MedHum Monday Presents: Blood Rises – Tension and Truth in The Knick

DailyDose_PosterWelcome back to the Daily Dose and our special series, Medical Humanities Monday! This feature takes a step back from medical collections in order to look more closely at the popular medical history drama, The Knick. Though fictionalized, the series is based on  historical figures at Knickerbocker Hospital, and today, series editor Catherine Osborn investigates the fact and fiction of blood transfusion. [post also appears at Dittrick Museum Blog]

“More suction, Bertie.” – Dr. Thackery

“I’ve lost the pedal pulse.” – Nurse

“Blood rises, air becomes scarce. Which man can survive the longest? Care to wager, Bertie?” – Dr. Thackery

(Soderbergh, The Knick, ep. 4)

Cover of "Elecktromedizinische Apparate," 1898.

During the showdown between Dr. Edwards and Dr. Gallinger over an exsanguinating patient in Cinemax’s The Knick, it was clear who was not most likely to survive. In this scene, Dr. Edwards, a “colored” physician is not allowed to physically assist in a procedure using a galvanized wire to treat an aneurism, despite the fact that he was the coauthor of a paper describing its success. While verbally instructing Dr. Gallinger, a white physician who is unfamiliar with the procedure, Dr. Edwards becomes silent – daring Gallinger to either pass over the scalpel or let the patient die.

Is such a scene a work of modern fiction? As inspired by the New York Academy of Medicine’s amazing posts on the series, we ask: What was it like to perform such innovative procedures at the turn of the twentieth century? Let’s find out!

In 1899, Dr. Forest Willard at the University of Pennsylvania provided case reports on “aneurism of the thoracic aorta” and its “treatment by introduction of wire and electricity” (p 256). This paper, one year before the scene in the fictional Knickerbocker Hospital, reads with a similar dramatic style:

Galvanic Battery from "Elektro-Medizin Apparate," 1898.
Galvanic Battery from "Elektromedizinische Apparate," 1898.

As the conditions were growing worse, and rupture certainly approaching, the patient consented to accept the risks of the only operation that offered any chance of success, the introduction into the sac a certain quantity of wire as a framework or skeleton, each coil of which might form a nucleus for coagulation, producing eddies in the sac and final consolidation. (p. 256)

The basics of this procedure are as follows: A patient presents with an aneurism, a ballooning of a weakened blood vessel that may burst and lead to death. A physician makes a nick in the vessel and inserts a cannula that will shield the walls of the vessel from the electricity. A coil of wire, anywhere from 5 to 225 feet long, is inserted (quickly!) through the cannula into the sac of the aneurism, and the free end of the wire is connected to a galvanic battery. The wire becomes charged to begin coagulation of the blood. After a variable amount of time, the current is disconnected, the cannula is removed, but the wire coils are left behind to serve as a structure for the clot (Siddique et al., 2003).

From D.D. Stewart in 1901. This heart of an autopsied patient showing the coils within the hardened aneurysm.
From D.D. Stewart in 1901. This heart of an autopsied patient showing the coils within the hardened aneurysm.

One of the major differences between these historical and fictional accounts is the use of ether during such a procedure. Willard mentions that “aside from the first shock at the sight of spouting blood, the patient suffered no serious inconvenience…and he talked cheerfully throughout the operation” (p. 257). Instead, Dr. Gallinger’s patient lays unresponsive and unaware of the conversation above him. Imagine had he not been anesthetized and had witnessed the men play a game of chicken with his life!

Who would have needed this surgery? Based on the age of the patient in The Knick, the “etherized” male would have likely been syphilitic – as the tertiary stages of the disease lead to inflammation and aneurism. Five of Willard’s cases were patients with syphilis who were occasionally “of intemperate habits” or simply “drunkard[s]” (p. 259).

The hardened anuerysm would remain visible as a large lump on the patient’s chest (Stewart 1901) after the surgery. Unfortunately although “life [was] prolonged and made much more comfortable,” post-operative patients typically died only months later (Willard 1899, p. 261).

Stewart 1901. A patient a few months after surgery displaying a harden aneurysm.
From D.D. Stewart in 1901. Patient a few months after surgery with a harden aneurysm.

Will the young patient at The Knick survive? He may have served simply as a backdrop for the interpersonal tensions between the main characters. Historically, twentieth century doctors followed up on these cases for equally self-serving reasons. Autopsies allowed physicians to retrieve the remaining coil of wire, determine the success of their work, and to fine-tune their pioneering methods.

References:

Reiniger, Gebbert, & Schall. 1989. Elektromedizinische Apparate und Ihre Handhabung. Siebente Auflage. Erlangen.

Siddique, Khawar, Jorge Alvernia, Kenneth Fraser, and Guiseppe Lanzino. 2003. Treatment of aneurysms with wires and electricity: A historical overview. Journal of Neurosurgery 99:1102-1107.

Soderbergh, Steven. Sept. 5, 2014. Season 1, Episode 4 “Where’s the Dignity?” The Knick. Cinemax.

Stewart, D. D. 1901. “The galvanic current in the treatment of saccular aneurisms.” In An International System of Electro-Therapeutics for Students, General Practitioners, and Specialists. Horatio R. Bigelow and G. Betton Massey, eds. 2nd edition. Philadelphia, PA: F.A. Davis Company.

Willard, Forest. 1899. “Aneurysm of the thoracic aorta of traumatic origin; Treatment by introduction of wire and energy.” University of Pennsylvania Medical Bulletin XIV(7): 256-261.

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