Category Archives: operations

How to cure your ulcer

John Parr had an ulcer from 1919 to 1946

John Parr had an ulcer from 1919 to 1946

In the old days, writes Dalrymple,

injections of histidine and various extracts of various animals’ stomach linings were tried, all with initial success and enthusiasm, all with ultimate failure. The gastric juice of people was infused, presumably by nasogastric tube, into the stomachs of sufferers. Then there were the operations: all those Billroth gastrectomies whose names were once such a torture for medical students to learn.

Dalrymple recalls a remark by Sir Heneage Ogilvie, the surgeon, about the use of eponyms:

If we must have names, let credit be properly attributed and call the operation the high posterior Finsterer-Lake-Lahey modification of the Mikulicz-Krönlein-Hofmeister-Reichel-Polya improvement of the Billroth II gastrectomy.

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Sir Heneage Ogilvie: ‘one of his most remembered admonitions was to require the performance of a colostomy for all wounds of the colon’

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Complication-free ops total 4,000 in one day

Screen Shot 2016-04-16 at 20.35.05That, Dalrymple points out, is not news. Nor is

Cured patients discharged from hospital numbered 5,000 yesterday.

The lack of such reports in the newspapers naturally, he says, puts him on the

qui vive for deficiencies in the care of an old and close friend of mine who was admitted to a provincial hospital with a very serious illness.

People, Dalrymple observes,

often talk as if they believed that there could be a world without untoward events.

  • There is a terrorist outrage: the security services have failed.
  • There is a miscarriage of justice: the judges are fools.
  • A patient dies: the doctors are incompetent and the nurses cruel.

It is almost as if there were a giant conspiracy afoot to subvert the ideal normal in which we should otherwise live.

The right day for your operation

Screen Shot 2016-04-09 at 12.04.19Dalrymple draws attention to a UK statistical study that examined 30-day death rates after non-emergency operations in 2008-11 (except day cases) according to the day on which the procedure was performed. There were 27,582 deaths after 4,133,345 operations, a raw rate of 6.7 per 1,000.

  • Those who underwent an operation on Friday had a death rate 44% higher than those who underwent an operation on Monday
  • Those who underwent an operation at the weekend had a death rate 82% higher

Screen Shot 2016-04-09 at 12.10.15The death rate

increased steadily as the week progressed.

Perhaps, says Dalrymple,

hospital staff, especially surgeons and nurses, grow steadily more tired or careless as the week progresses.

Not everyone who needs surgery can have it done on Monday. Therefore,

so long as the information is not known by everyone, the wise patient would be well-advised to keep it to himself. A small number of patients, but not many, can ask for their operations on Monday and have their wishes respected.

How a surgeon of experience and integrity acts

Screen Shot 2016-04-02 at 17.58.19Dalrymple has an example in his family history

of a surgeon who acted in a way that would now be deemed ethically reprehensible, and perhaps actionable, but which seems to me to have been in the very highest tradition of his profession.

His name was Cox,

and I don’t know whether he is still alive: by now he would be very old. I thanked him insufficiently at the time.

Dalrymple was in Africa when he telephoned his mother.

She was about to go to America on a visit, but she told me that she had been bleeding intestinally. I told her she must abandon her visit and see a surgeon at once, which she did.

It was cancer.

She underwent an operation within the week. I returned home before the operation.

Dalrymple mère

said that she wanted nothing hidden from her; she wanted to be told everything, and made me promise that I would hide nothing.

Dalrymple mère exuded

pride in her own rationality.

After the operation, the surgeon Cox

spoke to me. Whether he was franker with me than he would have been with a son who was not a doctor I do not know; but he told me that, while he had excised all the cancerous tissue that he could see macroscopically, histology demonstrated that my mother’s prognosis was very bad. There was an 80% chance of recurrence within a year.

Dalrymple said that Dalrymple mère had made him promise that he would tell her everything.

The surgeon said that, on his estimate of my mother’s character and personality, this would not be a good idea. He advised me against this course of action; and since he was clearly a man of experience and integrity, I took his advice.

Dalrymple mère asked Dalrymple, when she had recovered sufficiently from the operation, what the surgeon had said.

I told her that, as far as he could see, he had cut out all the cancerous tissue. This was the truth, but of course not the whole truth, and I rather dreaded further questions, to which I might have to reply with outright lies: and I might not prove to be a very convincing liar. My mother was perfectly well aware that removing all cancerous tissue to the naked eye was not the whole of the matter, but to my surprise – and relief – she enquired no further. Despite her protestations beforehand, she did not want to know everything.

In the event, Dalrymple mère

lived another 19 years without recurrence and relatively free of anxiety about her cancer because the surgeon had ‘cut it all out’.

Dalrymple was impressed by the surgeon Cox.

It seemed to me then, and seems to me still, that he had acted as the model of a fine medical practitioner. He was technically accomplished, it goes without saying; the operation went smoothly, with no avoidable complications. But more than that, he had given consideration to my mother as a person, as a human being; and on the basis of limited acquaintance with her – at most, a few examinations in the clinic – he had come to a shrewd and, I believe, accurate assessment of what was best for her, better indeed than my assessment.

Surgeons

are often accused of being brash, mere technicians without human subtlety, but this was certainly not the case with him.

The surgeon Cox

is a hero to me.

His

understanding of the requirements for decency was much more sophisticated than that of modern medical ethics. He understood that people generally live in a social situation, not as isolated beings, and that it is sometimes right for relatives to know more about an illness than the ill person him or herself.

Dalrymple is sure that the surgeon Cox

knew that truthfulness can descend into indifference to suffering or even to sadism. To try to force people to know what they do not want to know can be cruel, and ineffective into the bargain.

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David Rijckaert III, The Surgeon, 1638. Musée des beaux-arts de Valenciennes

A minor operation is an operation performed on somebody else

So said George Pickering, the great hypertension researcher, Dalrymple reminds us.

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Economics of sham operations

Dalrymple comes across a paper in the New England Journal of Medicine comparing physical therapy with surgery for meniscal tears in the knees of people with osteoarthritis.

There was no difference in outcome, an important finding since 465,000 people undergo operations for this situation every year in the USA alone.

Actually, says Dalrymple,

the uselessness of operation had been established before — uselessness from the patients’ point of view, that is. Two previous trials had compared real with sham operations, and with no operations at all, and found no difference in the outcome two years later. One might suppose that, in the light of these findings, the 465,000 operations still performed annually constituted something of a scandal.

Dalrymple considers the economic aspect of unnecessary operations. Granted that

unnecessary operations are more expensive than intensive physical therapy, do these operations increase or decrease gross national product? At first sight they do. As everyone knows, operations are not cheap. Without them, the GDP would fall. So would the incomes of those who perform them – orthopædic surgeons, for example, and their hangers-on such as operating room nurses. Presumably their incomes have a multiplier effect, for example on the legal profession. On the other hand, there are opportunity costs of employing money in this rather futile, indeed counterproductive, manner. But would the money in fact be better employed elsewhere? Would not something just as unproductive be done with it?

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In the operating theatre

Screen Shot 2016-03-18 at 18.47.37Writing of his Bulawayo days as a house officer at Mpilo Hospital (‘a large building of red brick in the parsimonious British municipal style of the 50s, with metal-framed windows and no embellishments’), Dalrymple says he learnt little in the operating theatre because

I wished to learn little. Assisting at operations was, for me, a kind of slow torture. It is one thing to take infinite pains yourself, quite another to watch someone else doing it.

It is a law of surgery that

Mpilo hospital opened in 1958

Mpilo hospital: it was opened in 1958

the assistant can never satisfy the surgeon. He either pulls the retractor too hard or not hard enough, but never just right. There is an old joke about a medical student who asks the famous professor of surgery: ‘And how would you like your stitches cut today, professor? Too long or too short?’

The layman may think

of the operating theatre as a place of drama,

Screen Shot 2016-03-18 at 18.41.33and it is true, says Dalrymple, that

there are moments of drama, or rather of crisis, but for the most part there is only tedium exacerbated by the desultory conversation between the anæsthetist (if he is not wholly absorbed in his crossword) and the surgeon concerning their sailing dinghies, dogs or vegetable gardens.

Screen Shot 2016-03-18 at 18.42.27Dalrymple admires the surgeon’s

capacity for prolonged concentration, up to ten hours at a time; the concern for the welfare of patients that such an effort implies; and the coolness with which crises, when they arise, are handled.

Screen Shot 2016-03-18 at 18.41.45He remembers a surgeon accidentally cutting an artery,

and the strong instantaneous jet of crimson blood spattering his face and soaking his mask. It was enough to make even a brave man flee, but in one swift and sure movement of his finger he staunched the jet, and the crisis was over before it had properly begun.

Screen Shot 2016-03-18 at 18.45.53This

was not work I could enjoy, and I never left the theatre without feeling great relief.

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