Blood and Guts (11 page)

Now, for the first time, patients with compound fractures were
likely to leave the hospital with all their limbs intact. The next stage
was to apply the technique to surgery. Operating theatres had
changed little since Liston's day. The stained wooden operating
table was usually surrounded by a raked gallery. When surgeons
were operating the spectators would often gather close around the
table, their outside boots grinding the dirt of the street into the
timber floor. Light was provided by gas lamps or even candles.
Devising an antiseptic operating technique under such conditions
was quite a challenge, so Lister decided to rely on carbolic.

Before the operation he washes everything in a solution of
carbolic. Hands, instruments, sponges and dressings are all dipped
in the diluted acid. The patient's skin is brushed with carbolic, and
towels soaked in carbolic are placed around the wound. To keep the
air free of germs Lister employs a special contraption heated by a
spirit lamp to send a spray of high-pressure carbolic steam over the
operating table. The spray has to be adjusted to ensure the droplets
are small because large ones could burn the eyes.

Once the patient has been put to sleep with chloroform, Lister
rolls up his sleeves and the operation begins. The procedure takes
place in a cloud of carbolic. Everything quickly becomes soaked. A
fog covers the table and those surrounding it. Lister turns up the
collar of his coat to avoid the acid reaching the skin of his neck. It
is like operating in a rainstorm. When the time comes to close the
wound, Lister uses sutures of catgut (made from the intestines of
sheep) that have been soaked in carbolic. In the days of suppurating
wounds it had been easy enough to pull out silk threads through
the slush of decaying tissue. Now, as there is no infection, removing
such sutures or ligatures could prove difficult. Not only is catgut
sterile, but because the threads are organic, they are reabsorbed by
the body and will not have to be removed later.

Operating under these conditions was deeply unpleasant, but
the results spoke for themselves. Before antiseptic operations were
introduced at the hospital, there were sixteen deaths in thirty-five
surgical cases. Almost one in every two patients died. After antiseptic
surgery was introduced in the summer of 1865, there were only six
deaths in forty cases. The mortality rate had dropped from almost 50
per cent to around 15 per cent. It was a remarkable achievement.

Not everyone was so easily impressed. 'Listerism' was dismissed
by some as nonsense. Despite the evidence, surgeons failed to
accept the very idea of infection being caused by germs. They
dismissed these 'little beasts' as a figment of Lister's imagination.
Even those surgeons who understood the scientific basis for germs
were not convinced by Lister's techniques. Operating under a spray
of carbolic was inconvenient and unpleasant. New York surgeon
William Halsted was even forced to operate in a tent because
Bellevue Hospital staff hated the fumes from carbolic so much.
Other surgeons had been getting good results of their own simply
by keeping their operating theatres clean and washing their hands
properly. Lister rinsed his hands in carbolic but was still operating
in his old, bloodstained coat.

Lister eventually abandoned the carbolic spray, realizing that
there was a greater risk of infection from his hands or his instruments
than from any germs in the air. It took more than ten years,
but gradually Lister's ideas started to be adopted and operating
theatres began to change. The rooms were scrubbed, the old
wooden tables replaced by shiny metal, the floors sealed with
linoleum. Surgeons hung their old operating coats up for the final
time and started wearing clean linen shirts and operating gowns.
They washed their hands and sterilized their instruments either by
using heat or dousing them in carbolic. Wounds were covered with
carbolic dressings. Some surgeons even started wearing rubber
gloves. No one yet wore masks in the operating theatre, so a cough
or a sneeze could still kill a patient, but death rates from operations
continued to fall.

Listerism was here to stay and Joseph Lister became a national
hero. He was the first surgeon to be awarded a peerage, and a public
monument was erected in his honour. He even had a bacterium,
Listeria
, named after him, and thousands of people honour his
memory every day when they gargle with Listerine mouthwash.

When Robert Liston, one of the world's finest surgeons, operated
on patients in 1842 they had a one in six chance of coming out
of hospital alive. If they had a compound fracture, an operation was
their only chance of survival. For that they would have to endure
the horrific torture of being held down on a hard wooden table,
without anaesthetic, while their leg was sawn off. Ten years later
they would have still have lost their leg, but at least there was pain
relief and, assuming the chloroform did not kill them, a similar
chance of survival.

Finally, by the end of the nineteenth century, surgery had
become reasonably safe. The odds of survival had improved to better
than one in ten (depending on the operation), and patients were
much more likely to leave hospital with all their legs and arms intact.
Despite many false starts, the four barriers to successful surgery had
been overcome. Surgeons understood anatomy; they could stem
blood loss and were able to control pain. Now they could even operate
without causing infection. No part of the body was off limits.
Surgery was becoming a science. Surgeons could do anything.

Montgomery, Alabama, 15 September 1902

It was only a few minutes after midnight and the small, dusty back
roads of the city were pitch dark. The horse kicked up the dirt as it
cantered along, the buggy jarring violently on unseen rocks and
hidden potholes. Physicians of Dr Luther Leonidas Hill's reputation
rarely came to this part of town; even during the day, it was easy to
get lost. This was the negro area, where few could afford proper
medical treatment; doctors usually called here only out of charity.
But despite Hill's discomfort and the late hour, this house call was
worth it. He might be able to save a life, if he was not too late.

Oil lamps burnt in the windows, and a small group of people
had gathered around the door of the small wooden cabin. Several
women were sobbing; another was trying to corral a group of bewildered-
looking children. The older men hung back in the shadows,
chewing on tobacco, mumbling and shaking their heads. A man and
a woman stood by the door clasping each other's hands tightly.

Dr Parker and Dr Wilkerson were waiting outside and ushered
Hill into the cabin's solitary room. The building was little more than
a long shed, sparsely furnished with a table, hard wooden chairs and
an iron stove in the corner. Then Hill saw the boy. Thirteen-year-old
Henry Myrick was barely alive. He lay on the bed, his skin almost
translucent, his breathing imperceptible.

Myrick had been stabbed with a knife at five o'clock that afternoon.
The circumstances of the crime were not clear, but Hill found
it hard to believe that the boy had been in a fight – his appearance
was far too delicate for that. Dr Parker and Dr Wilkerson had been
called six hours after the injury. Now, almost eight hours after the
stabbing, Hill leant forward to examine the boy.

The knife blade had entered the boy's chest about a quarter of
an inch to the right of the left nipple. Hill put his fingers to the
wound and could see that it went deep. With every weak beat of the
boy's heart, there was a bright red stream of blood, as if someone
were squeezing a blood-soaked sponge. The skin was marked with
a triangular patch of dullness, a bruise suggesting that most of
the blood was being squeezed out inside the boy's chest. The boy's
hands, lips and nose were cold. Hill felt for a pulse but could
find hardly any sign of it. Even when he bent close, the heartbeat
was barely audible.

The boy was slipping in and out of consciousness. Hill shook
him gently and asked him how he felt. When the boy spoke, his
voice was weak. He was clearly in great pain, but perhaps not beyond
help. Hill went outside to consult Henry's parents. The surgeon was
offering them a glimmer of hope that their son might survive. They
agreed that Hill could operate.

When it came to the heart, Dr Luther Leonidas Hill, MD was
one of the best-qualified doctors in the southern United States, if
not the world. Obtaining his first medical degree at the age of
nineteen, he had studied at medical schools in Alabama, New York
and Philadelphia. From September 1883 until March 1884 Hill
had even spent six months in London, being instructed by that
great father of modern surgery Joseph Lister. Since returning to
his native Montgomery, Hill had devised his own medical speciality:
the study of heart wounds. Two years previously he had
published a report drawing together the known cases of repairing
a wounded heart. Hill had studied heart operations: he knew how
they should be done and he knew how likely the patients were to
survive. However, this was the first time he had seen a wounded
heart for himself.

Hill asked for two lamps to be placed near the cabin's single
table. The other doctors started to clean the area around it with
carbolic as best they could. Hill lifted Henry from his bed and
placed him on the hard surface. By now the cabin was becoming
crowded with medical men. Hill's brother had arrived, as had a Dr
Robinson, who was preparing to administer the chloroform anaesthetic.
Hill doused his instruments in carbolic, then laid them out
beside the table. Robinson took his dropper bottle, applied the
measured amount of chloroform to the mask and held it over the
boy's face. At one o'clock in the morning in a battered wooden
cabin Dr Luther Hill was about to attempt one of the first operations
on a beating human heart.

Hill raises his knife and makes his first cut through the skin to
the left of the sternum, the breastbone that runs down the centre of
the chest. It is a deep incision. He continues this cut outwards from
the sternum along the third rib from the top. He must cut through
the skin, the connective tissue beneath and the muscles covering the
ribs. He makes a second incision along the sixth rib on the left-hand
side, then joins these two lateral incisions together with a further
vertical cut. Hill has carved three sides of a rectangle into the boy's
flesh, the lines of incision now outlined in red as blood seeps out.
This will become Hill's door to the heart.

Hill picks up some bone nippers and begins to cut through the
three exposed ribs along the vertical incision in the boy's chest. The
cutters go through the bone of each rib cleanly with a brittle snap.
Ribs are attached to the sternum by pieces of cartilage, so Hill can
lift up the skin where he has cut the bone and use the cartilage as a
hinge. He gently pulls up the flap and bends it back, opening a door
of skin and severed ribs to expose the heart.

The heart. The size of a large fist, this hollow muscular pump
beats around seventy times every minute, 100,000 times a day, 36
million times a year. Over a normal lifetime the human heart will
beat more than 2.5 billion times. Every minute it pumps some eight
pints of blood around the body through more than 54,000 miles of
blood vessels. Stop this circulation of blood for much more than
four minutes and the lack of oxygen leads to permanent brain
damage. Fail to repair a major wound or cut into the heart and a
human can bleed to death within a minute.

Hill looks down at Henry's beating heart. Its protective fibrous
sack – the pericardium – is bulging out, filling with blood from the
wounded organ. The heart is struggling against the pressure of this
blood pushing against it. The pericardium looks as if it could burst,
and with every beat the situation is only getting worse. Hill slits the
wall of the pericardium, enlarging the original stab wound. Blood
pours out, but with the pressure on the heart released, the heartbeat
grows stronger. This is a good sign.

Hill asks his brother to reach into the pericardium and pull the
heart upwards towards the opening in the boy's chest. Finally, Hill
can see where the wound has penetrated. The knife had cut
through the thick wall of the left ventricle, one of the two long
chambers of the heart. From the left ventricle oxygenated blood
leaves the heart at high pressure to circulate through the body.

Hill's brother cups the beating heart in his hand. A jet of blood
spurts from the wound with every pulse. It is difficult to keep the
organ steady – the blood makes it slippery as it jumps in his palm,
but he does his best. Dr Hill reaches for his curved suture needle
and some catgut thread and begins to stitch the wound together. As
he works, the flow of blood gradually lessens; the gap closes and the
blood begins to coagulate.

The heart keeps beating.

His brother gently slips the heart back within the pericardium
and Hill pours salt solution over it to both clean the cavity and act
as a mild antiseptic. He closes the cartilage hinge and stitches the
flap of bone, muscle and skin back in place. Forty-five minutes have
elapsed and the operation is over. Hill lifts Henry back to the bed.
The boy has a slight fever and is slipping in and out of consciousness,
but his heartbeat remains strong.

Three days after the operation, Henry's condition starts to
improve. Fifteen days later he is allowed to sit up. Within a few weeks
he has fully recovered and can show off his scar with pride. Hill is
delighted; he is the first American surgeon to successfully cure a
wound to the heart.

When Hill published a report of the case later that year, he
included it in a table of similar operations undertaken between 1896
and 1902. For any aspiring heart surgeons the table would make
depressing reading. There were wounds from knives, pistol shots and
even scissors (in this case the victim had been stabbed a total of six
times). Some of the patients received anaesthetic, some did not.
Some were operated on immediately, some were not. It was difficult
to draw any firm conclusions about the circumstances, given that so
many of the operations resulted in death. Patients died of haemorrhages
or infection, others bled to death on the operating table. Of
the thirty-nine operations Hill had compiled, only fourteen patients
survived (including the person stabbed with the scissors). In 1902 the
chances were that two out of every three patients who underwent
heart surgery would die. The odds were appalling. It was little wonder
that most surgeons avoided operating on the heart altogether.

It is not as if the heart is particularly complicated. The organ is
divided into two separate halves with a wall along the middle.
^*
Vesalius (see Chapter 1) had accurately described the organ's
anatomy in the sixteenth century, but believed blood was absorbed
by the body and replaced by blood manufactured in the liver. In
1628 (almost one hundred years after Vesalius) the English physician
William Harvey published his essay entitled 'The Movement of
the Heart and Blood in Animals', outlining his belief that the blood
circulated around the body.

^*
Galen (see Chapter 1) believed this wall contained tiny holes that allowed the passage of
blood from one side of the heart to the other. He was wrong, but before birth there is indeed a
hole. This allows blood to bypass the lungs because they are not yet functioning. After birth
this hole usually closes, although not in the case of babies born with a 'hole in the heart'.

Harvey described how the heart is divided into two principal
parts. The right side of the heart receives blood from the body
and pumps it to the lungs; the left side of the heart receives blood
from the lungs to pump it around the body. Each side has a
smaller upper chamber called an atrium and a long, lower chamber
called a ventricle.

Blood arrives at the heart through wide main veins known as the
inferior and superior vena cava. This blood, low in oxygen, enters
the heart and begins to fill the right atrium – a kind of holding
chamber. When the right atrium is full, the muscle contracts to help
push the blood through the tricuspid valve into the right ventricle –
the pumping chamber. As the right ventricle contracts, blood is
pumped out to the lungs to receive oxygen. This oxygenated blood
returns to the heart in the left atrium, passes through the mitral (or
bicuspid) valve and is pumped away from the heart in the left ventricle.
The muscle wall of the left ventricle is thicker than that of the
right as much more force is needed to push the blood all the way
around the body. In a normal human heart, this whole process
works smoothly and rhythmically: valves open and close, blood
enters and leaves, muscles contract and relax.

The history of surgery suggests that surgeons have rarely been
afraid of trying new, risky and untested procedures. By the 1900s
surgeons were quite happy to cut into the body to operate on the
internal organs. Appendectomies had become routine, tissue
damage could be repaired and complex fractures set. Surgery was
clean, relatively pain-free and generally successful. Surgeons were
confident, highly respected members of society. But when it came to
operating on the heart, they were terrified.

In 1896 the famous British surgeon Sir Stephen Paget declared
that heart surgery had 'reached the limits set by nature'. More
sobering to most surgeons perhaps were the words of Theodor
Billroth, a pioneer of surgery on the digestive system. 'Any surgeon,'
he wrote, 'who would attempt an operation on the heart should lose
the respect of his colleagues.' And no surgeon wanted that.

Even twenty years later, during the First World War, surgeons
would shy away from operating on the heart. Many soldiers had fragments
of shrapnel left embedded in their chests, others simply bled
to death. Some men survived for many years with bullets lodged
in their hearts, the tissue healing around the foreign objects.
Distinguished surgeon George Grey Turner summed up the situation
when he was operating in a military hospital. He had the
chance to remove a shell fragment, but concluded that 'it was
beyond human and surgical capacity'. Even if the chances were that
a patient would die without surgery, few surgeons were prepared to
risk operating.

D-Day, 6 June 1944

Within minutes of the first soldiers landing on the beaches of
Normandy, the early casualties were on their way home. The landing
craft became ambulances, shuttling backwards and forwards from
the beaches to the ships. The ships went from being troop carriers to
floating hospitals with makeshift wards and operating theatres. The
walking wounded were patched up and returned to the beach to
fight another day. As the ships wallowed in the heavy swell, the
medics on board made every effort to keep the most severely injured
alive. After the beaches had been taken and the Allied Army moved
inland, the ships returned to England.

The military operation to evacuate injured soldiers was as well
planned as the invasion itself. While hospital ships ploughed back
and forth across the Channel, teams of nurses and doctors set up
field hospitals to follow the advancing troops. There were flights to
repatriate the wounded, fleets of ambulances, and even special
hospital trains. Back in England, while the invasion force had been
gathering along the south coast, land was being commandeered for
new hospitals. The generals could only guess how many casualties
were going to need treatment.