Blood and Guts (4 page)

Patients had every reason to be fearful. Liston usually operated
on reasonably fit young men or women with strong constitutions,
and considered long operations cruel. That his were speedy affairs
helped minimize blood loss and reduced the risk of disease. Liston
also believed in keeping wounds clean. After the skin had been
stitched together – with stitches known as 'sutures' (from the Latin
word meaning 'to sew') – he advocated dressing the wound with
sheets of lint dipped in cold water. These were to be frequently
changed as the wound suppurated, with warm poultices applied to
reduce the swelling and 'encourage discharge'.

Not for Liston the filthy bandages and straps of some of his
rivals. These, as he was fond of saying, only encouraged 'putrefaction,
fermentation, stench and filth'. It wasn't unusual for surgeons
to reuse bandages and dressings already stiff with blood. For
convenience, one surgeon proudly kept a drawer of 'plasters' passed
from patient to patient over the years. Well, he and others reasoned,
why waste them?

Liston would also wash his hands before operating and always
wore a clean apron. Or at least it started off clean at the beginning
of the day. Other surgeons took pride in conducting operations in
the same frock coats they had used for years. The blood and pus that
had built up into a hardened crust of material were regarded with
respect. Surgeons were, after all, respected members of society; they
had almost the same standing as doctors.

Liston and most of his contemporaries could, with some justification,
claim to save lives. They had a firm grasp of anatomy, knowing
with some certainty the name and position of every bone, muscle
and organ in the body. They also knew broadly what each organ did,
even if they had only a limited understanding of the underlying
mechanisms. Crucially for Liston's generation of surgeons, they had
also developed the skills and dexterity to stop their patients from
bleeding to death on the operating table.

The decision to operate was determined by the pain the patient
could withstand. In some quarters pain was seen as a prerequisite for
a successful operation – a stimulant to the body's natural powers of
recuperation. Perhaps the Galway patient had not been in enough
pain? Many operations took far longer than the few seconds required
for a basic amputation. Liston considered some of these too cruel. A
mastectomy, for example, would take several minutes, the breast
being slowly dissected 'with all due caution and deliberation'.

Neither was there any understanding of infection – what it was
or how it was spread or prevented. Although Liston chose to operate
in a clean apron with relatively clean hands, instruments and
dressings, these practices owed everything to his sense of cleanliness
and common sense rather than any theory of disease or how it
was controlled.

The speed with which he conducted his operations, which
included the removal of tumours and growths, and even reconstructive
surgery (see page 217), was a hallmark of his work. Sometimes,
though, his arrogance would get the better of him. (Indeed, the arrogance
of surgeons is a theme throughout the history of surgery.)

Jealous rivals would whisper that Liston was so quick that he
once accidentally amputated the penis of an amputee. On another
occasion he was asked to look at a young boy with a swelling on his
neck. A junior surgeon was convinced that the tumour was
connected to the main artery in the neck – the carotid. 'Pooh!' said
Liston as he drove a knife into the tumour. Unfortunately, the junior
surgeon was right. The boy died within minutes.

However, the most worrying incident for his students occurred
during an amputation when Liston accidentally amputated an assistant's
fingers. The outcome of this operation was horrific: the
patient died of infection, as did the assistant, and an observer died
of shock. It was the only operation in surgical history with a 300 per
cent mortality rate.

Liston's operations were messy, bloody and traumatic but,
despite the occasional setback, he was one of the best surgeons of
the day. His patients suffered terribly, but a fair proportion of them
came out of hospital alive. This eminent surgeon owed his relative
success to two thousand years of surgical development. A tortuous
history involving dismembered criminals, wounded soldiers and
Roman celebrities.

Pergamum, Roman province of Asia Minor (Western Turkey), AD157

The gladiatorial display was the zenith of Roman entertainment, a
glamorous spectacle of skill, excitement and bloodshed. The day of
the contest was one of celebration, and the amphitheatre was
packed with expectant crowds ready to be entertained.

The day started with a display of exotic creatures gathered
from the far reaches of the empire – leopards, wild horses and an
angry bear. The animals were goaded in mock hunting demonstrations.
A few were killed, but others were saved and employed as
executioners to tear apart local criminals who were tied to stakes in
front of the baying crowd. As the gladiators entered the ring, they
waved to acknowledge the screams of the spectators, who idolized
them as celebrities, their beautifully toned bodies admired by men
and adored by women.

The gladiators fought in pairs – a warrior in heavy armour
pitched against a nimble opponent with a net and trident; a fighter
with swords against one with spears and daggers. Although the event
was staged, the brutality of the fighting was terrifyingly – and
thrillingly – real. The men fought to injure, to wound, to win. They
were taught to aim for the arteries of the neck, and behind
the knee. It was a fight to the death, but they shouldn't kill. The
choice of whether a gladiator would live or die was the prerogative
of the sponsor. He alone could decide whether the victor should
deliver a final, fatal blow. The sponsor could not afford to allow
too many gladiators to die – it would be like killing half the cast
of actors after each performance of a play – as he would have to
buy replacements.

Within the hierarchy of Roman society, gladiators were near the
bottom of the heap. They were slaves and members of what was
considered a disreputable profession. This was a standing they
shared with prostitutes and, of course, actors. But despite their lack
of freedom and their apparently low status, gladiators were rightly
treated as the elite sportsmen they were. Their rigorous training
was complemented by a high-energy diet and the very best medical
treatment. The post of physician to the gladiators in Pergamum,
or any major city of the empire, was a prestigious one. Celebrity
gladiators required their own celebrity surgeon. This was the perfect
position for a showman such as the ambitious Claudius Galen.
^*

^*
No one seems to know for sure what Galen's first name was. 'Claudius' is
used in many references, but some historians suggest it was more likely to be
Aelius or Julius.

Galen was a servant of the healing god Asclepius and had studied
alongside distinguished physicians. This did not necessarily
make him a surgeon, but he did know how to impress. When he was
interviewed for the post of physician to the gladiators, Galen took
along a monkey. He then proceeded to slice open its stomach and
sew it back together again. 'Can anyone else do that?' he asked. He
got the job and, as an added bonus, the monkey survived.

In his new role Galen would learn to deal with everything from
minor sports injuries, such as muscle strains, to serious battle
wounds. When the survivors of the contests left the arena Galen
would be waiting to set bones or amputate limbs. He became an
expert at stemming blood flow and restoring the fighters to
health. As one of the first trauma surgeons, he was perfectly placed
to study the inner workings of the human body. The exposed guts
of a defeated gladiator, spilling out from a stomach wound, enabled
him to examine the digestive system. An amputation revealed the
bones, muscles and structure of the tendons, the bands of tissue
that connect bone and muscle. He noticed how blood vessels
pulsed and that some blood was brightly coloured. Galen later
claimed that no gladiator under his medical care had died, but,
even given their superior fitness, this is hard to believe. The physician,
though, had a legend to build and a reputation to maintain.

As Galen's career advanced, he extended his studies of anatomy
to animals – dead or, quite often, alive. He held public lectures and
demonstrations where an animal was publicly dissected. Pigs
seemed to bear the brunt of Galen's experiments as he considered
them to be most similar to humans. His favourite demonstration
involved severing the nerves in the neck of a live pig. As he cut them
away, the wriggling animal became increasingly paralysed. First
unable to move its hind legs, its front legs would then become still.
With the final slice, Galen could stop the pig squealing.

In the manner of a true celebrity surgeon, Galen eventually
became a personal physician to the emperor Marcus Aurelius. His
ultimate ambition, though, was to become as famous as the Greek
'father of medicine' himself, Hippocrates. Galen hoped to be
immortalized by the medical profession as someone who understood
how the human body functioned. However, his only direct
knowledge of human anatomy came from his work as a surgeon.
Dissection of dead bodies was rare, and many considered it unclean
and blasphemous. As a respected member of Roman society, Galen
could not risk even suggesting such a thing, so instead he based
most of his descriptions of human anatomy on what he had learnt
by dissecting animals. The rest he surmised from consultations with
his patients, or simply made up.

Much of what he deduced was right. Stopping a pig's squeals by
severing its nerves made him realize that the brain controlled the
voice. Aristotle had previously suggested that the brain was some
sort of cooling system for the body. Galen concluded that arteries
contained blood (rather than air) and that each organ had a particular
function. He also advised that the strength, frequency and
rhythm of the pulse could be used to diagnose disease. Indeed,
he developed elaborate and complex theories on the differences
between the various types of pulse that eventually stretched to
sixteen books.

Some of his theories, however, were completely wrong. He
taught that the blood was produced in the liver and distributed in
veins. He saw the heart as some sort of furnace containing two
chambers with tiny pores or micro-holes between them that
allowed the blood to seep from one side to the other. There was no
sense that the blood circulated around the body or was pumped
from the heart. The pulsating movement of the arteries he attributed
to their muscular structure, which he supposed contracted and
expanded 'naturally'. And although he realized that urine was
produced in the kidneys rather than the bladder, he got the position
of the kidneys wrong.

Galen's crowning achievement was 'perfecting' the philosophical
medical theories developed by the ancient Greeks: the four
humours. Each humour corresponded to a different temperament
and element: yellow bile was associated with fire; black bile with
earth; phlegm with water; and blood with air. Illness occurred when
the humours were out of balance. To rebalance the humours, the
doctor could remove blood, induce vomiting or purge the body with
an enema. A fever, for example, might be attributed to an excess of
blood, so Galen advocated bloodletting to cool the body. A general
feeling of melancholy suggested too much black bile, requiring the
gut to be purged.

Galen believed he was a brilliant scientist and philosopher.
Considering that most of his anatomical experience was based on
animals, he did not do such a bad job. Many of his conclusions were
based on real experimental evidence and would have made ideal
foundations for later natural philosophers and doctors to refine and
so improve our understanding of anatomy. The problem was that
until the sixteenth century no one bothered.

The Roman Empire fell, Islam rose, Europe embarked on the
Crusades, Columbus 'discovered' America, Magna Carta was signed
and the printing press invented. Yet still, after one and a half thousand
years, our knowledge of medicine, surgery and anatomy was
based on the writings of Galen, a boastful Roman surgeon. That
Galen was wrong about so much was hardly his fault, nevertheless it
took more than one thousand years before doctors and surgeons
began to question his teachings.

Louvain, Flanders, 1536

It was nearing dusk. The city gates were about to be shut for
the night. Outside the walls of Louvain, swinging on a gibbet in the
gentle evening breeze, was the macabre silhouette of one of
the city's criminals. The body was still more or less intact, but you
could see through the ribcage. Ligaments connected many of the
bones, but the skull was snapped unnaturally to one side – evidence
that the hanged man had at least died quickly from a broken neck
rather than from slow strangulation. Some parts of the body had
fallen to the ground, the result of scavenging dogs jumping up and
tearing them off. The kneecaps had gone, as had one of the feet.
Birds too had feasted on the decomposing flesh, their activities
betrayed by the guano on the man's shoulder blades.

The authorities were particularly worried about undesirables
arriving in Flanders from France. A decomposing corpse stationed
outside the city gates sent a clear message that criminal activity
would be severely punished. There was little evidence that the
display worked, but it certainly unnerved most of the God-fearing
citizens passing by.

This evening the road is deserted and a precocious medical
student, Andreas Vesalius, is on his way home. He needs to be
back in the city by the evening curfew, otherwise he will have
to spend the night locked outside the city walls. He sees the gibbet
at the roadside and goes across to take a closer look. The dangling
corpse is exactly what he has been looking for – an ideal
subject for study. Getting hold of bodies is difficult, and if he
does not take this opportunity he thinks it likely that another
medical student will.