French physicist Jacques-Arsène d’Arsonval went a step further. He knew that electricity mainly generated heat at the point of greatest resistance. The human body is large enough to conduct electricity without much resistance and it could also flow freely through the metal of the scalpel. The point of greatest resistance was therefore where the scalpel and the body came into contact, more specifically in the small zone of tissues around the tip of the electric knife, exactly where the heat was required for the surgical effect. Moreover, the heat was only generated when there was contact between the scalpel and the tissues.
D’Arsonval came up with the idea that the power of the electric current, which is harmful to the body, could be kept at a low level if the energy were transferred in the form of alternating rather than direct current. Alternating current (AC) is the kind of electricity that comes out of our wall sockets. It is in principle lethal, having a paralysing effect on the nerves, the heart and the muscles. But the French physicist discovered that the undesirable effects of the alternating current disappears if the frequency is sufficiently increased, to above 10,000 hertz.
An electric knife is connected to a generator with a wire. The generator then has to be connected to the patient with a second wire, to complete the electric circuit. The patient thus becomes part of the circuit. Today, that second wire is connected to the patient by means of a conductive disposable adhesive pad attached to the thigh, generally called the ‘patient plate’. A surgeon will therefore never start an operation until he has asked the operation team if ‘the plate has been attached’.
Heat stems the flow of blood by converting the proteins in the blood and in the surrounding tissues from liquid to solid, just as the white of an egg solidifies when it is boiled. This specific property of protein is known as coagulation. When you do this with electricity, it is called electrocoagulation. If the temperature is increased by applying even more heat to a small area of tissues, all the water in the cells will evaporate suddenly, causing them to explode before the proteins have had the chance to coagulate. The effect is not to stem the bleeding but to cut the tissues.
In the 1920s, American engineer William Bovie further elaborated on the principle of electrocoagulation. He developed a generator in which the level of energy in the tissues could be much better regulated. He achieved that by increasing the frequency of the alternating current to as high as 300,000 hertz. His generator supplied this current in pulses, in what is known as modulated alternating current. Moreover, he could regulate the voltage. A higher voltage was compensated for by reducing the number of pulses per minute, so that the total energy level did not rise too high. This enabled the effect of the heat applied to vary from coagulation to cutting, while the current remained within safe limits. This principle continues to be applied unchanged in surgery today and, in many countries, the electrosurgical device is still called ‘the Bovie’ after its inventor.
Bovie’s instrument was introduced into surgery by Harvey Cushing – the pioneer of neurosurgery – in Boston on 1 October 1926. Cushing focused on the one organ in the human body in which bleeding cannot be stemmed simply by applying pressure, stitching or tying off: the brain.
The brain and most tumours in the head are amply supplied with blood by small blood vessels. Consequently, removing brain tumours proved to be an extremely bloody operation. Cushing developed a number of precautionary measures to deal with that. He used small silver clips that he could attach to small blood vessels to stop them bleeding and which could be left behind in the tissues. Cushing also made a habit of removing brain tumours in sections. If he was forced to stop operating because of excessive loss of blood, he would continue the procedure some days or weeks later when the patient’s blood levels had recovered. This was known as the piecemeal method. With major operations, he would ask a volunteer to be present in the operating theatre to donate blood for the patient on the spot if necessary. Mostly, they would be medical students who would take the opportunity to observe the pioneering brain operations close up.
Cushing described the operation in which he used electrocoagulation for the first time in a medical journal, to publicise the importance of this new method of stemming bleeding. He was, however, by no means the first to apply the new technique. Several surgeons had preceded him, but Cushing’s application of electrocoagulation in neurosurgery was so successful and Cushing himself was so famous that the publication of the astounding results of that one operation in 1926 proved decisive in advancing the use of the method.
But first a serious problem had to be solved before electrocoagulation could be used more widely. Although the city of Boston was already using alternating current to light streets and houses, the Brigham Hospital, where Cushing worked, still ran on direct current. The operating room therefore had to be connected to alternating current especially for Cushing’s groundbreaking operation by running a wire up from the street.
On that day, Cushing used William Bovie’s generator to operate on a man with a malignant tumour of the skull, an extracranial sarcoma. He had been forced to suspend his operation on the man three days earlier because of excessive loss of blood. Cushing had not made any great effort to understand the physics behind the coagulation device, saying, ‘One may learn to pilot a motor driven vehicle without necessarily knowing the principles of the internal combustion engine.’ He had therefore asked Bovie to be present in the operating room in person. If Cushing needed to regulate the amount of current applied to stem the bleeding, Bovie could fiddle with the knobs to give him more or less voltage and more or fewer pulses. Cushing reopened the wound from the first operation and continued removing the tumour piece by piece. This time, rather than using scalpel and scissors, he used electrocoagulation. The smell of the smoke as he cauterised the tumour was so bad that spectators in the gallery became nauseous. The medical student waiting to give blood fainted and fell off his chair, but Cushing was immediately convinced: the method was astounding.
During the next operation, to remove a similar tumour from the skull of a twelve-year-old girl, Cushing was able, with Bovie’s assistance, to remove the tumour completely in one session. Both patients recovered well without complications and Cushing continued to use the Bovie device in all of his subsequent operations. It even enabled him to perform operations that he had previously never dared to undertake. ‘I am succeeding in doing things inside the head that I never thought it would be possible to do,’ he wrote to a colleague. Surgeons from a wide variety of disciplines all over the world started to follow his example.
At first, things would still sometimes go wrong. During one operation on the skull, a blue flame shot out of the patient’s opened frontal sinus. A spark from the electrocoagulation had ignited the flammable ether that the patient was inhaling as an anaesthetic and that had escaped through the surgical opening. After that, Cushing ensured that the anaesthetic was administered rectally rather than through inhalation. On another occasion, Cushing received a shock from a metal wound retractor that he inadvertently leaned on with his arm. That inspired him to use wooden instruments and a wooden operating table for a while, until Bovie found a better solution by adjusting the settings on his generator.
Today, a wide variety of measures are taken to protect patient and operating team from electric shocks. The team wear surgical rubber gloves and the patient, operating table and all electrical equipment are earthed. The whole operating room is a Faraday cage: there is a network of copper wires in the walls and doors to ensure that electrical charges from outside, such as a lightning strike or an overload on the power grid, cannot enter the room and disrupt the operation. Moreover, modern operation complexes are isolated from the outside world. In other words, not a single electrically conductive wire may lead to them directly: the electrical circuits used in the operating room are all supplied through transformers and the data in the computer network is transmitted through fibre-optic cables.
Bovie’s electrocoagulation device has hardly changed in almost a cen
tury. It has been refined and made safer, and the circumstances in which it is used have to comply with much stricter requirements than in the pioneering age of Cushing. However, although the whole concept of electrocoagulation can now be considered completely safe, the charge administered to patients is still not much different from that generated by an electric eel – several hundred volts.
Epilogue
The Surgeon of the Future: A Top 10
ANY OPTIMIST TRYING to imagine what kinds of weird and wonderful things surgeons might be capable of in the future actually pinpoints the shortcomings of surgeons today. Science fiction has been in existence as a literary genre for more than two hundred years and, in that time, writers have often tried to imagine what a doctor or surgeon would be able to do in a time of unlimited possibilities. Sometimes their portrayals have displayed surprising insight, at others they have been ridiculously naive. Below is a top 10 of surgeons from the classics of science fiction.
10. Victor Frankenstein
Frankenstein was the ultimate do-it-yourself surgeon with an insane ambition. In Mary Shelley’s 1818 novel, the mad doctor cobbles together a new being from pieces of dead bodies and uses science to bring it to life. To his great alarm, his patient proves to be an intelligent being with its own opinions. Victor becomes a slave to the monster’s will, which costs him his health, his marriage and ultimately his life.
The surgeon–patient relationship has changed a lot in the past fifty years, but fortunately not with the negative consequences that Victor Frankenstein faced. Communication between patient and surgeon has increased in both directions. In the twentieth century, patients still tended to allow themselves to be led to the operating room like docile sheep, without a clear explanation of what was wrong with them or what the surgeon was going to do. If they were suffering from cancer, that was often not said in as many words, and if there were several options for treating their illness, it was frequently left to the specialist to decide which course of action would be taken, without any discussion.
Fortunately, patients became more vocal, organised themselves into support groups, and demanded more insight into the results of surgery. A modern patient will inundate the surgeon with questions before agreeing to an operation. And quite rightly. Of course that can sometimes be difficult for the surgeon but, even though a patient’s opinions or demands may at times push a doctor’s self-control to the limit, they will never be so bad that they cost him his health, his marriage or his life. On the other hand, surgeons also cover their backs much more these days by explaining as much as possible about the illness and the treatment. That may of course be daunting for the patient, who is not always pleased to be presented with a whole list of possible risks, complications and side effects, but it has become a fixed feature of the modern doctor–patient relationship. The downside of this improved communication is that modern patients no longer trust their doctors as in the past. They seek a second opinion more frequently, which leads to ‘medical shopping’ and overconsumption of health services.
9. Miles Bennell
Dr Miles Bennell was a man who told the truth but was not taken seriously. In Jack Finney’s The Body Snatchers (1954), Bennell’s patients turn, one at a time, into extraterrestrial vegetables, but no one believes him – except, eventually, his psychiatrist.
Today, surgeons are obliged to report abnormal cases and other calamities to the health inspectorate. An inquiry has to be set up to analyse what the normal circumstances would be and how it was possible that they no longer applied in the abnormal situation. This is followed by a plan of action, with a number of points for improvement, which must be assessed after a specified period. Patients unhappy about their medical treatment or how they have been dealt with by their medical carers can lodge a complaint with the complaints official or department at the hospital. Everyone is taken seriously these days – doctors and patients – no matter how strange their complaints may seem.
8. Dr Blair
In The Thing, the 1982 film directed by John Carpenter, a surgeon is infected while doing his work and becomes a monster himself. An extraterrestrial being arrives at a scientific research station in the Antarctic and starts taking the place of the researchers. After each killing, Blair has to perform an autopsy on the deformed body and finally becomes infected himself (he wasn’t wearing a surgical mask). He withdraws from the group and changes into The Thing.
Surgeons work with knives, needles and other sharp instruments all the time, with which they can injure themselves. The patient’s bodily fluids can also splash into the surgeon’s eyes or find their way into small wounds. Surgeons are therefore very concerned about avoiding infection. They wear gloves when touching anything, they have all been vaccinated against hepatitis B, and they wear surgical masks, glasses and a cap to protect themselves while operating. Despite all these precautions, diseases can be transmitted to the surgeon, perhaps through a small hole in the thin rubber gloves caused by a needle or the point of a scalpel, or a stray drop of fluid that manages to get into the eye. The patient then has to be asked for permission to be tested for HIV and hepatitis C. If the HIV test is positive, the surgeon has to take antiretroviral drugs for a month to minimise the risk of infection and only engage in safe sex to prevent further contamination. Infection with HIV and other viruses is an occupational hazard in surgery.
7. Helena Russell
Helena Russell was a doctor in the not too distant future, from the perspective of the 1970s. She was a character in the BBC series Space: 1999, which was aired from 1975–7. As the title suggests, the series is set in 1999. The Moon has been knocked out of its orbit around the Earth. The future looks very unpredictable for the lunar colonists of Moonbase Alpha. And their surgeon is a woman – a very futuristic choice in the 1970s.
There is nothing at all about surgery that makes it unsuitable for women. Women can deal with the physical load, the responsibility, the pace of the work and the night shifts just as well as men. And they can possess just as much technical insight. Women are not by nature less technically minded than men, and they can sometimes be much better than men in social terms. And yet, female surgeons are still very much in the minority. But, with the proportion of women surgeons increasing rapidly, that may indeed change in the not too distant future. Back in 1999, however, female surgeons were still relatively rare – no more than one in eight in the Netherlands, and in England only 3% of consultant surgeons were women.
6. Men in white suits
In Steven Spielberg’s 1982 film E.T. the Extra-Terrestrial, anonymous doctors from a secret government organisation perform their work ruthlessly on cuddly extraterrestrial E.T. Without asking, they take over the house where the young Elliott lives and transform the living room into an operating theatre. Because they do not take the time to first listen to the patient and to Elliott and his family, they don’t understand that E.T.’s only problem is that he is homesick, and they make everything a lot worse than it already was.
The frontiers of surgery are being pushed back further and further. That often raises the question whether all this progress is necessary. Mottos like ‘aiming not only to achieve the most humanly possible but also the most humanly desirable’, or ‘not only adding years to life, but also life to years’ are heard more and more in recent decades. Making a good decision whether to perform an operation or not means striking a good balance between benefits for the patient – in terms of both length and quality of life – and the risks of the procedure. Both patients and surgeons can have a say in this decision. Patients are given a treatment code based on their own wishes and the nature and prognosis of their illness. Choosing full treatment without restrictions means that everything will be done to cure the patient and save his or her life. Specific treatment limits can be agreed upon, for example, that everything should be done except resuscitation, if that should prove necessary. Opting for a complete limitation of treatment means that nothing more is done to save the patient’s life, and only those st
eps are taken that make the end of life as comfortable as possible.
* * *
Women
Although it is almost taken for granted today that surgery is practised by both men and women, the profession has been so male-dominated in the past 200 years that it seems as if women wielding surgical knives are something new. Yet there have always been respected female surgeons. Around the year 1000, (male) surgeon Abu al-Qasim Khalaf ibn al-Abbas Al-Zahrawi, better known as Albucasis of Córdoba, wrote that women who suffered from bladder stones could best be treated by a female surgeon. Descriptions of the skills of female surgeons are also to be found in twelfth century French literature. In Italy, women were trained to be surgeons as early as the thirteenth century and in France the widow of a surgeon was even allowed to take over her late husband’s practice. The more than 3,000 surgeons who graduated in Salerno in the fourteenth century included eighteen women. In the same century, the surgeon at the court of the King of England was also a woman. After the Middle Ages, however, two remarkable changes of attitude led to the almost complete disappearance of women from surgery: the witch-hunts of the sixteenth century and the prudery of the nineteenth century, which prevailed until at least 1968. In the Netherlands, the proportion of women among newly registered surgeons between 1945 and 1990 was around 3 per cent. That increased to 12 per cent between 1990 and 2000. In 2010, 25 per cent of surgeons in the country and 33 per cent of those in training were women. By 2016, 11.1% of consultant surgeons in England were female.
* * *
5. Three sleeping doctors in cryogenic hibernation
In Stanley Kubrick’s 1968 film 2001: A Space Odyssey, three doctors spend their voyage on the spacecraft Discovery One fast asleep. They were put into cryogenic hibernation at the start of the mission and are due to be woken up when Discovery One reaches its destination, Jupiter. However, while they sleep soundly, suspecting nothing, the on-board HAL 9000 computer hijacks the ship. The ‘IT department’ completely takes over the tasks of the three doctors and ends their lives.
Under the Knife Page 29