Under the Knife

Author: Arnold Van de Laar

Background

In what is truly an ingenious and refreshing perspective of the history of surgery, this book chronicles the evolution of surgical practice through gripping stories of renowned historical figures, and the operations that either relieved or exacerbated their ailments. By skilfully intertwining the lives of prominent historical personalities with the lives of the surgeons who catered to their afflictions, the author graphically conveyed the precarious state of early surgery – a time when its practitioners were as likely to save their patients as to hasten the progression of their illness. The book explores a wide array of surgical diseases, especially the enduring ones such as varicose veins, groin hernias, and haemorrhoids – maladies of humanity since Lucy, our common ancestor, adopted the upright posture and ‘decided to walk on two legs‘. Beyond their informative and entertaining value, all the stories in the book are potent reminders of the breathtaking transformation that surgery has undergone over the centuries, and of the myriad of harmful ideas and practices that had stifled its progress. Symbolic of the unshackling of surgery is its paradigm shift away from institutionalised dogmas such as Theodor Bilroth‘s dictate that ‘surgeons who attempt to operate on the heart can no longer count on the respect of their colleagues’ (pages 1-2, 89-90, 76 and 53).

Synopsis

At the centre of the book are the valuable lessons the author extracted from the engaging stories of famous people and the operations that came to define them. One of the most illuminating of such accounts relates to the surgical travails of Pope John Paul II after he survived an assassination attempt in 1981. The author described how, after he was shot in the abdomen by Mehmet Ali Agca, the Pope required a stoma to divert the intestinal fluid that was leaking from ‘five holes in the small intestine and mesentery‘ and ‘a long tear in the sigmoid colon‘. Using this story as lynchpin, the author recounted the history of the stoma, noting that it first ’emerged out of necessity‘ in the late Middle Ages when it was advocated by Paracelsus. The author went on to critically appraise the Pope’s surgical team, censuring them because they just ‘stitched up‘ the tear in his large intestine ‘without removing the damaged part’. On the contrary, the author thought the surgeons should have performed a Hartmann operation – ‘the safest solution’ – which would have entailed them removing the sigmoid colon and deferring reconnecting the open ends to a later time. It is interesting that the Pope’s sigmoid colon was eventually removed after he developed a tumour in it; this, the book noted, was along with other operations the Pope later yet needed – a hip replacement, an appendectomy, and a tracheotomy. Another religious figure the book referred to was Pope John XXIII – ‘the most interesting of all 305 pontiffs‘ because ‘he underwent the most operations’ (pages 65-74).

The book’s narration of the surgical tribulations of politicians and royalty were as interesting as those of the Popes, and in chronicling this account, the author liberally featured America Presidents and European monarchs. Arguably the most prominent of these stories related to the futile surgical attempts to save the life of assassinated US President John F. Kennedy. The author’s exploration of this seminal event was particularly forensic as reflected by his scrupulous re-enactment of the tracheotomy performed on the President by the duty surgeon Malcolm Perry. Explaining how and why the procedure failed, the author drew an interesting comparison to the fate of another US President, George Washington, who the author said would have survived epiglottitis if his three doctors had come to a unanimous agreement to perform a tracheotomy to improve his breathing. Besides Presidents, many of the anecdotes the book related referred to the afflictions of royalty, such as when he discussed thoracotomy for lung cancer in the context of King George VI; umbilical hernia in the context of the ‘hopelessly obese’ Queen Caroline; anal fistula in relation to King Louis XIV; and splenectomy going disastrously wrong on the backdrop of the Shah of Iran Reza Pahlavi. Other famed surgical cases in the book were diverse, from Harry Houdini to Albert Einstein (pages 26-33, 187-194, 208-218, 131-136, 273-285, 91-99, and 160-166).

The biographies of the pre-eminent surgeons who left their mark on the history of surgery were as enlightening as the stories of the patients in the book. One of such influential practitioners the book acclaimed was Ambroise Pare, the French army surgeon who took the ‘first step’ towards launching modern surgery when he noticed that soldiers whose wounds were treated traditionally with boiling water during the Battle of Turin in 1537 fared worse than those whose wounds were left untreated. Other similarly outstanding historical figures the book featured included the famously quick Robert Liston – ‘the fastest knife in the West End’; the innovative but cocaine-addicted William Halstead who defined breast surgery treatment for generations; Edoardo Bassini who solved the problem of groin hernia repair; Theodor Kocher who, more than any other surgeon, ‘has given his name to so many surgical terms‘; Joseph Murray who performed the first kidney transplantation; Christian Barnard who performed the first heart transplantation; and Michael Harrison who was the first to perform an ‘open operation on a foetus in the womb’. The book also profiled the surgeons who midwifed key surgical turning points such as John Warren who performed the first operation under general anaesthesia, and Philipp Bozzini who paved the way for minimally invasive surgery when he invented the endoscope (pages 1-2, 262, 105, 222-231, 270-272, 101 and 167-174).

The gradual evolution of surgical operative techniques, highlighted across several chapters, formed a major theme of the book. A most illustrative example of this relates to surgery for bladder stones, an operation that began in the seventeenth century as lithotomy – the removal of stones through perineal incisions. The author documented how lithotomy became ‘almost completely obsolete’ by the introduction of transurethral lithotripsy in the early nineteenth century, and how this was yet later modified by the introduction of the cystoscope. A more hazardous procedure that evolved in a similar way is the ‘treacherous operation‘ for tumours of the gastric outlet. First carried out by Jules-Emile Pean, the author chronicled its evolution to the Billroth II operation after Theodor Billroth added an intestinal anastomosis, and its further modification to the Roux-en-Y Bilroth II by Cesar Roux. Surgical metamorphosis also symbolised the transition of varicose vein surgery – an operation first performed by Ambroise Pare when he tied off the great saphenous vein in the upper leg, and subsequently modified by Friedrich Trendelenburg and Jerry Moore who introduced crossectomy and stripping. The book portrayed its even further evolution into an endovascular procedure based on the technique of Sven Ivar Seldinger, ‘a Swedish radiologist who turned the whole of vascular surgery on its head’ (pages 19-22, 263-268 and 85-87).

Some of the topics the author covered were curious phenomena which nevertheless had surgical historical appeal as well as contemporary relevance. A prominent example of this was the author’s exploration of castration, an operation the author referred to as ‘one of the most frequently performed surgical procedures in the history of humankind’, and as ‘a primal operation – simple, dangerous and with serious consequences’. The book narrated mythological depictions of castration such as when the Greek Titan Chronos, hoping to assume ‘the reins of power‘, castrated his father, Uranus, with the help of his mother. The author pointed out that castration was initially applied as a form of punishment when the Chinese used it ‘as an alternative to execution for prisoners of war’. He however documented its subsequent cultural applications such as to generate the three types of palace eunuchs in the Roman empire – castrati, spadones, and thlibiae. Just as the book described the gory details of the procedure, it also highlighted famous castrati such as Carlo Bosch – ‘castrated as a child because he had such a beautiful voice’, and code-breaker Alan Turing – chemically castrated purportedly to cure his homosexuality (pages 175-185).

Opinion

With a fine balance between anecdotes and surgical techniques, this book provides a most enthralling account of the history of surgery. With a focus on famous historical personalities, the book provides context for the operations that have defined the specialty. The author also conveys a perspective by which to better understand the progressive march of surgical advances. The emphasis on stories about royalty may seem disproportionate, but this is perhaps because these were more likely to be documented in historical accounts than operations performed on commoners. Some chapters were unduly lengthy, and some commentaries appeared irrelevant to the main theme of surgical history. These aside, the book’s contents brilliantly project the spectrum of surgical history – from poor judgments to laudable breakthroughs – and these made enlightening reading.

Overall assessment

This enthralling book provides important educational material within the context of interesting, and even entertaining, anecdotes. Its accounts of insightful surgeons and ingenious techniques are inspiring, and it puts into context the emergence of today’s surgical principles and practices. The book has enlivened the history of the operating room, and I recommend it to all doctors.

Book details

Publisher, Place, Year:  John Murray, London, 2014
Number of chapters: 28
Number of pages: 357
ISBN: 978-1-473-63368-1
Star rating: 5
Price: £10.99