Sunday 18 March 2018

A history of fatal castrations and gory amputations

Medicine: Under the Knife, Arnold van de Laar, John Murray, hardback, 368 pages, €24.70

Under the Knife by Arnold van de Laar
Under the Knife by Arnold van de Laar

Helen Brown

In any debate over the social worth of "so-called experts", a defender of experience will at some point play their trump card: surgery. If you had a brain tumour, they'll say, wouldn't you want an "expert" brain surgeon to remove it? In the 21st century, the answer is, well, a no-brainer. We would choose the expert.

But go back more than 150 years, and surgeons no longer seem such shining examples of the expert class. Indeed, Arnold van de Laar, the Dutch surgeon, opens this fascinating history of surgery with the tale of a 17th-century blacksmith who had been so sorely disappointed with the botched operations performed by the scalpel-wielders of his day that he took matters into his own hands and cut a 4oz stone from his own bladder while his wife was at the shops.

Today, with decent hygiene, bladder stones are rare, but then they were rife. From a simple urine infection, they would grow like pearls inside oysters, pressing on the sensors that prompt urination while impeding the act. Hippocrates, the father of medicine, would have counselled any doctor against attempting to remove one, as the operation was more likely to kill the patient than the stone itself. But the pain drove sufferers to seek the relief offered by professional "cutters", even though the procedure had a 40pc mortality rate.

It was only after two cutters had failed to remove 30-year-old Jan de Doot's stone that he decided to do it himself. He made a surgical knife in his own forge, then instructed his apprentice to hold his scrotum out of the way as he made three, deep horizontal slits in his own perineum, and extracted a stone larger than a chicken's egg. De Doot succeeded where the experts had failed, and became famous for his extreme DIY.

Yet de Doot is an exception. Most of us lack the courage to hack into our own skin, and the self-control to proceed sensibly after the initial shock. Ever since human beings have seen pus that needs draining or bones that need setting, we have entrusted these tasks to others.

The word surgeon comes from the Greek kheirourgia, or hand work. Successful surgeons would have been well paid and respected, but those who failed risked their lives. According to the Babylonian Code of Hammurabi (dating back to about 1754 BC), surgeons who caused the death of nobleman would have their hands cut off. So, van de Laar asks: what kind of people were surgeons? Were they "insane, brilliant, unscrupulous, heroes or show-offs"?

Inevitably, van de Laar manages to find example of all those traits in the surgeons who appear in the "28 remarkable cases" he uses to take his readers on a brisk but revealing tour of the human body. Each story shines a light on the wonders and weaknesses of our biology, and the science we have used to treat it. Under the Knife doesn't aim to be comprehensive, just eye-opening and, frequently, eye-watering. We wince at tales of counterproductive bloodletting, fatal castrations and gory amputations (one army sawbones performed 700 at the Battle of the Sierra Negra in 1794 - averaging one every four minutes); we breathe a sigh of relief at the game-changing discoveries of disinfectants and anaesthetics.

There's a great chapter on how, after a series of seven traumatic labours and post-natal depressions, Queen Victoria became one of the first women to use chloroform while giving birth to her eighth child. Anaesthesia was first used to put a patient to sleep in Boston in 1846 but was dismissed in Britain as "Yankee humbug" for quacks not good enough to operate quickly. But in 1853, Victoria dismissed the biblical scholars who insisted women should suffer labour pains as a punishment for the Fall of Man in favour of "that blessed chloroform, soothing, quieting and delightful beyond measure," she wrote in her diary.

She is just one of many famous patients to appear in a book that invites readers to peer up the bottoms of kings, into the souls of rock stars and down the ear canals of astronauts.

Van de Laar glams up a chapter on clogged arteries by exploring how they troubled the celebrated pins of Marlene Dietrich. (The smouldering cigarettes that dangled from her seductress's lips may have got her fans' blood pumping, but they had the opposite effect on her own circulation). Van de Laar also tells the sad story of Evarts Graham, the American lung surgeon and lifelong smoker, who set out to prove that smoking did not cause lung cancer but actually proved the opposite in 1950, before dying of the disease himself in 1957.

As van de Laar whisks us up to today, he describes the minimally invasive keyhole surgery he practices in Amsterdam; how operations can now be performed remotely, with surgeon and patient separated by an ocean; how advances in drugs and robot technology have made operations "smaller and smaller". The same can't be said of many surgeons' egos, but van de Laar admits that most of his peers are still hiding "perpetual doubt behind an air of self-confidence". The wisest experts will always be asking themselves if they can still cut it.

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