Authors: Richard Hollingham
Blood and Guts
BLOOD
AND
GUTS
AND
GUTS
A HISTORY OF SURGERY
Richard Hollingham
Foreword by Michael Mosley
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ISBN 9781407024530
Version 1.0
Published to accompany the BBC television series
Blood and Guts
,
first broadcast on BBC2 in 2008.
1 3 5 7 9 10 8 6 4 2
First published in 2008 by BBC Books, an imprint of Ebury Publishing.
A Random House Group Company.
Copyright © Richard Hollingham 2008
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ISBN: 9781407024530
Version 1.0
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To my mother, Penelope Ann Hollingham,
who would have made an excellent surgeon.
by Michael Mosley
In the early 1980s I trained to be a doctor at the Royal Free Hospital
in Hampstead, London. I had five wonderful years, made lifelong
friends and met my future wife, Clare. So although I now work in
television and no longer do any form of hands-on medicine, I have
few regrets about the years I spent poring over books and dissecting
corpses. I did at one point in my training think about becoming a
surgeon; after all it was a branch of medicine that was sexy, glamorous
and well paid. Then something happened that made me realize
that surgery was probably not for me.
One of the essential manual skills we had to learn early on was
how to stitch up wounds. We practised by sewing bits of orange peel
together and were then let loose on patients. The transition from
uncomplaining oranges to human skin was always going to be a
challenge. I remember with some embarrassment my first time. I
was down in casualty on a Saturday night, a third-year medical
student, intensely nervous. The place was crowded with the usual
mix of drunks and minor injuries. I was asked to stitch up one of the
drunks, an old tramp with a badly battered face, who had fallen over
and gashed his forehead.
I pulled on gloves over my sweating hands and, with the assistance
of a nurse, got together needle and thread and began to sew.
I was slow, meticulous and careful. My patient was garrulous,
confused and uncooperative. Finally I finished. But as I tried to pull
away my left hand, which I had been using to hold the wound
closed, we both got a nasty shock. I had sewn my glove to his head.
I cut the stitches and started again, but I think I realized at that
moment that I didn't have the manual dexterity, the precision, the
sheer attention to detail that marks out the best surgeons.
Since then I have been in many operating theatres and watched
many surgeons perform their magic. Fifteen years ago a surgeon
saved the life of my son, Jack, and I have met many other people
whose lives have been transformed by surgery. All this stimulated my
interest both in surgery and its history, particularly the individuals
and their discoveries who got us to where we are today.
The actual decision to make a television series rather than just
think about it emerged from a conversation I had with Janice
Hadlow, the dynamic controller of BBC4. I had just completed a
series for BBC4 called
Medical Mavericks
, a history of medicine told
through the stories of self-experimenters. Janice suggested that a
series on surgery would be the next obvious thing to do. We soon
agreed that the best approach would be a five-part series covering
five different areas of surgery, and I went off to decide what exactly
those programmes should contain.
Making television programmes is a collaborative process, and
the end product the result of many different people's thoughts and
insights. After some debate with my production team we decided to
go for trauma surgery, cardiac surgery, plastic surgery, transplant
surgery and neurosurgery. Each area illustrates something different
about how surgery has progressed, and each is packed full of colour-ful
characters and moral dilemmas.
We also decided that the programmes should not be purely
historical but should start with an example of the best of modern
surgery in that particular field. We would then use the modern case
to look back at how the various elements of that particular operation
had come about.
Many of the operations I witnessed while filming were memorable,
but the one I found particularly striking was performed by
cardiac surgeon Steven Westaby at the John Radcliffe Hospital in
Oxford. The patient was thirty-four-year-old Sophie Clark.
Sophie had a couple of serious cardiovascular problems, which
she'd had since birth. The first was a defect in a heart valve, the
second an aortic aneurysm. An aneurysm is a weakening and
swelling of a blood vessel, rather like a faulty tyre. As with a tyre, the
risk is that under pressure it will burst. If the problem lies in
the aorta, the main artery of the body, this would almost certainly
mean death. The operation to correct both these two defects was
extremely complex.
First Sophie was anaesthetized – a development pioneered in
the mid-nineteenth century by William Morton, James Simpson and
others (see Chapter 1).
Then she was connected to a heart-lung machine, the first of
which was built and tested by John Gibbon in 1953 (see Chapter 2).
Next her heart was stopped, using potassium chloride, a chemical
more commonly used for making fertilizer.
Then her body was cooled from a normal body temperature of
37°C to a decidedly chilly 16°C. This was to slow her metabolism and
cut her brain's oxygen demands during the operation. It's an
approach that was first suggested by Bill Bigelow, who was in turn
inspired by research he had been doing into the hibernating habits
of groundhogs (see Chapter 2).
Finally, all her blood was drained. As Steve put it, 'Heart surgeons
are basically plumbers. You have to get the blood out the way just as
you have to switch off the water before you change the pipes.'
At this point Sophie looked like something from the morgue.
She was chilly to the touch, grey in the face, had no heartbeat, and
the EEG technician could detect no signs of brain activity. She was
as close to death as anyone I have ever seen.
Steve, under some pressure to get the operation done in as
short a time as possible, did a magnificent job correcting her problems.
He replaced her faulty heart valve with an artificial one,
repositioned and reattached blood vessels using techniques first
developed by Alexis Carrel (see Chapter 3), then warmed her up,
started her heart, sewed her back up and the operation was done.
She has since made a full recovery.
Not all surgery ends quite so happily. The thing about pioneering
surgery is that it can, and often does, go wrong. The price of going
first is that it is often those who come later who benefit from the
lessons learnt. The history of surgery is littered with stories of
patients who died while undergoing experimental procedures. In
many cases, the sort of procedures attempted would not pass a
modern ethical committee.
To be fair, the problem does not always lie with the surgical
team. Take the case of Clint Hallam, the New Zealander who
became the first man to have a 'successful' hand transplant. The
operation took place in France in September 1998, and I remember
vividly being impressed and slightly disturbed when I first saw this
reported all over the news. I did not realize at the time that I would
become involved and obsessed with Clint's story as it unfolded like
a Greek tragedy.
In 1998 most people had got used to the idea of swapping body
parts, as long as those parts were internal. Heart, liver, kidneys,
lungs – all have long been eminently respectable organs to transplant,
the main issues with them being around limited supply. Who
should get the organ when it becomes available? Is it right to pay for
organs? Questions like these were the main preoccupation.
Suddenly we were confronted by something very different. Not only
was the transplanted organ, the hand, quite obviously on display,
but in some ways the operation itself was seen as 'cosmetic'. You
can't live without a heart or lungs, and your quality of life without
kidneys is poor. Surely, however, you can function perfectly well
without a hand? The cost of keeping a transplanted organ is high.
The drugs that prevent rejection will take something like ten years
off your life. Many people felt that performing a hand transplant
was morally indefensible.
Those who argued the counter-case – that a patient should have
the right to choose whether thirty years with two biological hands
was preferable to forty years with one – were not helped by what
happened next. First it emerged that Clint had a criminal past
(albeit for a minor tax fraud), then things began to go wrong with
the transplanted hand. Clint stopped taking his pills and the arm
started to be rejected.
At the time I was making a series for the BBC called
Superhuman
,
looking at cutting-edge medicine. I sent a producer over to Perth,
Western Australia, to film an interview with Clint. The transplanted
hand looked absolutely terrible, more like a huge pink rubber glove
than something human. It was useless for anything more sophisticated
than holding a toothbrush, and it was clear that Clint now
hated it. He talked about how people he met were repelled by it and
said he was thinking about having it removed. However, he was still,
in some wholly unrealistic way, also hoping to save it.
A year later I was flying back to London from California when
I noticed Clint on the plane. We chatted about how things had
been going and he told me that he was on his way to London to
have the hand removed. It had reached the point where it was not
just failing, but rotting. He had finally accepted that it was dead
and the dream was gone. The following day he had it removed
by surgeon Nadey Hakim.
So why did the world's first hand transplant go so badly wrong?
When I asked Clint, he accepted that he had not been a model
patient, but felt that his French medical and surgical team had not
prepared him adequately for what was to come. In particular, he felt
that the hand they had chosen to transplant was not well matched:
'I was ****ing angry with the doctors, and I am still angry that they
didn't match it. It was huge and quite different to my other hand.'
Despite this, Clint told me that he does not regret having had
the operation, and had recently rung around transplant surgeons
offering himself as a candidate for a further hand operation. It's fair
to say that there has been no rush to put him on a waiting list.
Since Clint's operation, more than thirty hands have been transplanted
successfully. I went to Louisville in Kentucky to meet one of
the most recent patients and try to understand what makes the
difference between success and failure. On the way to the hospital I
had a chat with my cab driver about his views on transplants. He felt
that there should be no limits, that it should be down to the patient,
the donor and the surgeon to decide. Oddly enough, he seemed
most worried about where the donor organ had come from: 'I
would not have an organ from anyone on death row as I would not
like to have bad genes injected into my body.'
The surgeon who heads the transplant team at the Jewish
Hospital in Louisville is Warren Breindenbach. Charming and
hyperactive, Warren believes that what has been done so far is just
the beginning; that eventually there will be no part of the body
that's not transplantable.
Back in 1998 Warren and his team had been widely regarded as
the ones most likely to perform the first hand transplant. Clint had
travelled to Louisville and offered himself as a patient to the
American team. That same year, on 23 September, Warren was in
New York to meet Clint for further discussions when he turned on
the television and discovered to his considerable surprise that not
only was Clint in Paris, but he had had a hand transplant. The
French had got there first. When I asked Warren if he felt disappointed
he said, 'I think every human being always wants to be
a leader, but I have told my team and I have emphasized over
and over again: it doesn't matter who does it first. It matters
who does it best.'
Since 1998 Warren has performed three hand transplants, and
the latest is perhaps the most remarkable. In November 2006 he
led a team of surgeons in replacing the right hand of fifty-four-yearold
David Savage. What is unusual about this particular case is
that David had lost his hand in an industrial accident thirty-two
years earlier. As Warren explained, this made the operation rather
tricky: 'We ran into problems which were novel and new, and the
analogy I make is kind of like closing your house down for thirty-two
years, then coming back and deciding you are going to take a
shower. You turn on the faucet and it sputters a little, and sometimes
it works and sometimes it doesn't, so we had some sputtering
as we tried to get the blood to flow into the hand that we were
transplanting. But it worked.'
The operation was, in the end, a technical triumph. But I
wondered if David, unlike Clint, was truly comfortable with his new
hand. When I first met David and his wife, Karen, I was instantly
struck by how different his new hand was from his other one. While
David is powerfully built, relatively dark-skinned and has thick
black hair on his forearms, the new hand was smaller, paler and
more delicate.
I asked David if he found it strange to have the hand of someone
now dead, and he said 'no'. Since the operation, he had felt
it was part of him. I then asked him if he had considered the
possibility that this hand had come from a woman, and he said he
had, but it didn't bother him. He had found the fact that the fingernails
on the new hand grow twice as fast as those on his own hand
slightly disconcerting, but his main feelings were of gratitude to the
family of the unknown donor.
David is undoubtedly happy to have had the operation, and
optimistic about the future. When I watched him in his physiotherapy
session I began to see why. He can catch things, lift up objects
and manipulate tools. He has around 60 per cent of the function
of a normal hand, and with more physio he may eventually get
to 80 per cent.
The nerves that supply sensation are regrowing, and feeling is
slowly coming back. He described with enormous satisfaction some
of the simple pleasures of being able to use both hands again: 'Last
September I went to my granddaughter's birthday party and just
grabbing hold of her and picking her up was a fantastic feeling.'
Warren Breindenbach believes that successful surgery relies
on cooperative patients. 'It's no good to only have a good surgeon.
If you hook everything up properly but the patient goes home
and doesn't use the hand, doesn't do physical therapy, then you
get a lousy result. It is extremely important, the physical therapy
and the cooperation, and that's where David has been an
excellent patient.'