Under the Knife
Page 30
Somewhere in the period of the Internet bubble, in the mid-1990s, a definite start was made on computerising health-care. Surgeons, too, had to go with the flow and accept these developments. Anyone who chose not to fell hopelessly behind. Handwritten medical records, prescriptions and referral letters are becoming things of the past. Every modern hospital has electronic patient records and all treatments, admissions, results and complications are registered digitally. The number of medical secretaries has consequently decreased, with the result that surgeons now find themselves with much more work to do. It all sounds wonderful, the electronic letters and files, but there is no output without input. Computerisation has not been able to prevent a sharp increase in the volume of administration that surgeons and other medical specialists are expected to contend with. There is (unfortunately) as yet no question of computers completely taking over the tasks of human doctors.
4. Leonard McCoy
Leonard McCoy was the quiet ship’s doctor on the USS Enterprise in Gene Roddenberry’s original series of Star Trek, which was aired from 1966 to 1969. For a man of the twenty-third century, McCoy is quite old-fashioned. He wants nothing to do with the technology and ice-cold logic of his sparring partner Mr Spock. No evidence-based surgery nonsense for him, just good old rest, routine and cleanliness. His patients lie in the neat and tidy four-person sick bay, fast asleep. Under McCoy, there is no fast-track when it comes to post-operative care on the Enterprise.
In our minds, bed-rest is inextricably bound up with post-operative care. Who could ever have thought in the 1960s that lying in bed actually does more harm than good in the important phase of recovering after an operation? McCoy did have a small device, about the size of a smartphone, with which he could obtain a detailed diagnosis simply by moving it back and forth over the patient. His treatments, too, were futuristic, even if only because he could get every crew member who had been attacked by an alien back on his or her feet in no time, leaving no handicaps or scars. But there was nothing futuristic about his policy after administering this high-tech treatment: just as in the great hospitals of the seventeenth century, he would simply put his patients in bed and wait for them to recover.
3. The Robot Surgeon
In George Lucas’s 1980 epic Star Wars: The Empire Strikes Back, an anonymous robot fits Luke Skywalker with a mechanical arm after the young hero loses his right hand in the war between good (The Force) and evil (The Dark Force). At the same time, Luke realises that the evil Darth Vader, who had hacked off his hand with a laser sword, is actually his father. Such a half-baked fairy tale always has to have a happy ending. As a kind of deus ex machina, the robot replaces the lost limb with a bionic hand. Although in this future, Luke Skywalker is a satisfied patient, surgeons seem to have become completely superfluous.
Breathtaking technical developments have been made in surgery in the past thirty or forty years. Increasingly complex operations have become possible, with smaller and smaller incisions. Remarkably enough, robotics have not played a particularly important role in that rapid progress. Certain abdominal operations can be performed using a robot, but the robot cannot be pre-programmed; a surgeon always has to control it in real time. Moreover, robotic surgery offers no new options: the same procedures can be performed without robots. Other technologies, however, such as those relating to navigation and virtual reality, are more interesting in terms of improving operating procedures. In that respect, films like The Matrix (Andy and Larry Wachowski, 1999) and Total Recall (Paul Verhoeven, 1990) present a more realistic picture of the future of surgery than Star Wars.
2. Dr Ash
Ash is the doctor on board the space freighter Nostromo in Ridley Scott’s 1979 film Alien. When a nightmarish alien appears on board by bursting out of the chest of one of the crew members, Dr Ash thwarts the efforts of the rest of the crew to destroy it. The crew kill him and discover that he was not human, but a mechanical android that blindly followed its pre-programmed instructions. The company operating the spaceship had given the android secret orders to search for alien life. Ash was thus a doctor who follows the instructions of his board of directors to the letter, even at the expense of his own colleagues.
Medical specialists determine the quality of their care themselves. Together with the patient, they decide what is to be done and the best way to do it. This is in the hospital’s interests, but hospital boards have other interests, too. They have to pay salaries, purchase medical supplies and manage the hospital building, all without spending too much money, of course. Although the same quantity of care can sometimes be provided with less money, less well-trained staff, cheaper materials and fewer facilities can naturally have a negative impact on quality. Of all the specialists in a hospital, surgeons are perhaps most dependent on well-trained staff, good quality materials and up-to-date facilities. That also makes them the most dependent on the policy of the hospital board. They should therefore be able to keep a finger on the pulse of how that policy is made. Unfortunately, surgeons have the least time of all medical specialists to do this. Generally speaking, policy-making in health care – nationally and in individual hospitals – is in the hands of managers and non-surgical doctors, while surgeons look on from the sidelines.
1. Peter Duval
Peter Duval is the handsome surgeon on board the submarine Proteus in Richard Fleischer’s 1966 film Fantastic Voyage. A prominent scientist from the Eastern bloc defects to the West, bangs his head and suffers a brain haemorrhage. Only a minimally invasive operation can remove the blood clot in his brain. And that is taken very literally in this science fiction film. Using futuristic technology, a nuclear submarine, crew and all, is reduced to the size of a red blood cell and injected into the man’s neck. The sub loses its way and has to take a much more exciting route to the brain, via the heart and the inner ear. To make things worse, it proves to have been a serious error to take an internist along on the voyage. As the story evolves, it becomes clear that the internist, Dr Michaels, is a spy and is sabotaging the team’s well-intentioned plans. But Michaels receives his just deserts when he is devoured by a white blood cell. Surgeon Peter Duval can then put on his tough-guy diving suit and, with the beautiful Raquel Welch at his side, start zapping the blood clot with a large laser cannon.
Only a surgeon could have written such a scenario! Unfortunately, even now, blood clots are not treated by surgeons in miniature submarines, but by medicines administered by non-surgical medical specialists. Just as minimally invasive, but not as much fun.
Minimally invasive treatment is the key concept in the surgery of the near future. Operations are becoming smaller and smaller and take much less time, so that the patient experiences less discomfort and inconvenience. Moreover, fewer operations are necessary because some illnesses can just as easily be treated with drugs or non-surgical procedures. Yet surgeons will never disappear completely, or be replaced by robots or computer technology. There will always be a need for a man or a woman with a knife to save people’s lives, repair damage, remove cancer and alleviate suffering.
Woodcut print from the 1594 book Opera Chirurgica (Surgical Works) by French army surgeon Ambroise Paré, showing various war injuries one could encounter as an army surgeon. (Ambroise Paré, 1594)
In the Old Testament, patriarch Abraham performs a surgical operation on himself, trying to cure what might have been a disease of the object he cut away: the foreskin of his penis. The relief must have been great, as he did not hesitate to perform the same operation on all males of his household. (Maître de la Bible de Jean de Sy, ca. 1355–1357)
The colon, or large intestine, is situated not far below the skin. A colostomy can be performed by bringing out the colon through the skin. The suffix ‘-stomy’ means opening. (Blausen.com staff (2014). “Medical gallery of Blausen Medical 2014”. WikiJournal of Medicine 1 (2). DOI:10.15347/wjm/2014.010. ISSN 2002-4436.)
When Darius the Great seized power in 521 BC, he became both king of the Persian Empire and pharaoh of Egypt.
None of the many images of him, including this relief carving in Persepolis, show his alleged physical handicap from a complex ankle fracture. (Frank Haf)
These remains of the skeleton of a female human ancestor, nicknamed ‘Lucy’, were found in 1974. Lucy was an Australopithecus afarensis, an extinct species of the family of hominids, the scientific name for human-like animals. (Vincent Mourre, 2007)
Reenactment of the first operation performed using ether anesthesia, shortly after the actual operation took place on 16 October 1846 at the Massachusetts General Hospital in Boston. (Southworth & Hawes, 1846)
Albert Einstein visited New York for the first time on 2 April 1921, arriving with his wife, Elsa, on the steamship Rotterdam. It was later in New York that he met a fellow countryman, German surgeon Rudolph Nissen, who operated on his – ultimately fatal – abdominal aneurysm in 1948. (Underwood & Underwood, 1921)
President John F. Kennedy was shot at three times on 22 November 1963. The first bullet missed its target, but the other two were deadly: the second one hit the president in his back and pierced his windpipe, and the third damaged parts of his skull and brain. This medical drawing by Ida Dox depicts the windpipe behind the bullet exit wound in the front of the neck. (Warren Commission exhibit F-58, 1963)
Lee Harvey Oswald’s arrest card in Dallas, 23 November 1963. One day after his arrest for assassinating President John F. Kennedy, he was assassinated himself, shot in the upper part of his abdomen by Jack Ruby. He did not survive the attack, despite a heroic operation that involved several vital organs in his abdomen and his heart. (Heritage Auction Gallery, Warren Commission, 1963)
No human body would ever tolerate this nineteenth-century artificial shoulder made of platinum and rubber, especially not in the presence of a fierce infection like tuberculosis of the bone. Yet French surgeon Jules-Émile Péan implanted this contraption in 1893 in a patient suffering from consumption. It had to be removed two years later. The antique prosthesis is now located in Washington DC. (Alan Hawk, 1993)
Painting of famous French surgeon Jules-Émile Péan, before the operation, by Henri Gervex (Paris 1887). The surgeon is portrayed as a hero about to save a life. (Gebbie & Husson Co., 1889)
In the late twentieth century, Austrian surgeon Theodor Billroth was practically a god to doctors and surgeons. The characters depicted in this 1890 painting by Adalbert Seligmann focus on Billroth as the central figure. (Adalbert Seligmann, 1890)
Surgeon William Halsted operating at Johns Hopkins Hospital in Baltimore, Maryland, in 1904. Halsted was the first to use rubber gloves during an operation, mainly to protect the skin against the disinfecting chemicals. (Wellcome Collection)
Although Vladimir Ilyich Uljanov – or Lenin, as he was more commonly known – never smoked, he suffered from a series of strokes at a relatively young age. In this photograph of Lenin recovering from his third stroke, taken on 28 August 1923, the paralysis of his right arm is clearly visible. (M. I. Ulyanova, 1923)
Without artificial light, no cavity of the body could be inspected that was farther away than the reach of a doctor’s finger. For centuries, these were inspected with the light of the sun or a candle. The first organ to be reached by artificial light was the stomach, with a metal tube the size of a Roman sword that had to be swallowed in its entirety. On the tip there was a small electric lightbulb, illuminating the organ from the inside. (Wikimedia Commons)
King Louis XIV was France’s magnificent seventeenth-century monarch known as the Sun King, but this didn’t prevent him from falling victim to a painful anal fistula. The fact that he dared to undergo an operation – and survived – would have given the reputation of his surgeon’s profession a tremendous boost. (Louis XIV Collection, 1701)
The electric eel of Amsterdam’s Artis Zoo during his operation to examine a tumor in 2013. The tube in his mouth supplied fresh oxygenated water containing anesthesia, so that the operation could be performed without electric shock hazard. (From Arnold van de Laar’s personal collection.)
Acknowledgements
THE ACCOUNTS IN this book are based on true events in the lives of well-known and not-so-well-known patients, based on historical sources, interviews and media reports, biographies and what others have written about them. They are not intended as an exact and complete reproduction of historical facts, but more as an interpretation of them from a surgical perspective. They appeared in abridged form between 2009 and 2014 in the Nederlands Tijdschrift voor Heelkunde, the journal of the Dutch Surgical Association, edited by Victor Kammeijer.
I would like to thank Boris Liberov for the correct interpretation of the Russian source on Lenin’s operation, Agatha Hielkema for her additional information on Dutch medical law, Marno Wolters and the Natura Artis Magistra Zoo in Amsterdam for the interview on the electric eel, my wife Laverne and my colleagues Maurits de Brauw, Eric Derksen, Eric van Dulken and Thomas Nagy for proposing useful ideas for subject matter, and Pleun Snel for reading the manuscript and providing constructive criticism.
Glossary
Abdomen Informally known as the belly. The Greek word laparos is used in surgery to refer to the abdomen, e.g. laparotomy: cutting open the abdominal cavity.
Abscess Accumulation of pus under pressure between the tissues of the body. To prevent it getting worse, a ripe abscess must be opened. This rule of thumb in surgery is expressed by the Latin aphorism ‘ubi pus, ibi evacua’, ‘where there is pus, evacuate it’. Cutting open an abscess and draining the pus is a surgical procedure. An accumulation of pus in an existing cavity is known as an empyema. See Pus, Incision, Drain.
Acute Sudden or immediate (not to be confused with urgent). Opposite of chronic, persistent, not sudden. Hyperacute means very sudden. Subacute means quickly, but not sudden.
Amputation Partial or complete removal of a limb. From the Latin word amputare, to prune.
Anaesthesia Medical specialisation that deals with local, regional or general anaesthesia of a patient for an operation. An anaesthetist is a medical specialist qualified to administer anaesthesia.
Anamnesis Literally ‘from memory’. Asking a patient about the nature, severity, development and duration of symptoms. If a doctor finds out about a patient’s symptoms from others, it is called hetero-anamnesis. Anamnesis is the first part of the examination of a patient. It is followed by a physical examination and, if necessary, supplementary tests. See Symptom.
Anatomy Literally ‘to discover by cutting’. Description of the macroscopic structure of a living being. Deviations from the normal anatomy of the body can be caused by natural differences (anatomical variations) or by an illness or disorder (pathological anatomy).
Antisepsis, antiseptic The use of antiseptics (disinfectants) to remove bacteria from the skin, mucous membrane or a wound. The first disinfectants were wine and cognac. Carbolic acid was used later, but that was too harmful to bodily tissues. Today, chemicals containing iodine or chlorine are used. Simply washing with soap and water also disinfects to a certain extent, explaining why surgeons wash their hand so often. Not to be confused with asepsis/aseptic.
Arteriosclerosis Inflammatory disease of the arteries. The inner wall of the artery is affected by accumulations of cholesterol, causing an inflammation. That creates scar tissue in which calcium carbonate can be deposited. It eventually leads to narrowing (stenosis) of the artery, which can gradually or suddenly be completely blocked (occlusion).
Artery Blood vessel that carries blood from the heart under high pressure (blood pressure). Arteries are shown in red in anatomy books, because the oxygen-rich blood is bright red in colour. The pulmonary arteries are exceptional, because the blood they transport from the heart to the lungs is oxygen-poor.
Artificial ventilation Taking over a patient’s breathing artificially. That may involve placing a mask over the mouth and nose, inserting a tube into the windpipe via the mouth or nose (intubation), or making an opening at the front of the neck to provide direct access to the windpipe (tracheotomy). Ventilation c
an be provided with a hand-held balloon or a mechanical ventilator. The simplest form of ventilation is by artificial (mouth-to-mouth) respiration.
Asepsis, aseptic Not to be confused with antisepsis/antiseptic. See Sterile.
Assistant Someone who assists. A medical assistant is a health professional who supports the work of doctors and other health professionals. During operations, the other members of the team supporting the surgeon are known as surgical assistants, and may include both surgeons and paramedical staff.
Atherosclerosis See Arteriosclerosis.
Autopsy Examination of a dead body. See Obduction.
Biopsy Removal of a piece of tissue for further testing, for example under a microscope. An excisional biopsy means removing all the affected tissue. With an incisional biopsy, only part of the affected tissue is removed, leaving the rest in place. See also Excision, Incision.
Blocked arteries See Arteriosclerosis.
Bloodletting Draining blood. Used until well into the nineteenth century to treat all kinds of complaints. Beneficial effects based completely on superstition. See Fleam.
Cachexia Severe malnutrition, emaciation.