, hitting Lenin with two bullets, both in the area of his left shoulder.1 The third shot hit a bystander, a woman called Popova, in the left elbow. Comrade Lenin lost consciousness and fell to the ground, breaking his left upper arm. He came round quickly, was pulled into his car by his driver, and rushed, bleeding, to his apartment in the Kremlin. There, he walked upstairs to the third floor. Fearing further attacks, he remained within the walls of the Kremlin and doctors did not come to examine him until early on the morning of the following day. Surgeon Vladimir Nikolaevich Rozanov examined him and was seriously alarmed. Lenin was deathly pale, short of breath, had blue lips and his blood pressure was so low that his pulse was no longer detectable. The patient tried to reassure the surgeon and told him in a weak voice not to be concerned, but Rozanov knew better. The situation was serious. He tapped Lenin’s chest with his fingers and, instead of hearing a hollow sound, heard a muted sound on the left side. He concluded that the left chest cavity was filled with blood, explaining his patient’s pale colour and low blood pressure. That could have compressed the left lung, which would explain the blue lips and the shortage of breath. He could feel a bullet just below the skin, above the joint between the sternum and the right collarbone. The bullet wound was to the left
, at the base of the neck. It must somehow have passed through the neck, between the spine, the oesophagus, the windpipe and the blood vessels without having caused much damage. A second bullet had lodged in the area of the left shoulder. Lenin therefore had two bullets in his body, one of which must have caused the bleeding in the upper left of the chest cavity.

  The doctors insisted that Lenin should not speak or move and should rest. The immediate danger had passed, otherwise he would not have survived the hours after the attack. He was put to bed, with the broken arm in traction. It was then a matter of waiting. The doctors were concerned that the bullets would cause an infection, but decided to wait and see how that developed. Their weakened patient would probably not survive an operation to remove them, and Lenin himself urged them to leave both bullets where they were. He recovered slowly, there was no infection and, three weeks later, he was able to leave his bed.

  * * *

  Subclavian steal syndrome

  A stricture (stenosis) or blockage (occlusion) in an artery as a result of arteriosclerosis can in theory occur anywhere, but usually develops in parts of the body where there is turbulence in the flow of blood. A notable syndrome occurs when a particular large artery becomes blocked in a very specific place. Subclavian steal syndrome is the name given to a blockage of the subclavian artery, the artery below (sub) the collarbone (clavicle), which supplies the arm with blood. The blockage occurs just before the vertebral artery – one of the four arteries to the brain – branches off from the subclavian artery. The two carotid arteries at the front and the two vertebral arteries at the back come together below the brain to form a ring of arteries known as the circle of Willis, named after the doctor and scientist Thomas Willis. With subclavian steal syndrome, the subclavian artery is blocked but the arm still receives blood from the vertebral artery, the blood flowing in the opposite direction. The circle of Willis then supplies blood not only to the brain but also to a whole arm. If the patient exerts a load on the arm, the muscles ‘steal’ blood from the brain. The reduced supply of blood to the brain causes diminished consciousness. Consequently, someone suffering from subclavian steal syndrome can faint while, for example, using a screwdriver to turn a screw. The occlusion can usually be cleared by percutaneous angioplasty, in other words, pushing open the blood vessel with a small balloon from the inside.

  * * *

  Fanya Kaplan was executed on 4 September after a short interrogation. The incident inspired Lenin and the Bolsheviks to unleash the ‘Red Terror’, a purging operation during which tens of thousands of ‘reactionaries’ were tortured and murdered by the Cheka, the secret police.

  In the years that followed, Kaplan’s two bullets caused no major problems in Lenin’s body. But because they were made of lead and had been in there for so long, the German professor had seen them as a possible reason for Lenin’s psychological problems, as chronic lead poisoning can affect the nervous system. The idea was presented to Vladimir Rozanov, the same surgeon who had treated Lenin in 1918, but he thought it irresponsible to risk operating purely on the grounds of what he considered a rather far-fetched explanation of the leader’s symptoms. Lenin had also had another surgeon called Moritz Borchardt brought in from Berlin, because he clearly did not completely trust his Russian doctors. But Borchardt agreed that operating was a bad idea, calling the very thought unmöglich (‘impossible’). In Rozanov’s memoirs, he describes how he and Borchardt proposed a compromise with their patient. Lenin did not believe that the bullets were the cause of his health problems, but he had had enough of the doctors with their conflicting advice. They agreed that the surgeons would remove the bullet on the right at the bottom of his neck, because it was close to the surface and easy to get at, and leave the one on the left, which was much deeper, where it was. None of this was released to the outside world. Officially, Lenin was to undergo an operation to remove a bullet that had hit him in 1918. That bullet had struck him on the left side of his body. That the bullet was now on the right and that a second bullet would remain in his left side, was not made clear.

  First, the surgeons conducted a fluoroscopy, an old-fashioned method that uses X-rays to obtain real-time moving images. They saw that the two bullets had not moved compared with the X-rays made in 1918. Borchardt performed the operation, assisted by Rozanov, at midday on 23 April 1922 in Soldatenkov Hospital in Moscow. It was, according to Rozanov, a simple procedure. The skin was anaesthetised locally with an injection of Novocain and an incision made to expose the bullet, which could then be squeezed out. To prevent infection the operation wound was not stitched up, but filled with a gauze, which was replaced daily until the wound had healed completely, per secundam. It was a minor and successful operation and the patient would normally have been able to return home immediately, but Lenin was kept in hospital for one night, much against his will, to be on the safe side. The wound closed up completely after two and a half weeks.

  A month after the operation, on 25 May 1922, Lenin suffered his first stroke. He had partial paralysis on his right side and trouble speaking clearly, suggesting that the problem was in his left carotid artery. A few days later, Lenin’s blood was tested for syphilis (the Wassermann test) as, in an advanced stage, syphilis can also affect the brain. The test was negative. Lenin himself was convinced that he was incurably sick and in a hopeless situation. He was desperate and, five days after the stroke, asked his comrade Joseph Stalin to bring him poison. The doctors, however, were able to convince him that his prospects were far less bleak than he thought, but in June and July Lenin noticed that the symptoms of paralysis returned briefly while he was walking. He had also become overly sensitive to noise, violin music in particular, and was driving everyone around him to distraction. He spent the summer convalescing in the country in Gorki, picking mushrooms, breeding bees and weaving baskets. He learned to walk again, rested and practised using his right hand. In October, he was back at work in Moscow.

  On 16 December, Lenin had his second major stroke, on the same side. He was again partially paralysed, but his speech was much more badly affected. He recovered gradually until, on 9 March 1923, suffered his third stroke in a year. He could no longer speak clearly, had attacks of rage and was confined to a wheelchair. For months, he was under surveillance day and night. He recovered slightly, was able to talk a little and understand what was said to him, but he no longer appeared in public. The following January, he suffered his fourth and final stroke. It proved fatal. He died on 21 January 1924, aged fifty-three.

  Is it feasible that Fanya Kaplan’s bullet ultimately felled the Soviet leader? According to Rozanov the surgeons had left the bullet near the left carotid artery in place. If his account is correct, the operation to remove a bullet on 23 April 1922 cannot be blamed for the series of strokes that Lenin subsequently suffered. And yet, there has been much criticism of that operation since from commentators and biographers. The theory of the toxic bullets might seem far-fetched, but in the light of the therapeutic options available at the time, Professor Klemperer’s decision seems to have been correct. Five possible causes of Lenin’s symptoms had been proposed. Of those five, three could still not be treated in the 1920s: syphilis, depression and arteriosclerosis. What his symptoms required in any case was rest, and rest would also be exactly what was required if the workaholic dictator was suffering from neurasthenia or burnout. Lead poisoning was the least likely cause, but was certainly one that could be treated. It was therefore logical both to order the patient to rest and to remove the bullet, but that was all the doctors had to offer at the time.

  Normal, healthy arteries are supple and have a smooth inner wall. Arteriosclerosis affects the inner lining of arteries by depositing cholesterol and chalk, causing inflammation. The disease occurs with increasing age, as a consequence of smoking, genetic predisposition, high blood pressure, obesity and high cholesterol levels. The smooth inner wall of the artery becomes irregular and the supple blood vessel becomes inflexible. The resulting progressive narrowing
of the artery does not necessarily cause great problems, as the brain receives blood through four arteries in the neck. Therefore narrowing or blockage of one of the major carotid arteries does not always lead to a cerebral infarction, because the other three arteries can take over. An infarction occurs if something breaks free from the inner lining of the artery, an embolus that is carried along in the bloodstream, and becomes stuck further on in a much smaller artery in the brain, blocking the flow of blood. This loosening of a piece of material from the wall of the artery can occur again and again. That is why Lenin had not only one, but a series of strokes, one after the other. If the affected part of the artery could have been removed, his subsequent strokes could have been prevented.

  The operation that could have saved Lenin’s life, first carried out in 1954, was a great step forward in surgery. Performed in London by surgeons H. H. Eastcott and C. G. Rob, the procedure is called a carotid endarterectomy, which means ‘cutting out the inner lining of the large carotid artery’. The procedure entails locating the large carotid artery and placing clamps above and below the affected part. That half of the brain temporarily receives blood from the three other arteries via the circle of Willis. The artery is then cut open lengthways, the affected inner lining is peeled out, and the artery wall is stitched closed again.

  The official cause of Lenin’s death was arteriosclerosis of the carotid arteries resulting in multiple cerebral infarctions. It was determined at his autopsy, one day after he died on 21 January 1924. That is unusual for a man of only fifty-three, who had never smoked, was not overweight and whose blood pressure was normal. There had been cardiovascular disease in his family, however. Moreover, there are records of an incident in 1921 – before the operation and the strokes – when Lenin had to postpone a speech because he was unable to speak clearly for a short time. That may have been a TIA, a harbinger of his later strokes. What, however, the arteriosclerosis cannot account for are the psychological problems, the headaches, the obsessions and the insomnia that he experienced before the strokes.