Читать книгу Confessions of a Doctor - Stanley Feldman - Страница 11

The senior surgeon at Westminster Hospital was Sir Stanford Cade. If the surgeons were the kings of the medical fraternity, Sir Stanford was their emperor. Born in Russia and educated in Belgium, he never lost his guttural foreign accent or his old-world charm. He was a famous cancer surgeon with a prodigious memory and a terrifying bedside manner. He was a pioneer of radium treatment for cancer and he carried a tin tobacco box, full of radium needles, in the back pocket of his trousers. When the occasion arose he would select some of them for insertion into a patient’s inoperable tumour.

From time-to-time some of the radioactive needles would fall onto the theatre floor, necessitating the theatre staff to scrabble around on their hands and knees to find them. They would be retrieved and picked up with unprotected hands, washed under running water from a tap and replaced in the surgeon’s tin box, but neither Sir Stanford, nor any of the staff ever suffered from any ill effects of exposure to the radioactivity. Today such an event would set off a full-scale radiation alert and would result in the immediate evacuation of the operating theatre.

Sir Stanford was a legend in himself. Once he embarked on a new project he would not rest until he was the acknowledge master of the subject. It was said that within a year of taking up stamp collecting he pointed out a forgery on sale at a stamp auction. Within two days of seeing his first case of the rare skin disease Kaposi sarcoma (now seen quite commonly in patients with HIV), he had read every paper published on it, irrespective of the original language.

It was rumoured he obtained the figures for the outcome of his surgery from the obituary columns of The Times, which he read avidly every day from cover to cover. If Lady X’s obituary was not there she was noted down as having survived his surgery and presumed to be still alive. He was a tireless, terrier-like surgeon. He knew no bounds when there was a cancer to be excised. He would go on cutting out bits of the patient’s anatomy until all signs of tumour were extirpated. He was said to have once remarked that, ‘There is no tumour too big that if you pull hard enough it won’t came away’. He was a pioneer of pelvic evisceration (colloquially known as the hemi-humanectomy) for extensive cancer involving pelvic structures. It often necessitated removing the bladder, rectum, the uterus and vagina and any part of the pelvic skeleton that the cancer had invaded. He saw cancer as a very personal affront that had to be fought, no matter what the cost to the patient.

Sir Stanford expected total commitment and enthusiasm from his staff. Once you became his houseman you signed on for six months of indented labour: there were no weekends off, no half days and no holidays. Often, his operating sessions would not end until before midnight. On one occasion a houseman complained to Sir Stanford that he felt unwell and asked if he could have a weekend off. Sir Stanford replied, ‘By all means, but if you go, don’t bother to come back’. That weekend the unfortunate houseman suffered a perforated gastric ulcer and found himself undergoing surgery. Sir Stanford remained convinced that he did it deliberately to undermine his authority. That particular houseman was persuaded to give up his ambition for a career in surgery.

As a reward for their dedication, his staff found Sir Stanford to be a loyal chief who went out of his way to help establish the careers of those who had worked for him and had shown promise. He was always fulsome in his praise for those who gave particularly good service to his patients. Following the death of his wife from cerebral malaria while they were on a trip to South Africa, Sir Stanford became a lonely figure, totally absorbed in medicine. He would often invite his junior staff to his home in Harley Street after a particularly long operating session. There he would feed them on caviar and champagne; he would enquire about their families and their medical aspirations and ambitions and he would keep them talking until the early hours of the morning. He seemed to need no sleep. Indeed, on one occasion, long after he had retired, I met him during a consultation over a private patient when he admitted that he was beginning to feel old, as he now needed four hours sleep a night.

Westminster Hospital had a strong team of chest surgeons. When King George VI was diagnosed with cancer of the lung it was the team from Westminster Hospital that was invited to Buckingham Palace to perform the operation to remove the tumour. The operation was a great success and the surgeon, Clement Price Thomas, was knighted for his services.

(Sir Clement was a fiery Welshman who operated wearing wooden Welsh clogs. Should any registrar get in his way, one of these weighty clogs would deliver a blow to his shins that would soon cause the offender to mend his ways. More experienced registrars soon learned to wear football shin pads under their socks as a badge of honour.)

The king had expressed a wish to be nursed by men, as he was rather shy and was embarrassed by the attention of female nurses. As a result, Sir Clement’s registrar was deputed to look after him. When the young surgical registrar arrived at the palace carrying a paper bag containing his personal luggage, he announced his presence with the immortal words, ‘Where are the ladies in waiting? I am the man they have been waiting for’. He was the only member of the surgical team not to receive an honour or a gift from the royal establishment.

In later years, that particular registrar became a consultant chest surgeon at Westminster Hospital. He soon developed a private practice composed largely of Greek patients with impossible names. He took to calling them all ‘Mr Onassis’, as that was a name he could remember and spell. On one occasion the operating list, which was published the evening before the following day’s surgery, contained the information that a Mr Onassis was to have his cancerous lung removed. Unbeknown to the staff, one of the hospital porters had established a profitable sideline by informing the press of important people who were having operations at the hospital. The news that Aristotle Onassis was to undergo surgery for cancer soon hit the headlines – followed by a rapid denial from the office of the famous Greek shipping magnate, who at that time was married to Jacqueline Kennedy.

Miles Foxen was a distinguished ear, nose and throat surgeon. He was a good, thoughtful doctor who had acquired the epithet of ‘gloomy’. His analysis of life was that ‘things are never so bad they can’t get worse’. I can remember him remarking, after a temporary setback, how it was that every silver lining had a cloud. There was one occasion when he and Sir Stanford Cade had been operating together on a patient with an advanced cancer of the throat. After some hours Sir Stanford announced he had to leave to catch a train to Paris where he was to give a lecture the next day. We eventually finished the operation and retired to the changing room where, to his dismay, Miles found that Sir Stanford had gone off wearing his shoes. He had left his own, a rather down-at-heel pair, in their place. Miles regarded the poor, worn shoes and turned to me and remarked with a pitiful look, ‘It is not that I particularly mind him going off in my shoes, what really upsets me is that my shoes will be going round Paris without me in them’. Sir Stanford, meanwhile, never noticed he was wearing the wrong shoes.

Our cardiac surgeon, Charles Drew, was in the vanguard of open-heart surgery and pioneered the use of a technique to lower body temperature to levels that reduced the oxygen requirements of the various organs to a point where it was safe to stop the heart and the circulation for a short period. This made it possible to operate upon a non-beating heart rather than one that was actively contracting about 100 times every minute. It was a technique that was particularly valuable in babies and children. In small babies it is very difficult to place stitches with any degree of accuracy in a tiny, rapidly beating structure about the size of a small orange.

Drew was a very inventive and caring doctor but who, when under stress, could be irascible and difficult. In the early days of cardiac surgery every operation was an experiment which carried a high failure rate, especially in babies with congenital heart disease. Operations were only carried out on the very sick children for whom not to operate would have meant imminent death. As a result, the mortality was inevitably high. After staying up all night nursing a child after one of these high-risk operations, helping its breathing and carefully judging every dose of drug that was administered, you came to understand the strain that this sort of surgery put upon the surgeon. It was at these moments one understood the tensions that led to Charles Drew’s occasional outbursts of emotion in the operating theatre.

The success or failure of early paediatric cardiac surgery often depended on obtaining an accurate diagnosis of the particular defect and how it was affecting the function of the heart. These were pioneering days for this speciality, and knowledge about the complexities and the variety of the various congenital defects were only slowly being appreciated. It was largely due to studies that were made on post-mortem specimens that we came to appreciate how these abnormalities could be corrected. To find out the mechanical effect of a particular defect necessitated catheterising the heart and making pressure and flow measurements in its various chambers. This involved inserting a tiny tube through a vein in the thigh and advancing it, under X-ray control, until it was encouraged to enter the heart. It was a difficult procedure on a tiny baby, and was made even more difficult as initially the procedure had to be carried out in the darkened radiology department. It fell to the anaesthetist to work out some suitable method of putting these desperately ill babies to sleep, in the dark, using a technique that did not change the dynamics of cardiovascular system.

It was as a result of these investigations that the functional disability of each particular baby with an unusual heart defect came to be appreciated and a scheme of surgical correction devised. Occasionally, emergencies occurred during these investigations when the catheter became knotted in one of the chambers of the heart and could not be withdrawn, or when it perforated the tiny thin-walled appendage of the heart, the auricle of the atrium. In spite of these risks no baby died during the extensive investigations in the three years in which I was involved in these studies. This was largely due to the unflappability of the consultant paediatrician who invariably continued to chain-smoke during the whole of the procedure.

Looking back at those days in the chest unit I am struck by the change in the pattern of disease treated in these units over the past 40 to 50 years. In the 1950s and 1960s, the chest unit at the hospital was one of the largest and busiest departments. Cancer of the lung was so common that we would see about ten new cases every week. A large proportion of these patients had such bad bronchitis and emphysema, as a result of their smoking, that surgery to remove a lung or part of it would have incapacitated them. Instead of surgery, these patients received radiotherapy; the rest were operated upon. We would operate on about six to seven new patients every week. Although the five-year survival of these patients was not very good, it was all we had to offer to prolong their lives. But the reduction in cigarette smoking and the Clean Air Acts of the 1950s has had a dramatic success in turning these once common lethal diseases into a clinical rarity.

As the number of thoracic cases declined, the development of open-heart surgery grew. Until 1958 heart operations were more or less restricted to the surgeon inserting a finger, capped by a small blade, into a beating heart in order to split open a tightly closed, sclerotic valve – the operation known as mitral valvotomy. It was in the early 1960s that open-heart surgery really took off. In those days it was largely restricted to correcting congenital heart defects and simple valve lesions, but as it became more and more successful, operations for coronary artery disease became increasingly common. Today many of these procedures have been replaced by non-invasive techniques, such as angioplasty and the insertion of stents, although coronary artery bypass surgery still has a part to play.