A coachman鈥檚 lot was not a happy one in 18th-century London. The streets were dirty and crowded. The air was grimy and damp, and he was exposed to the elements day and night. And, as if that wasn鈥檛 enough, he had a lot of trouble with his legs. Tight gaiters and the constant banging of legs against the edge of the driver鈥檚 seat weakened the arteries behind the knees, often causing dangerous bulging of the artery wall. If one of these blood-filled balloons burst, the victim bled to death. You could be forgiven, then, for thinking that the carefully prepared 鈥渃oachman鈥檚 leg鈥� on display at the Hunterian Museum at the Royal College of Surgeons in London is a sad reminder of the grim life of the working man in those days. But it鈥檚 quite the opposite. This is a souvenir of a great surgical success story.
IN the late 18th century, the attentions of a surgeon were about as welcome as the services of the hangman. In the days before anaesthetics or antiseptics, patients were quite likely to die of shock. And if they didn鈥檛, they often succumbed to infection. Major surgery was something you submitted to only when the alternative was certain death. Doctors-the proper sort, with medical qualifications-had little to do with surgery. That was work for a lower type of person altogether, a knife-wielding butcher rather than a healer.
John Hunter helped to change all that, transforming surgery into a respectable science. His career was remarkable: at 13 he dropped out of school, but by his forties he was Surgeon Extraordinary to King George III. His patients included the young Lord Byron, who wore a surgical shoe of Hunter鈥檚 design to disguise his lameness, the composer Haydn and the writer James Boswell, whose drinking played havoc with his liver. But Hunter鈥檚 reputation as the man who put science into surgery stems from his treatment of some less illustrious patients-the cabbies who drove their carriages through the stinking streets of London.
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By the time Hunter worked out how to treat the blood-filled bulges, or aneurysms, in the arteries of the leg, he was a successful surgeon and the most famous teacher of surgery in the country. He had always been an inveterate experimenter, curious about all aspects of animal anatomy and physiology, and how animals coped with injury and disease. He believed that a surgeon must be able to justify an operation physiologically. If he was going to operate, then he wanted to know what the cause of the problem was and what the effect of his treatment would be. 鈥淣ever,鈥� he said, 鈥減erform an operation on another person which, under similar circumstances, you would not have performed upon yourself.鈥�
At that time, some surgeons tried to treat aneurysms in the leg by tying off the artery immediately above and below the bulge, often opening up the sac and removing the clotting blood inside. The cleaned-up stretch of artery would heal and within a few weeks the ligatures would break away from the vessel-at least, that was the idea. In most cases, the artery burst open within a few hours, and the patient bled to death. 鈥淚 have tried it myself more than once鈥ut the event has always been fatal,鈥� said Percivall Pott, one of the eminent surgeons who had taught Hunter. Amputation, with all its attendant horrors, was considered safer.
Hunter suspected that the operation failed in part because the artery was tied too close to the bulging sac. He was convinced that an aneurysm was the result of some underlying disease of the artery and that tying it where the walls were diseased was asking for trouble. The solution, he concluded, was to place a ligature well above the damaged part.
Leading surgeons, including Pott, objected to this idea on the grounds that the limb would be starved of blood and gangrene would set in. Hunter鈥檚 curiosity about animal physiology, and his fondness for experiments, led him to think otherwise.
One of the puzzles of nature that interested Hunter was how a deer grows new antlers each year. With the King鈥檚 permission, he tried an experiment on one of the fallow deer bucks in the Royal Park at Richmond. Hunter tied off the main artery supplying the 鈥渧elvet鈥�, the skin that covers the growing antler, to see what happened. Immediately, the blood stopped pulsing through the artery and the antler grew cold to the touch.
A week later, to Hunter鈥檚 surprise, the antler was warm again. His ligature around the artery was still in place, but the smaller vessels on either side had expanded and joined together to create a bypass and keep the blood circulating. The fact that the body could compensate for a lost artery by pressing smaller vessels into service was known already, but the speed at which it happened was a revelation. It meant the body could restore the flow of blood fast enough to prevent gangrene, even if an artery was tied off near the top of a limb.
In December 1785, Hunter acquired a new patient, a coachman with a large aneurysm in his leg. The man begged him not to amputate his leg. On the basis of what he had discovered from his experiments, Hunter decided to try a new operation, tying the artery high up in the thigh. Within six months, the man was back in his driver鈥檚 seat. He died a year later from another occupational disease of coachmen, pneumonia.
In the next two years, Hunter treated three more coachmen. The first died. The others recovered-a near-miraculous cure rate for the time. The fourth man, whose name is now lost, was the owner of the leg in the Hunterian Museum. This man was so ill that at first Hunter refused to operate. Then he changed his mind. The coachman lived another half century. When he died in 1837, one of Hunter鈥檚 admirers, Thomas Wormald, saw an opportunity to check out Hunter鈥檚 handiwork. He asked the coachman鈥檚 widow if he could remove the leg. She agreed, so it鈥檚 said, because she had been so grateful for Hunter鈥檚 treatment of her husband.
Although Hunter performed only a handful of these operations, the technique became a classic and was used routinely for more than a century. Today鈥檚 surgeons have more options. With modern anaesthetics and drugs to combat infection, they have plenty of time to repair or replace damaged vessels with grafts. But for patients who are too frail for major surgery, or who have a fast-growing, potentially leaking aneurysm, Hunter鈥檚 operation is still the best chance of saving their limb.