Under the Knife Read online

  Jan de Doot became famous throughout the country. Many people will have declared him insane. The month after the operation, he described his actions in a deed drawn up by notary Pieter de Bary in Amsterdam on 31 May 1651. It noted that ‘Jan de Doot, resident in the Engelsche Steeg, of 30 years of age…’ had also produced a poem about it ‘… written, rhymed and composed with his own hand’. The proud smith alluded to the fact that, although both his action and his last name suggested that he should have been dead, he was still alive:

  What wonders the whole land

  About this fortunate hand?

  Although it is a deed of man

  It’s guided by God’s own plan.

  When to survive was quite remote

  He gave life again to de Doot.

  What must his wife have thought when she returned from the market?

  2

  Asphyxia

  The Tracheotomy of the Century: President Kennedy

  IT IS EARLY Friday afternoon at Parkland Memorial Hospital in Dallas. A forty-five-year-old man is brought into the emergency room with a gaping bullet wound to the head. Blood and brain tissue are dripping from the hole. Other patients are quickly diverted away from the department. A large number of people, all of them agitated, come in with the victim. Journalists mill around outside. The man’s wife walks alongside the stretcher, her face spattered with his blood. The victim is wheeled into the trauma room and the doors close behind him. He is alone with a doctor and a nurse, while his wife waits outside in the corridor.

  The doctor is twenty-eight-year-old Charles Carrico, a second-year surgical resident on duty in the Emergency Room. He recognises the victim at once. Lying in front of him, covered in blood and with a large hole in his head, is President John F. Kennedy. He is unconscious and his body is making slow, spasmodic movements. Carrico can see the president is having trouble breathing and immediately inserts a breathing tube into the windpipe through his mouth. Using a laryngoscope, a hook-shaped instrument with a small light, he looks deep into the oral cavity, pushing the tongue to one side and opening the throat as far as possible until he can see the epiglottis, the cartilaginous valve covering the entrance of the windpipe. Behind it, he can just about see the vocal cords, and he manages to squeeze the plastic tube in between them. The president’s other wounds all require attention, but first air has to get into his lungs. Blood is flowing slowly from a small wound in the middle of his neck. The door opens, there is a lot of commotion in the corridor. Dr Malcolm Perry, the surgeon on duty, enters the room.

  As the whole world knows, Kennedy did not survive and died there in the trauma room. That same evening, far away in the Bethesda Naval Hospital in Washington DC, military pathologist Dr James Humes conducted an autopsy on the president’s body, which had been flown there in all haste. Humes was aware that this was the autopsy of the century. He could not afford to make mistakes and there were plenty of people watching his every move. Men in dark suits whose identities were a mystery. In front of him lay not just a dead body. It was also the most important piece of evidence in establishing exactly what had happened that day – and that was a matter of national interest. If all the bullet wounds Humes found came from the same direction, the shooting could be the work of one man, a solo action by a disturbed lunatic. But if he were to discover that the shots came from different directions, it had to have been a coordinated attack by more than one gunman.

  But Humes had a problem right from the start. No bullets showed up on the X-rays, meaning that they must have all passed through the body, each leaving an entry and an exit wound. And yet he found only three bullet wounds. Two were clearly in a straight line, a small hole in the back of the head and a larger one on the right side. The third was a small wound on the right side of the back, just below the base of the neck. As it was so small, it could have been an entry wound. Entry wounds are always smaller than exit wounds, but an exit wound from a high-velocity bullet can also be that small. Either way, the question remained where the corresponding exit or entry wound was. There was no sign of it anywhere on the body.

  Kennedy was succeeded by his vice-president, Lyndon Baines Johnson. LBJ was sworn in as president the same day in the same presidential aircraft in which Kennedy’s body had been flown from Dallas to Washington. One of President Johnson’s first decisions, taken exactly a week after Kennedy’s death, was to set up a presidential commission chaired by Chief Justice Earl Warren, to investigate the shooting. The Warren Commission also questioned the doctors who attended Kennedy. The commission’s final report is accessible to the public and the transcriptions of the doctors’ testimonies can be found easily on the Internet. The following can be deduced from their accounts.

  Within eight minutes of being shot in Dallas, John F. Kennedy was taken to the Emergency Room at Parkland Memorial Hospital, where he was attended by nurse Margaret Henchcliffe and surgical resident Charles James Carrico. Carrico immediately inserted a breathing tube and connected it to a respiratory machine. At that moment, thirty-four-year-old Dr Malcolm Oliver Perry entered the room. Like Carrico, he saw that the president was choking. He looked at the small wound in the middle of the front of the neck, from which blood was flowing slowly. He must have had only a fraction of a second to assess the situation and make a decision.

  The president was unconscious, but his chest was rising and falling slowly. These were not normal breathing movements, however, despite the breathing tube. Either the tube was not in the right position or something else was wrong, perhaps a pneumothorax (a collapsed lung) or a haematothorax (where blood fills the chest cavity). And then there was the small wound in the front of the neck. Was it an injury to the windpipe? If Carrico’s breathing tube was in the windpipe, why were there no air bubbles escaping through the wound? And what if the tube was in the wrong place, in the oesophagus (gullet) and not in the windpipe at all? That called for immediate action.

  Perry took a scalpel and performed a tracheotomy – literally a cut (-tomy) in the neck and into the windpipe (trachea) to get air into the lungs. A special tracheostomy tube can then be inserted in the windpipe. Because the small bullet wound in the neck was precisely in the spot where he needed to make the incision – in the middle of the neck, just below the Adam’s apple – Perry decided to use the hole for the tracheotomy, widening it horizontally on both sides with the scalpel. And that is why Hume could not find the fourth bullet hole.

  After Perry, Trauma Room 1 quickly filled up with a lot of other doctors. The first two to arrive after him, Charles Baxter and Robert McClelland, immediately assisted him with the tracheotomy. While they inserted the tracheostomy tube in the windpipe, the next two doctors on the scene, a surgical resident and a urologist, placed a chest tube on either side. This is a plastic tube inserted through the chest wall, between the ribs, and into the chest cavity to drain air or blood from around the lungs in the case of a pneumothorax or haematothorax. An anaesthetist attended to the respiratory machine, heart activity was monitored by an electrocardiograph and veins were cut open in the arms to administer blood and fluid. The blood was O-negative and the fluid was lactated Ringer’s solution, a solution of water and minerals.

  Neurosurgeon William Kemp Clark inspected the brain injury. Because he happened to be standing there, he was also asked to remove the breathing tube from the mouth, so that Perry could replace it with the tracheostomy tube in the windpipe. As he removed the tube, Clark saw blood in the throat. A nasogastric tube was also inserted through the oesophagus into the stomach. Despite all these efforts, however, the president’s breathing did not improve. He had also lost an enormous quantity of blood from the head wound, to which a nurse was applying pressure with a gauze. The doctors saw blood and brain tissue on the floor and the stretcher. After the attempts to free the airway, they could no longer feel a pulse. Clark and Perry immediately started heart massage, but this caused more blood to flow from the head wound. Dr Clark finally had the courage to stop the resuscitation and pronounced the p
resident dead at 1 p.m., 22 minutes after he had been admitted.

  Shortly afterwards the body of the president was commandeered by secret service agents and taken to the military hospital in Washington. There was no exchange of information between the doctors in Dallas and the military doctors. This led to a controversy about the bullet wounds that gave rise to many persistent and long-lasting conspiracy theories. Perry and ten other doctors in Trauma Room 1 in Dallas had not had the time to turn the president over and examine him from behind, and therefore never saw the wound in his back just below the neck and the wound in the back of his head. Immediately after the tragic events of that afternoon, Perry found himself overwhelmed by reporters at an improvised press conference. He referred to the bullet wound in the neck as an entry wound, leading the media to assume, in the first hours and days after the assassination, that there had been one or more shots from the front. This was, of course, completely at odds with the reason given for arresting Lee Harvey Oswald. The young man had been apprehended less than an hour and a half after the attack and was immediately identified as the sole gunman, even though he had shot from a position behind the president.

  The reports on the president’s death were therefore inconsistent with the autopsy report and there was a feeling that there had been a cover-up. Humes had not called Perry until the following morning and then heard about the bullet hole in the windpipe. That information was the final piece in the puzzle, as far as he was concerned: the bullet wound in the back just below the neck, a bruise on the top of the right lung that he had found in the president’s chest cavity, and the hole in Perry’s tracheotomy, were exactly in line, and were consistent with a shot from behind, just like the wound in the head. That meant the president had been killed by two shots from behind. One assassin, no coup. And yet, many people continued to attach more importance to the spontaneous account of the heroic young surgeon, who had seen the wounds with his own eyes while the president was still alive, than to the report of a secret autopsy conducted in the middle of the night at a military hospital.

  * * *

  The ABC of emergency medical assistance

  The alphabet provides us with a useful memory aid for medical assistance in emergencies. ABC tells us the sequence of actions that need to be carried out to stabilise a patient in a life-threatening situation. A stands for airway: this has to be free, or the patient will choke to death within minutes. That usually entails inserting a breathing tube through the mouth and between the vocal cords into the windpipe. This is known as intubation. If it does not work for some reason, the windpipe has to be cut open immediately through the front of the neck. This is called a tracheotomy. There is no time to hesitate, as every second counts. ‘When you think of tracheotomy, perform it!’ This is how urgent and life-saving it can be. B stands for breathing: you have to make sure the patient’s lungs are getting enough oxygen and expelling sufficient carbon dioxide. This can be ensured by connecting the patient to a respiratory machine. Insufficient gas exchange between the blood and the external environment causes the brain, the heart and all other vital organs to not receive enough oxygen, creating a risk that they will stop functioning. This is known as ischaemia. The muscles can do without oxygen for six hours, but the brain only four minutes. Secondly, the pH level of the blood falls if the carbon dioxide it contains is not exhaled. Acidic blood damages the organs even more and has a detrimental impact on the circulation. That is what the C stands for. You have to stabilise the circulation, make sure the patient does not bleed to death, and keep the heart and blood pressure under control. And then there is a D and an E …

  * * *

  The explanation of Kennedy’s bullet wounds is to be found on an amateur film shot by Abraham Zapruder who, thanks to his secretary, made a crystal-clear recording of the motorcade – and therefore the attack on the president – in clear focus. Zapruder had stood on a wall to get a better view and, since he had vertigo, his secretary had held on to his legs while he was filming. The recording, not released until fifteen years later, shows the images that are now so familiar to everyone, of fragments of the president’s head flying through the air and of his desperate wife Jackie climbing over the boot of the moving car. Less well known is what the film shows five seconds before the shot to the head. It is hardly noticeable but, suddenly, Kennedy grimaces and grabs his throat with both hands. No one seems to notice and, while everyone is smiling and waving cheerfully, the president seems to be choking.

  This is what happened. The horrific head wound was caused by the third shot. The second shot hit Kennedy in the back and passed diagonally through his windpipe, below his vocal cords. That prevented him from calling out or screaming and no one noticed that he was suffocating. The bullet exited the front of his neck and hit Texas governor John Connally, who was sitting in front of Kennedy, in the chest, the right wrist and the left thigh. Because of its seemingly bizarre trajectory, this bullet was to become known as the ‘magic bullet’, aka Warren Commission Exhibit Number 399. A reconstruction based on the Zapruder film shows, however, that the trajectory of the bullet was not at all as bizarre as it seemed. Before this second shot, a first shot was fired. But it missed its target and wounded a spectator, James Tague, on his right cheek. The noise of the first shot caused Connally to turn around in the car and pick up his Stetson, so that all the wounds he and Kennedy suffered as a result of the second shot were in a line. This line can even be retraced to the open window on the sixth floor of the Texas School Book Depository. Whether it was Lee Harvey Oswald who had been at the window or another shooter remains unclear, as Oswald denied the killing and was shot dead himself two days later.

  What actually happened, in medical terms? The two bullet wounds threatened the life of the president in three different ways. The shot to the head had blown away a large part of the right half of his brain. We will never know how much exactly and which part: John F. Kennedy’s brain has gone missing. But no matter how horrific a wound to the brain may be, it is not always fatal. Damage to the right half of the brain causes paralysis (hemiplegia), reduced sensitivity (hemihypoesthesia) or a deficit in attention to stimuli (hemineglect) on the left side of the body, or decreased vision in the left side of the visual field (hemianopsia). It can also cause personality change (frontal lobe disorder), an inability to perform simple mathematical tasks (acalculia), the loss of appreciation for music (amusia) and loss of memory (amnesia). But the capacity to speak and understand language is largely located in the left half of the brain, while the most important zones for regulating respiration and consciousness are further away, in the brain stem. There would therefore not have been much left of Kennedy as a person, but his body could probably have lived on with the results of his brain injuries.

  Nor was the serious loss of blood from his head necessarily lethal. Severe blood loss can be replenished with fluid and blood transfusions, as long as the heart can maintain the blood pressure. Kennedy must have had sufficient blood pressure when he arrived at the hospital, because his pulse was still detectable and he was still moving. The autopsy revealed no other unexpected internal bleeding. But it is difficult, of course, to say after the fact whether it would have been possible to stem the bleeding from the gaping wound in the brain.

  A much more immediate threat was the wound to the windpipe. In the eight minutes between the shot through his windpipe and Carrico inserting the breathing tube, Kennedy had been unable to breathe. Insufficient oxygen in the blood for too long is known as asphyxia, the medical term for suffocation. It quite quickly causes damage to the brain and the brain stem as – of all the parts of the body – they survive the shortest time without oxygen. Initially, the damage is reversible; the victim loses consciousness and faints. Then the damage becomes irreversible. The victim can no longer regain consciousness, but still breathes independently. That is what we call a coma. Finally, the damage becomes fatal and the systems for maintaining life, the regulation centres for our consciousness, respiration and blood pressure in
the brain stem, shut down completely. The damage to the respiration centre in the brain stem resulting from a lack of oxygen was what caused the strange movements the president made as he suffocated. The autopsy revealed no collapsed lungs or large quantities of blood in and around the lungs. Inserting a breathing tube or conducting a tracheotomy could therefore perhaps have saved his life, if only they had been performed earlier. Today, unconscious victims are never moved without a breathing tube being inserted first. The tube is put in place by the ambulance crew, as every second counts.

  And so, the 35th President of the United States died as a result of blood loss so severe that a room full of doctors could do nothing to stop it, and of suffocation, for which the tracheotomy came too late. Strangely enough, the very first president of the United States, George Washington, died in a similar way, though in his case the loss of blood was caused by his doctors, who also allowed him to suffocate by refusing to perform a tracheotomy.

  Washington’s final hours are described in detail by an eyewitness, his personal secretary Colonel Tobias Lear. On Friday 13 December 1799, Washington had woken up with a sore throat. The day before, he had ridden through the snow on his horse. He was hoarse and coughing a lot. And yet, he still went out on his plantation in the cold winter weather. That night, he awoke with a high fever. He could hardly talk and began to have difficulty breathing. He was unable to swallow and became increasingly agitated. He tried to gargle with vinegar, but almost choked on it. On the Saturday morning, despite his wife’s vigorous protests, he ordered his overseer to bleed him. But he felt no better and three doctors were called, James Craik, Gustavus Richard Brown and Elisha Cullen Dick. They bled the president several times, taking almost two and a half litres of blood in less than sixteen hours! Washington was eventually so weak that he could no longer sit upright, a position that is very important to breathe properly. Towards the evening, his breathing became increasingly laborious. He must have had a throat infection, causing his epiglottis to swell so much that it threatened to close off his windpipe. That makes the patient feel that he may suffocate at any moment, usually an extremely alarming experience. But Washington, who had by now lost nearly half of his blood, remained relatively calm. Dr Dick, the youngest of the three, wanted to perform a tracheotomy to save him but the other two, Craik and Brown, thought it too risky and refused to allow it. Washington died at ten o’clock in the evening, exhausted by the severe loss of blood and asphyxiated by a throat infection. He was sixty-eight years old.