Under the Knife: A History of Surgery in 28 Remarkable Operations

by Arnold van de Laar

operations, wounds, bruises and fractures, and ‘cure’ – to ‘restore to health’ – for diseases. Roughly speaking, a surgeon heals and a doctor cures.

* * * What kind of people are surgeons? What on earth makes you want to cut into someone’s body, even if they can’t feel it? How can you sleep if a patient is fighting for their life after you have operated on them? How do you carry on if a patient has died as a result of you operating on them, even though you made no errors? Are surgeons insane, brilliant or unscrupulous, heroes or show-offs? There is a great deal of tension involved in being a surgeon. Operating is a wonderful thing, but the responsibility weighs very heavily.

Every surgeon has had patients die during or after their operations, even though they made no mistakes. You have to get over it and move on, as the next patient will be waiting to be treated.

You also have to be physically capable of working for hours on end under pressure of time, mostly standing up and without fixed breaks, to work night shifts and then continue in the morning, write discharge letters, train young surgeons, lead your team, stay friendly, tell people bad news, give them hope, record everything you say and do, explain everything adequately, and yet never leave the next patient in the waiting room for too long.

When they take the Hippocratic oath, young doctors swear by the gods to promise a number of things. They boil down to four basic principles: the duty of care (to always do your best for all those who are sick), professional ethics (respect and loyalty to colleagues), professional secrecy (privacy and discretion) and the all-embracing starting point of ‘first do no harm’ (Primum non nocere in Latin).

He even described several forms of contraception and ways to abort a foetus. Anyone who claims that contraception and abortion are incompatible with the prevailing views of the Vatican should take a look at this book by Pope John XXI.

Let us assume that Lucy’s mother still walked on all four legs. That meant that the liquid column in the major veins between her groin and heart was horizontal. And because no pressure builds up in a horizontal liquid column, Lucy’s ancestors did not suffer from varicose veins. Valves in the major veins ‘above’ the saphenous arch would have been pointless for the simple reason that they were not above it.

Lucy brought humankind even more problems. If she did not happen to have three small blood vessels in her rectum that kept her anus watertight (the haemorrhoidal veins), she would probably have changed her mind after her first few steps and gone back to walking on four legs. The act of defecation has never succeeded in adapting: we still have to bend our hips at 90 degrees to do it. The fact that this now requires much greater pressure leads to typical human problems like haemorrhoids, prolapses and constipation.

Another regular feature in the daily work of a surgeon that we have Lucy to thank for is the inguinal canal. This is a weak spot at the bottom of the abdominal wall, exactly where it should be at its strongest. Gravity continually forces the contents of the abdomen against the inside of this weak spot. That can lead to a hole, known as an inguinal or groin hernia, an opening that evolution seems to have forgotten. But if we imagine ourselves on four legs again, the inguinal canal then appears to be higher than the centre of gravity of the abdomen, not lower. So no problem for our four-legged friends, but a real design flaw for us bipeds. Because we walk upright, modern men have a 25 per cent chance of developing a groin hernia in their lifetimes. And that means plenty of work for the surgeon.

the hips and knees had to bear twice as much weight. And the intervertebral discs, which separate the individual vertebrae in the spine,

The most conspicuous fault can be seen in the arteries running to the legs. They still make a 90-degree bend characteristic of quadrupeds, deep down at the back of the pelvis. This bend was necessary because the hind legs of an animal are at right angles to the trunk. Since we spent most of the time we were evolving from primitive land animals to humans walking on four legs, natural selection has made the 90-degree bend in our arteries wide, spacious and gradual. That causes the least possible turbulence in this stretch of the circulation system, which is important for our survival, as turbulence in the arteries can cause damage to the artery wall. Because we now walk upright, however, after making the gentle, gradual bend of the quadruped, the leg arteries now have to bend back another 90-degrees in the groin. This is not a smooth curve, but a sharp kink that has not adapted and does cause turbulence. That leads to hardening of the arteries (arteriosclerosis), resulting in narrowing of the blood vessels near the kink. And that is why hardening of the arteries in humans is most common in the groin.

the arteries gradually become narrower, the legs receive insufficient oxygen-rich blood at the moment that they need it most – during exercise. That causes pain when walking, which disappears immediately again when standing still. This condition is known medically as intermittent claudication (from the Latin claudicare, ‘to limp’), but in Dutch it is appropriately called ‘window-shopping legs’, referring to the fact that the pain of walking down the street will subside every time you stop to look in a shop window.

The first operation performed under general anaesthesia had, at that time, been performed seven years earlier, on 16 October 1846, at the Massachusetts General Hospital in Boston, United States. A dentist called William Morton had anaesthetised a patient called Edward Abbott, by getting him to inhale ether, diethyl ether to be exact. Abbott had a tumour in his neck that had to be removed. While he was asleep, a surgeon called John Warren cut the tumour out. Everything went well, the patient had felt nothing and simply woke up after the operation. Warren was very impressed, uttering the historic, if understated, words ‘Gentlemen, this is no humbug.’ It was a turning point in the history of surgery.

Until around a hundred and fifty years ago, surgeons would always wear a black coat when operating. That made it less obvious that it was covered in blood and they did not have to wash it so often. Some surgeons used to boast that their coats were so stiff from all the blood that they could stand upright on their own. So you had to be quick, otherwise it would end badly. Speed meant safety. And that called for short, deep and accurate incisions – in the right place, and passing through as many layers of tissue as possible with one cut. The flow of blood was therefore always stemmed at the end, ‘on the way back’, by tying off the tissue layers with thread, searing them closed with a branding iron or simply applying a very tight bandage. This method was effective, but not very secure. It left no time to examine closely what you were doing and there was little time or space for unexpected circumstances. So, that was what operations were like until 16 October 1846: quick and bloody – and standardised, with no time for specifics.

Within a few decades, the days of the old, quick surgery were over and a new order emerged. Thanks to anaesthetics, surgeons now had time to work more precisely, and they were no longer distracted by their patients thrashing around and screaming in pain. Operations became precise, meticulous and dry, with no noise, and no blood spattering everywhere.

One of the great new names was the American William Halsted. An innovator in treating inguinal hernias and breast cancer, Halsted had introduced rubber gloves in surgery and with a number of colleagues he had put together a working group to develop local anaesthesia, a wonderful new invention. The procedure, which entailed injecting an

anaesthetic drug around a nerve, allowed the patient to remain awake, but to feel nothing in the anaesthetised, numb area. The group met regularly to practise on each other and enjoyed wonderful evenings together. Halsted became not only a pioneer of local anaesthesia, but – because the drug they used was cocaine – he also became an addict. Cocaine has long since been replaced in local anaesthesia by derivative drugs that have the same effect locally, but without the stimulating side effects.

In 1847, the Hungarian Ignaz Semmelweis discovered that childbed fever – an infection contracted by mothers shortly after childbirth – occurred when medical students returning from the dissecting-room after practising anatomy on dead bodies did not wash their hands before assisting with births.

Semmelweis’s basic principle of hygiene was not accepted until Louis Pasteur exposed bacteria as the cause of disease and Joseph Lister was the first, in 1865, to prevent the infection of a surgical wound by using an antiseptic.

John Snow was able to monitor his patient in this way. And despite his services to the queen, Dr Snow is not remembered as a great anaesthetist. He is, however, remembered for a completely different reason. In 1854, he described an outbreak of cholera in London, identifying a single public water pump as the source of the infection. He was the first to show how a disease can be contagious, and the founding father of epidemiology, the study of how diseases spread.

The word gangrene is a general term to describe the dying off of living tissue. It is the terrifying final stage of a shortage of oxygen in the skin, the subcutaneous tissue, the muscles or even an entire limb. Although the dead tissues feel as cold as ice, the victim develops a high fever. Gangrene can be caused by a blocked artery. You could then speak of an infarction. That leads to a sharply defined black mummification of part of the limb. The dead part dries out. That is referred to as dry gangrene. But tissue can also die off due to infection of a wound. Because of the pus and the rotting fluids that this produces, it is called wet gangrene. Some bacteria also produce gas, resulting in a form of wet gangrene called gas gangrene.

Gas gangrene is the deadliest form of gangrene and is mostly caused by a micro-organism with the appropriate name Clostridium perfringens, from the Latin verb perfringere, which means ‘crush’, ‘demolish’, ‘assault’ or ‘break through with violence’. It can be found everywhere on the planet. Sand, soil, faeces and street refuse are full of it. Perfringens comes from a dangerous family. Clostridium tetani causes the lethal disease tetanus, or ‘lockjaw’, Clostridium difficile a life-threatening great bowel infection and Clostridium botulinum deadly food poisoning. In unhygienic conditions, Clostridium perfringens also causes the much-feared childbed fever, which unnecessarily cost the lives of so many women in childbirth in the past. The Clostridium perfringens bacteria is an anaerobic life-form, meaning that it only survives in an oxygen-free environment. The bacteria has two dangerous properties: it emits rotting gases and produces toxic substances known as toxins. For many centuries, surgery was frustrated by gas gangrene and wound infections. But why does one wound become infected and another not, and why would gas gangrene have developed in Peter Stuyvesant’s wound? And why does it hardly occur in the present day? Three elements determine whether an infection or gangrene develop in a wound. Firstly, of course, there has to be a wound. The size of the opening in the skin is not that important. Bacteria are small enough to enter through even the smallest wounds. The second ...

called the ‘wound bed’. The state of the wound bed is crucial to what follows. In a wound caused by a sharp knife, the wound bed will hardly be damaged. The edges of the wound will remain unharmed and the healthy tissues will allow the immune system to kill any bacteria that enter the wound. A clean cut with a sharp knife can even be closed up again immediately, if you rinse it out quickly with water, soap or disinfectant. This is primary healing or healing in the first instance (per primam). If the cut is not clean, the wound will become infected, producing pus. The infected wound can then no longer be closed up per primam and will have to heal per secundam, through secondary healing or ‘healing in the second instance’. However, the healthy wound bed also guarantees a sufficient supply of oxygen. As the Clostridium perfringens bacteria cannot survive in the presence of oxygen, gas gangrene has little chance in a healthy cu...

Clean the wound as quickly as possible. Rinse it out with clean water (for example, the crystal clear sea water in the bays of Saint Martin) and leave it open. Then use a sharp knife

to cut away all the dead material until you come to healthy tissue. There are fine-sounding surgical terms for this: debridement or nettoyage in French, anfrischen in German, or necrosectomy in English (from the Latin/Greek). Then keep the wound clean until it is fully healed, per secundam.