144

ROYAL OPERATIONS

HAROLD ELLIS D.M., M.Ch., F.R.CoS

Pr'ojessor of Surgery, Westminster Hospital, Medical School, London

Based on a lecture given at the Medical treatment. These were either to incise School in Malta 011 the 31st July 1974. boldly through the neck of the sac or to carry out the lesser procedure of lancing A study of the surgical histories of the fundus of the hernia in order to release Kings and Queens of the past can be re­ any of th3 pent up fluid therein. Ranby commended as a rewarding hobby for any favoured the latter and in this he was no surgeon. In the often detailed documents doubt correct. In those pre-anaesthetic that have been handed down to us comes days, in the presence of obstruction in a a wealth of information about medical and grossly obese patient, he rcalis3d that social customs of former times which well incising the neck of the sac would release repay study. Perhaps by recording a few coils of distended intestine into the wound of these case histories the author will which it would be impossible to reduce. persuade others to go back into the warmth The decision was taken and the following of the past and to escape for a short time day Ranby gingerly incised the dome of from the cold reality of modern surgery. the hernia. A little blood-stained fluid escaped but, as we can well imagine, thert' A Queen's Rupturo> was little relief of the symptoms. The fol­ lowing day, the Sunday, we were told that Caroline of Ansbach, wife of George "the lips of the wound began to mortify" II of England, ascended the throne as a and the Queen's doctors despaired of her pretty young girl. Six children and survival. Caroline called her husband to innumerable banquets later, at the age of her bedside and was heard to tell him that 55, and at the time of her fatal illness, she when she died she expected him to marry was no longer particularly attractive and again. George was beside himself in misery had become grossly obese. Severe abdo­ and in tears; between his sobs he was heard minal pain and vomiting commenced on to say "no, I shall never marry again, I shall Wednesday, November 9th 1736. In those simply live with other women". The next few days, even a Queen would not readily con­ days of continuous pain were borne with sult a surgeon and so she submitted her­ great bravery by the royal patient. On the self to the apothecary's bleeding, purging Wednesday the strangulated coils of intes­ and medicines, including Sir Walter tine within the hernia ruptured, soaking Raleigh's cordial and Duffy's elixir, which the royal bedclothes, sheets and mattress were the popular cure-aIls of the day. Her with excrement but without any relief of symptoms persisted and on the Thursday her suffering. Caroline died on the Sunday, and Friday' she was bled and purged again. the 11th day of her illness, her last words Only then did she consent to call in a sur­ being to her daughter, Princess Emily; geon. She was examined by John Ranby, they were "pray". Nowadays, one would be Surgeon to the King, who discovered, to disappointed to lose a feeble old patient his horror, an enormous strangulated with a strangulated hernia, yet only 20 umbilical hernia. Other surgeons were years ago the first lady in the land in the called to the sick bed and in consultation prime of her life, treated by the best that Ranby discussed the two possible lines of medicine in those days could offer, died 145 miserably of this simple abdominal emer­ dinner he would sleep for a few minutes gency. then off again to lecture or visit and seldom home until midnight. One is hardly sur­ A Royal Sebaceous Cyst prised that he died without issue - there is a limit to what a man can crowd into In 1820 King George IV of England a day! consulted Astley Cooper of Guy's Hospital Cooper was the first surgeon to llgate because of an inflamed sebaceous cyst of the abdominal aorta. This was no piece of the scalp. Cooper wisely advised against its surgical adventure or showmanship since removal while in its infected state. The he had already shown by experiment that following year Cooper was summoned to the aorta of the dog can be successfully Brighton and the King demanded that the ligated. A beautifully injected specimen cyst should now be removed there and then still exists demonstrating the efficient at one o'clock in the morning. Cooper collateral circulation which develops wisely said "Sire, not for the world now, around the site of occlusion. His your life is too important to have so serious patient was a Charles Hutson, 38 a thing done in a corner". The King was years of age, who had a rapidly enlarging persuaded to have the operation performed and leaking iliac aneurysm. The operation in London - during daylight! This was was carried out on the evening of June duly carried out at Carlton Palace and 24th 1817. The abdomen was opened and Astley Cooper was assisted by his old chief within a few minutes Cooper turned to his Henry Cline. George bore the operation audience saying "gentlemen, I have th~ without a murmur and indeed requested pleasure of informing you that the aorta that there should be no hurry in its per­ is now hooked upon my finger". Th'e formance. His recovery was uneventful patient died 40 hours after the operation; apart from an attack of gout. After the the circulation had indeed been adequate operation he said to his surgeons "What do in the normal limb but on the side affected you call this tumour?" To which Astley by the aneurysm the collaterals' had replied "a Steatoma, Sire" The King said obviously been damaged and the Emh "Then I hope it will stay at home and not become ischaemic. bother me again". For this small but im­ portant service to the King, Cooper was Roval Bladder Stone!' made a Baronet, ,becoming Sir Astley Cooper. As he had no son of his own the We turn now to the extraordinary title passed to his adopted nephew and the story of the English surgeon who operated line of succession stIll contfnues to this on two European Kings for stone in the a day! bladder. Sir Astley Cooper was perhaps the The history of bladder stone itself is hardest working surgeon the world has full of fascination. Cutting for the stone is, ever seen. He would invariably rise at six of course, mentioned in the Hippocratic o'clock in the morning even in the depths Oath and again in the writings of the of winter, often at five or even four a.m. ancient Hindus. Up to the sixteenth cen­ After dressing, he would go straight to his tury stones were removed by lithotomy private dissecting room where he "ould through the perineal approach. The patient carry out his own dissections or experi­ was held in the lithotomy position by ments for two or three hours. He would strong assistants. The perineum was mas­ then breakfast on tea and rolls and then saged with grease to render it more pliable see a continuous stream of patients at his and the surgeon would then sit facing his; house until lunch time. He would then victim with his knife gripped between his hurry in hip coach to Guy's Hospital, go teeth, rether like a pirate about to board round his wards surrounded by his adoring a ship. Two fingers of the left hand were students, lecture for one hour, then spend inserted into the rectum in order to fix the the time until evening seeing patients or stone against the perineum. The surgeon carrying out private operations. After then took the knife from his mouth with 146 his right hand, thrust it into the p~rineum, fore when Astley Cooper removed George dropped the knife on to the floor, and then IV's sebaceous cyst. Brodie gave the King hooked out the stone with his finger or excellent advice; to go home and call in else with a hook. Because of the few instru­ Civiale of Paris. Civiale made two attempts ments required (a knife, a hook, and four to remove the stone with his lithotrite but or five muscular assistants,) the operation each attempt was not only unsuccessful was known as the "Aparatus Minor". In but was followed by severe, pain, fever and the sixteenth century the formidable bleeding. Langenbeck of Berlin, then at operation of the "Aparatus Major" was in­ the height of his professional success, was troduced, in which the wound in the peri­ summoned and made four further attempts, neum was tom open with fierce retractors, but each was again unsuccessful and ac­ often with serious complication of haemorr­ companied by violent catheter fever. hage, extravasation of urine and tears Henry Thmpson, then only in his early into the rectum. forties, was called from London. Thompson In the seventeenth century, an extra­ crushed the stone and removed it without ordinary thing happened. We all know the bleeding, pain or fever: he received a fee French nursery rhyme "Frere Jacqu2s, of £ 3,000, he was knighted by his de­ "Frere J acques, dormez vous? dormez lighted Queen and overnight achieved vous?" but perhaps fewer realise that universal fame. In fact, no one was more Frere J acques was, in fact, a French litho­ surprised than Thompson at this success tomist. Indeed his name was Jacque Baulot and it was only some years later, when the and he was born in 1651 of humble parents. work of Pasteur and Lister had become He served as a trooper in the French well established, that he realised why his cavalry, from which he wisely deserted; he patient had made such smooth progress. On then adopted a religious habit and became being summoned to Brussels, Thompson an untrained itinerant lithotomist. Appar­ had not unnaturally ordered a new litho­ ently purely by chance he hit upon the trite and used it fresh from its wrappings; lateral perineal approach to the bladder presumably this was the first time that a whic~ traversed the base of the prostate sterile instrument had been passed into and which gave roomier and safer access. the Royal bladder. It is perhaps worth In one session at Versailles he performed reflecting on what hvists of fate fame no less than thirtyeight lithotomies with­ often depends. out a single death. In 1872 Sir Henry Thompson, together Over the centuries attempts have been with Sir William Gull, leading physician of made to evacuate bladder stones though the day, was called to Chislehurst, then a the urethra but it was not until 1824 that little town outside London now an outer Civiale of Paris developed a satisfactory suburb of the metropolis, to see the ~xiled apparatus to crush the stone per urethram, Napoleon Ill. He had suffered for many the lithotrite. A young surgeon called years from th? severe symptoms of the Henry Thompson of University College bladder stone and indeed his illness must Hospital London, came over to Paris, have' played at least a part in the French studied Civiale's methods and took a litho­ defeat in the Franco-Prussian was of l870 trite back to London with him; he was to in which Napoleon had been Supreme gain international fame by operating on a Commander. The stone was crushed at two King of Belgium and on an Emperor of sessions under Chlor0form administered France. by Dr. Clover, one of the pioneers of anaes­ In 1862 Leopold 1st of Belgium came thesia. The Emperor died three days after to London to visit his niece, Queen the second application of the lithotrite. Victoria. He was an old gentleman of 73 Post mortem showed gross bilateral pyone­ but while on his visit he developed th2 phrosis and half the stone still lying with- severe symptoms of bladder stone. He in the infected bladder. . consulted dear old Sir Benjamin Brodie, Thompson was an interesting man. the serjeant surgeon, who, interestingly He was born in relatively humble circum­ enough had been present many years be- stances, his father being a corn merchant, 147 and young Henry started life serving How should the Royal patient be behind the counter in his father's shop. He treated? To this we can only turn for did not become a medical student at Uni­ advice to the late Lord Dawson of Penn versity College Hospital until the age of 24, who well deserved his nickname "Physi­ but after qualifying he progressed with cian of Kings" from the extraordinary extraordinary rapidity and became the number of members of European Royal first specialist urologist in Great Britain. families who were his patients. His very Apart from his eminence in this fielcl (for first Royal consultation was Edward VII example, he crushed more than 1.,000 whom he attended in his terminal illness bladder stones with the lithotrite), hE:' was of chronic bronchitis complicated by a man of many parts. He was a distin­ cor pulmonale in 1910. When Edward asked guished painter, who exhibited iD the this young man how he propofled to treat RoyaL Academy, an authority on pottery, him, Dawson replied, no doubt to the con­ a pioneer of cremation, a notable cook, a sternation of his more senior colleagues, distinguished conversationalist, and one of "Sire, I shall treat you in the best possibb the first surgeons in London to visit manner, in the same way I treat my patients by car. He was even the father of patients in my wards at the London Hos­ the modern fashion for medical novels, in pital". This must indeed be the answer; that he wrote a book called "Charlie the Royal patient is much safer if managed Kingsley's Aunt" about the escapades of a by standard and routine treatment than young medical student which was based by attempts at taking short-cuts or by very largely on his own experiences. He sparing the indignities of some examina­ was well named by Sir Zachary Cope "Th€' tions and nursing procedures. Eminent Victorian". Our former and much loved senior surgeon at Westminster Hospital, Clement Royal patients and their management Price Thomas, knowingly or unknowingly followed the precepts of Lord Dawson of What must it be like to be called upon Penn when he was called upon to perform to treat a Royal patient? Naturally success a pneumonectomy on George VI, in 1952. brings with it international fame and in The operation was carried out just like any Great Britain, an undisclosed sum ~f other operation performed by this M?ster money paid from the Privy Purse. Failure, surgeon. He operated with the assistance however, must be disastrous, although not of his registrars and house surgeon, using as dreadful now-a-days as in the time of the rather battered operation table brought Blind King John of Bohemia, who in the over from his theatre at Westminster Hos­ Middle Ages, had his surgeons drowned in pital. Just like in any other routine opera­ the River Danube when they failed to res­ tion, all went smoothly. tore his sight. This operating table, now looking even . The Royal patient will prove to be, older and more tired, is still in daily use WIthout doubt. brave, polite and grateful. at Westminster Hospital but now bears a When Lord Lister drained the axillary proud inscription on its plinth, which. we abscess of Queen Victoria (incidentally thp. are always glad to show our visitors, com­ first time that a sterile tube drain had memorating its Royal patient. ever been employed) she said, as only The author of this paper does not envy Queen Victoria could possibly have said, the responsibility of a surgeon called upon on recovering from the anaeasthetir, "A to perform a Royal operation, nor dor;:s he most unpleasant task, Lord Lister, most deny him the honours which he so richly pleasantly performed". Her bravery .and deserves following its successful outcome. politeness were onyl in the tradition of Indeed, each time he removes a ssbaceous' her predecessors, poor Queen Caroline and cyst from a scalp he breathes a sigh of King George II who bore their operations, relief at its conclusion that the patient is without an anaesthetic, with extraordinary just an ordinary citizen of the great City stoicism. of London and not George II of England.