Painful Operations: Removing Bladder Stones before Anesthesia

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If you visit the Gordon Museum at Guy’s Hospital in London, you’ll see a small bladder stone—no bigger than 3 centimetres across. Besides the fact that it has been sliced open to reveal concentric circles within, it is entirely unremarkable in appearance. Yet, this tiny stone was the source of enormous pain for 53-year-old Stephen Pollard, who agreed to undergo surgery to remove it in 1828.

People frequently suffered from bladder stones in earlier periods due to poor diet, which often consisted of lots of meat and alcohol, and very few vegetables. The oldest bladder stone on record was discovered in Egyptian grave from 4,800 B.C. The problem was so common that itinerant healers traveled from village to village offering a vast array of services and potions that promised to cure those suffering from the condition. Depending on the size of these stones, they could block the flow of urine into the bladder from the kidneys; or, they could prevent the flow of urine out of the bladder through the urethra. Either situation was potentially lethal. In the first instance, the kidney is slowly destroyed by pressure from the urine; in the second instance, the bladder swells and eventually bursts, leading to infection and finally death.

2Like today, bladder stones were unimaginably painful for those who suffered from them in the past. The stones themselves were often enormous. Some measured as large as a tennis ball. The afflicted often acted in desperation, going to great lengths to rid themselves of the agony. In the early 18th century, one man reportedly drove a nail through his penis and then used a blacksmith’s hammer to break the stone apart until the pieces were small enough to pass through his urethra. It’s not a surprise, then, that many sufferers chose to submit to the surgeon’s knife despite a very real risk of dying during or immediately after the procedure from shock or infection. Although the operation itself lasted only a matter of minutes, lithotomic procedures were incredibly painful and dangerous—not to mention humiliating.

The patient—naked from the waist down—was bound in such a way as to ensure an unobstructed view of his genitals and anus [see illustration below]. Afterwards, the surgeon passed a curved, metal tube up the patient’s penis and into the bladder. He then slid a finger into the man’s rectum, feeling for the stone. Once he had located it, his assistant removed the metal tube and replaced it with a wooden staff. This staff acted as a guide so that the surgeon did not fatally rupture the patient’s rectum or intestines as he began cutting deeper into the bladder. Once the staff was in place, the surgeon cut diagonally through the fibrous muscle of the scrotum until he reached the wooden staff. Next, he used a probe to widen the hole, ripping open the prostate gland in the process. At this point, the wooden staff was removed and the surgeon used forceps to extract the stone from the bladder. [1]

L0015225 Lithotomy scene

Unfortunately for Stephen Pollard, what should have lasted 5 minutes ended up lasting 55 minutes under the gaze of 200 spectators at Guy’s Hospital in London. The surgeon Bransby Cooper fumbled and panicked, cursing the patient loudly for having “a very deep perineum,” while the patient, in turn, cried: “Oh! let it go; —pray, let it keep in!’” The surgeon reportedly used every tool at his disposal before he finally reached into the gaping wound with his bare fingers. During this time, several of the spectators walked out of the operating theater, unable to bear witness to the patient’s agony any longer. Eventually, Cooper located the stone with a pair of forceps. He held it up for his audience, who clapped unenthusiastically at the sight of the stone.

Sadly, Pollard survived the surgery only to die the next day. His autopsy revealed that it was indeed the skill of his surgeon, and not his alleged “abnormal anatomy,” which was the cause of his death.

1200px-Thomas_Wakley72But the story didn’t end there. Word quickly got out about the botched operation. When Thomas Wakley [left]—the editor of The Lancet—heard of this medical disaster, he accused Cooper of incompetence and implied that the surgeon had only been appointed to Guy’s Hospital because he was nephew to one of the senior surgeons on staff. Wakley used the trial to attack what he believed to be corruption within the hospitals due to rampant nepotism. Outraged by the allegation, Cooper sued Wakley for libel and sought £2000 in damages. The jury reluctantly sided with the surgeon, but only awarded him £100. Wakley had raised more than that in a defence fund campaign and gave the remaining money over to Pollard’s widow after the trial. [2]

Bransby Cooper’s reputation, like his patient, never did recover.

If you’re interested in the history of pre-anesthetic and pre-antiseptic surgery, you can pre-order my book The Butchering Art in the US (click here) and in the UK (click here). Information of foreign editions to come!

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1. Druin Burch, Digging up the Dead: Uncovering the Life and Times of an Extraordinary Surgeon (2007), p. 26. I am greatly indebted to his work for bringing this story to my attention.
2. Thomas Wakley, A Report of the Trial of Cooper v. Wakley (1829), pp. 4-5.

“We Have Conquered Pain!” The Uses & Abuses of Ether in History

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The surgical revolution began with an American dentist and a curiously sweet-smelling liquid known as ether.

Officially, ether had been discovered in 1275, but its stupefying effects weren’t synthesized until 1540, when the German botanist and chemist Valerius Cordus created a revolutionary formula that involved adding sulfuric acid to ethyl alcohol. His contemporary Paracelsus experimented with ether on chickens, noting that when the birds drank the liquid, they would undergo prolonged sleep and awake unharmed. He concluded that the substance “quiets all suffering without any harm and relieves all pain, and quenches all fevers, and prevents complications in all disease.” [1] Yet inexplicably, it would be several hundred years before it was tested on humans.

00_01_morton-inhaler-replica-mThat moment finally arrived in 1842, when Crawford Williamson Long became the first pioneer to use ether as a general anesthetic when he removed a tumor from a patient’s neck in Jefferson, Georgia. Unfortunately, Long didn’t publish the results of his experiments until 1848. By that time, Boston dentist William T. G. Morton had won fame by using it while extracting a tooth painlessly from a patient on September 30, 1846 [see Morton’s inhaler for administering ether, right]. An account of this successful procedure was published in a newspaper, prompting a notable surgeon to ask Morton to assist him in an operation removing a large tumor from a patient’s lower jaw at Massachusetts General Hospital. After the demonstration, someone nicknamed the surgical amphitheater the “Ether Dome,” and it has been known by this name ever since.

It was an incredible breakthrough. Up until that point, surgery had been brutally painful. The patient, fully awake, would be restrained while the surgeon cut through skin, tissue, muscle, and bone. Surgeons were lauded for their brute strength and quick hands. A capable surgeon could remove a leg in under a minute. But with the discovery of ether, the need for speed in the operating theater had now vanished.

On November 18, 1846, Dr. Henry Jacob Bigelow wrote about this groundbreaking moment in The Boston Medical and Surgical Journal. He described how Morton had administered what he called “Letheon” to the patient before the operation commenced. This was a gas named after the River Lethe in classical mythology which made the souls of the dead forget their lives on earth. Morton, who had patented the composition of the gas shortly after the operation, kept its parts secret, even from the surgeons. Bigelow revealed, however, that he could detect the sickly sweet smell of ether in it. News about the miraculous substance which could render patients unconscious during surgery spread quickly around the world as surgeons rushed to test the effects of ether on their own patients.

The term “etherization” was coined, and the use of ether in surgery was celebrated in newspapers. “The history of Medicine has presented no parallel to the perfect success that has attended the use of ether,” a writer at the Exeter Flying Post proclaimed. [2] Another journalist declared: “Oh, what delight for every feeling heart… the announcement of this noble discovery of the power to still the sense of pain, and veil the eye and memory from all the horrors of an operation…WE HAVE CONQUERED PAIN!” [3]

5A curious by-product of all this was the ether parties that sprang up all over the world. Thomas Lint, a medical student at St. Bartholomew’s Hospital in London, confessed: “We sit round a table and suck [on an inhaling apparatus], like many nabobs with their hookahs. It’s glorious, as you will see from this analysis of a quarter of an hour’s jolly good suck.” [4] He then went on to describe several “ethereal” experiences he and his fellow classmates had while under the influence of the newly discovered substance.

Ether wasn’t just inhaled. It was also drunk, like alcohol. In Ireland, the substance replaced whiskey for a while, due to its low cost (a penny a draught). After drinking a glass of water, “ethermaniacs” would take a drop of the drug on their tongues while pinching their noses and chasing it with another glass of water. Taken this way, ether hit the user hard and fast. Dr. Ernest Hart wrote that “the immediate effects of drinking ether are similar to those produced by alcohol, but everything takes place more rapidly.” [5] Recovery was just as swift. Those taken into custody for drunken disorderliness were often completely sober by the time they reached the police station, with the bonus that they also suffered no hangover. In this way, 19th-century revelers could take draughts of ether several times a day, with little consequence. [6]

Today, the “Ether Dome” at Massachusetts General Hospital has become a national historic landmark [pictured below], visited by thousands of members of the public each year. Although surgeons haven’t operated there for well over a hundred years, the room is still used for meetings and lectures at the hospital. The Ether Dome looks more or less like it did 165 years ago. Display cases at either end of the room contain surgical instruments from Morton’s day, their blades dull and rusted with age. At the front of the room an Egyptian mummy lords over the phantom audience. One can almost detect the sweet smell of ether in the air from so long ago.

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1. Quoted in Steve Parker, Kill or Cure: An Illustrated History ofMedicine (London: DK, 2013), 174.
2. “Etherization in Surgery,” Exeter Flying Post, 24 June, 1847, 4.
3. London People’s Journal, 9 January, 1847.
4. Punch, or The London Charivari (December 1847), 259.
5. Quoted in David J. Linden, Pleasure: How Our Brains Make Junk Food, Exercise, Marijuana, Generosity & Gambling Feel So Good (Viking, 2011), 31.
6. Sterling Haynes, “Ethermaniacs,” BC Medical Journal (June 2014), Vol. 56 (No.5), 254-3.

The Chimp & The Surgeon: A History of Heart Transplants

Today isn’t just Valentine’s Day. It’s also the end of Congenital Heart Defects Awareness Week. With that in mind, here’s a short piece on the history of heart transplants.

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When Boyd Rush, aged 68, was admitted to the University of Mississippi Medical Center on 23 January 1964, Dr James Hardy [below] was waiting for him. Hardy, who had been conducting research on organ transplantation since the mid-1950s and had successfully performed a lung transplant the year before, wanted to replace Rush’s heart with a human equivalent. Unfortunately, strict medical regulations did not recognise brain cessation as a sign of death, which meant that a surgeon had to wait till a person’s heart stopped before it could be used for transplantation.

_100On the day Rush was brought to the hospital, none were available. As the minutes passed, the situation became more and more critical.

‘The prospective recipient went into terminal shock at approximately 6 p.m., with a blood pressure of 70 and virtually without respiration except for the continued use of the mechanical ventilation through a tracheotomy tube’, Hardy later recalled in his memoirs. ‘Death was clearly imminent and it was obvious that if heart transplantation was to be performed, it had to be done at once’. [1]

Rush was wheeled into the operating theatre, where Hardy polled his surgical team about whether or not a transplant attempt should be made using a chimpanzee’s heart.

‘I polled each of the five primary members of the transplant team individually, and their votes were recorded. Four voted to proceed with transplantation… The fifth abstained’. [2]

The surgery went ahead even though everyone in the room was ‘well aware that any transplantation of a heart in man would be followed by public consternation’ and that ‘the use of a chimpanzee heart would augment the criticism immeasurably’. Hardy later described it as a ‘profoundly sober moment for all’. [3]

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Several hours later, Hardy and his team made history by performing the first ever heart transplant. The chimp’s heart beat for 90 minutes inside Rush’s chest, but unfortunately proved too small to keep its new human body alive. Hardy’s patient died shortly after the operation was complete.

Hardy’s decision to use a chimpanzee’s heart fell under immediate attack from both the public, as well as those within the medical community. The operation ‘precipitated intense ethical, moral, social, religious, financial, governmental and even legal concerns’, Dr. Hardy wrote years later. ‘We had not transplanted merely a human heart, we had transplanted a subhuman heart’. [4]

_100Undeniably, the heart is one of the most vital organs in the human body. Without it, we would die. However, the controversy that arose in the 1960s when Hardy implanted a chimpanzee’s heart into Rush had less to do with physiology than it had to do with philosophy. For thousands of years, the heart was considered to be the seat of the human soul. Over time, the scientific community came to recognise the role the brain played in human consciousness. Nevertheless, people continued to equate emotions with the heart. Indeed, to some extent, we still do this today.

The ‘criticism from the media and our peers was vicious’, Hardy’s daughter remembered. ‘Many believed that if you transplanted the heart, you transplanted the soul. Even at school, we were aware that people were upset. As a child, it was difficult to understand why’. [5]

Hardy’s systematic murder of chimpanzees for use of their organs was also controversial. Invited to speak at a surgical conference in New York City several days after the historic operation, Hardy was shocked when the moderator introduced him by saying: ‘In Mississippi, they keep the chimpanzees in one cage and the Negroes in another cage, don’t they, Dr. Hardy?’ [6]

_100Over the next several months, some of the criticism within the medical community waned after Hardy published a paper in the Journal of the American Medical Association in which he described the strict ethical guidelines he and his team had followed when evaluating both donor and recipient. [Note: for more about the use of animals in medicine, click here].

It wasn’t until 1967 that the first human-to-human heart transplant took place at the Groote Schuur Hospital in Cape Town, South Africa, where a young surgeon named Christiaan Barnard was experimenting with pioneering surgical procedures. Barnard’s patient was 55-year-old Louis Washkansky, who was suffering from incurable heart disease. Washkansky could either wait for death, or risk undergoing surgery.

‘For a dying man it is not a difficult decision because he knows he is at the end’, Barnard later recalled. ‘If a lion chases you to the bank of a river filled with crocodiles, you will leap into the water convinced you have a chance to swim to the other side. But you would never accept such odds if there were no lion’. [7]

So the surgeon and his patient waited for the right moment. Then one day in early December, a woman named Denise Darvall was brought to Barnard’s hospital after incurring fatal injuries in a car accident. She and Washkansky shared the same blood type; her heart was still healthy. On the 3rd, Barnard prepped his patient for surgery. Over the next 5 hours, he would successfully replace Washkansky’s diseased heart with Darvall’s healthy one.

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Washkansky’s new heart beat strongly and steadily. Unfortunately, due to a suppressed immune system, he contracted double pneumonia and died 18 days later. Nevertheless, his case would signal a turning point in the history of medicine.

Years later, Barnard recalled how the landmark surgery changed his life: ‘On Saturday, I was a surgeon in South Africa, very little known. On Monday, I was world-renowned’. [8] Barnard, more than Hardy, was celebrated for his accomplishments, appearing on the covers of magazines and touring the world with stories of his success.

_100Christiaan’s brother, Dr Mario S. Barnard, published a paper in the South African Medical Journal describing the historic operation. In it, he credited Hardy and the Mississippi team for paving the way, arguing that this earlier operation proved that ‘the feasibility of cardiac transplantation was now irrefutable’. [9]

Even after the first successful human-to-human heart transplant, surgeons continued to experiment with animal hearts. Between 1964 and 1977, sheep, baboon and chimpanzee hearts were transplanted into at least four adults, all of whom died within a few days of the operation. It wasn’t until 20 years after Hardy’s operation on Rush that surgeons were somewhat successful with a cross-species heart transplant.

On 14 October 1984, Stephanie Fae Beauclair was born prematurely with hypoplastic left heart syndrome, a rare congenital defect in which the left ventricle is severely underdeveloped. Baby Fae’s parents took her to Loma Linda University Medical Center in California, where they met with Dr Leonard Bailey.

‘In those days, the advice to parents was to leave the baby here to die or take it home to die’, Bailey recalled. [10]

Bailey, who had performed more than 150 heart transplants on various species over the past 6 years, offered the grief-stricken parents a second option. He proposed replacing their daughter’s defective heart with that of a baboon. On 26 October 1984, Bailey and his surgical team did just that.

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Baby Fae lived for 21 days, two weeks longer than any previous baboon heart transplant recipient. At a news conference following the child’s death, Bailey told reporters: ‘Infants with heart disease yet to be born will some day soon have the opportunity to live, thanks to the courage of this infant and her parents’. [11]

Shortly after this feat, surgeons abandoned inter-species heart transplants due to the high risk of infection that followed such operations.

Today, approximately 3,500 human heart transplants are performed annually worldwide. The vast majority of these are done in the United States. Due to the development of powerful anti-rejection drugs, 85% of patients survive up to one year after surgery; 75% make it to their third year.

And it all began on 23 January 1964 with the heart of a chimpanzee.

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1.James Hardy, According to The World of Surgery 1945-1985: Memoirs of One Participant.
2. Ibid.
3. Ibid.
4. Ibid.
5. Quoted in Lynne Jeter, ‘Having a Heart-to-Heart’,
Mississipi Medical News (2008).
6. Quoted in Tony Stark, Knife to the Heart: The Story of Transplant Surgery (1996), p. 162.
7. Quoted in D. McRae, Every Second Counts: The Extraordinary Race to Transplant the First Human Heart (2007).
8. Quoted in Fred C. Pampel & Seth Pauley, Progress Against Heart Disease (2004), p. 78.
9. M. S. Barnard, ‘Heart Transplantation: An Experimental Review and Preliminary Research’, South African Medical Journal (30 December 1967), p. 12.
10. Quoted in Ansel Oliver, ‘Surgeon Bailey Reflects 25 Years After “Baby Fae”’, Adventist News Network.
11. Quoted in Claudia Wallis, ‘Medicine: Baby Fae Loses Her Battle’, Time Magazine (26 November 1984), p. 88.