Introduction
Healing by Hand: Chirurgeons and Surgeons
ONE NIGHT IN 1537, after a long day of fighting in the battle for Turin, young French army surgeon Ambroise Paré lay wide awake. He was seriously troubled. The battlefield was strewn with soldiers with wounds inflicted by arquebuses and muskets, which Paré had never dealt with before. He had read in a book that you should pour boiling oil into the wound to counteract the toxic gunpowder. So he had dripped the bubbling liquid onto the bloody flesh and it had sputtered like meat in a frying pan. But there were so many wounded that his cauldron of oil was empty halfway through his round of the battlefield. With no oil left, he had to alleviate the suffering of the wounded men with an ointment of rose oil, egg yolks and turpentine. The whole night he listened to men screaming and fighting death, thinking that it was his fault. He was astounded to discover the following morning that it was the soldiers he had treated with boiling oil that had been screaming and not the others. He never used boiling oil again and would later become a great surgeon. This was a first step towards modern surgery.
Surgery must have evolved quite naturally since, as long as humans have walked the earth, they have suffered from ailments that had to be healed ‘by hand’. The healer who used his hands was known as a chirurgeon, from the Greek kheirourgia, meaning hand (kheir) and work (ergon). Our modern word ‘surgeon’ derives from the same origin. Fighting, hunting, migrating, digging for roots, falling from trees, fleeing predators – the hard life of our ancestors exposed them to endless risk of injury. Tending to wounds is therefore not only the most basic of surgical procedures, but was probably also the first. Common sense tells us that we should rinse a dirty wound with water, apply pressure to a bleeding wound, and cover an open wound. If you see that the wound then heals, you’ll do the same thing again next time. But in the Middle Ages, common sense was obscured by tradition. Rather than looking at the results of their actions, our medieval forefathers would follow what some great predecessor had written in an ancient book. So wounds were not cleaned, but seared with a branding iron or boiling oil and dressed with a dirty piece of cloth. Only after that dark age, during that sleepless night in Turin, did common sense prevail and a new form of surgery, based on experiment, begin to emerge.
But back to the beginning. When were our ancestors first inspired to treat infections like festering wounds, pustules, carbuncles or abscesses by cutting them open? Draining pus is the second basic surgical procedure. All you need is something sharp, like an acacia thorn, a flint arrowhead, a bronze dagger or a steel scalpel. This is how the knife made its way into surgery and we surgeons still have the old adage ubi pus, ibi evacua – Latin for ‘where there is pus, evacuate it’ – hanging above our beds.
The third basic procedure for surgeons is treating fractures. Fleeing from wolves, hunting mammoths, stumbling over rocks and tree roots – prehistoric life must have presented ample opportunities to break your bones. Was there anyone sensible enough back then to pull a broken bone straight, painful as that was for the victim? It was, in any case, not something everyone could do; you had to have the guts to do it and – much more importantly – the patient had to be willing to let you. Only someone with enough courage, authority and experience, and who showed enough empathy, would be able to win that trust. And you had to be good with your hands. And that was where the chirurgeon came in, the man who could heal with his hands.
Giving patients emergency treatment has remained part of the surgeon’s work. Dealing with injuries and severe loss of blood, making sure patients can breathe and making them stable are still the primary tasks of surgeons in emergency departments in hospitals. This basis is clear and sound. Treating wounds, abscesses and fractures, and giving emergency treatment to someone in acute distress, results in grateful patients.
But going a step further and performing an operation is a completely different matter. You don’t heal a wound, you make one. A sensible surgeon (and a sensible patient) will weigh up the risks. Does the operation usually succeed or fail? Are there alternatives? What will happen to the patient if I do nothing? What will happen to me if the operation is a failure? It is always a matter of seeking a balance between doing your best and not causing harm. And yet … Roman consul Marius had a surgeon remove his varicose veins. He survived and continued to rule for many years. Surgeon John Ranby thought it advisable to operate on Queen Caroline of England’s umbilical hernia, causing her to die a miserable death. Yet his Roman colleague was given a severe reprimand and was not permitted to operate on Marius’s other leg, while Ranby was knighted for his services to the royal court. Surgery can be an unpredictable profession.
Wounds, fractures, pus infections and operations leave scars, while diseases like colds, diarrhoea and migraine can disappear without leaving any trace. This difference is illustrated by two different words for ‘getting better’: we use ‘heal’ – to ‘make whole’ – to refer to operations, wounds, bruises and fractures, and ‘cure’ – to ‘restore to health’ – for diseases. Roughly speaking, a surgeon heals and a doctor cures. Surgeons have incidentally long been both doctors and surgeons, but they restrict themselves to problems treatable by surgical means, which are a minority of all the ailments a patient can suffer from. Most complaints do not require the intervention of a surgeon or an operation at all. The services provided by chirurgeons in the sixteenth century were so straightforward and limited that they could perform them, as simple tradesmen, in a small shop. In Amsterdam, surgeons were so insignificant as a professional group that they shared a guild with three other trades – skate-makers, clog-makers and barbers.
Until well into the eighteenth century, wounds, infections and fractures constituted the lion’s share of the limited range of complaints that surgeons treated. To that list could be added cutting or burning away misunderstood tumours and growths and, of course, bloodletting – the most popular surgical treatment which, however, had more to do with superstition than treatment. All in all, it was a rather simple and dull business. If I had been a surgeon at that time, I would certainly have taken much less pleasure in it than I do now.
As methods and knowledge improved with experience, the diversity of complaints that could be treated with surgery increased. Walking upright is one of the main causes of many of the typical complaints we suffer from as human beings. That first step, taken by our ancestors 4 million years ago, brought with it a series of medical conditions that account for a large number of surgical interventions. Varicose veins, groin hernias, piles, impaired blood supply to the legs (intermittent claudication), wear and tear of hip- and knee-joints (arthrosis), spinal hernias (slipped discs), heartburn and torn menisci in the knees are all caused by our walking on two legs.
Two complaints that account for a significant part of a surgeon’s work these days did not pose a serious threat to human life until relatively recently. Cancer and hardening of the arteries (arteriosclerosis) have made their way into our lives in the past couple of centuries, brought on by a lifestyle typified by a high-calorie diet and the consumption of tobacco. Furthermore, these diseases are usually contracted in later life and in the past you would simply have died before you got cancer or your arteries blocked up.
Clogs, a cap and a surgical mask
Modern surgeons change their clothes regularly. To do an operation they put on ‘scrubs’ – a clean light-blue or green top and trousers, white clogs and a cap. In the operating theatre they also wear a surgical mask and, when they are operating, a sterile operating jacket, called a surgical gown, over their scrubs and sterile rubber gloves. At the end of the nineteenth century, when it was discovered that germs could be spread via minuscule droplets of saliva in the air, surgeon Johann von Mikulicz from Breslau decided not only to speak as little as possible during an operation, but also to wear a mask over his mouth. Perhaps the cloth masks that gentlemen surgeons wore at the time were primarily intended to cover their beards, just as the operating caps were to cover their hair. In any case, according to Johann von Mikulicz, they rapidly became accustomed to them and, as he wrote in the Centralblatt für Chirurgie in 1897, it was as easy to breathe through the masks ‘as a lady on the street breathing through her veil’. The AIDS epidemic also led to many surgeons wearing splash-proof glasses during their operations. These can be troublesome with a mask, as the glasses will fog up if the mask is not a tight fit around the cheeks and nose. Magnifying glasses known as loupes are used for precision surgery, sometimes together with a light on the forehead. The most unwieldy items of surgical clothing are the lead jackets worn under the surgical gown during operations involving X-rays, which are very heavy.
From the nineteenth century, people suddenly started to live longer due to a remarkable development in the Western world, which meant more for modern surgery than any great discovery or renowned surgeon you can name: people started to be more aware of hygiene. This led to a radical change in surgery. It is difficult to imagine why it took so long for hygiene and surgery to be linked together. We would be deeply shocked if we found ourselves in an operating theatre in the eighteenth century. The screaming must have been indescribable; blood would have been spattering in all directions, and the stench from searing the stump of an amputated limb would have made us retch. It would have been like something from a horror film.
Modern operating theatres are generally quiet places that smell of disinfectant. A vacuum may be used to remove blood or fluids. The only background noise is from the sleeping patient’s heartbeat on the monitor and possibly the radio will be on, but the operating team can talk to each other freely. Yet the real difference between operations today and in the past is much more subtle, and is not immediately clear to an outsider. That difference is sterility, achieved by applying stringent rules that form the basis of all modern medicine.
In the surgical world, sterile means ‘completely free from bacteria’. Our scrubs, gloves, surgical instruments and other equipment are all sterilised. They are placed in an autoclave – a kind of pressure cooker – for several hours, where they are subjected to steam, or are treated with gamma rays to kill all bacteria and other germs. During operations, we take almost draconian measures, creating a sterile zone around the wound where nothing or no one inside the zone can touch anything or anyone outside the zone. If you are part of the team, you are sterile – that means there is not a single bacterium on your clothes or gloves. To preserve that sterility, you have to observe a strict procedure in putting on the gown and gloves and in walking around the patient: always keep your hands above waist level, look at each other as you pass, turn around completely as you tie up your gown and never turn your back on the patient. To restrict the number of bacteria in the operating theatre even further, everyone wears a cap and a mask, the number of people present during the operation is kept to a minimum, and the door stays shut as much as possible.
All of these measures have produced very visible results. It used to be considered normal that pus would leak from a wound after an operation. Only a stupid surgeon did not know that. That is why you had to leave the wound open, so that the pus could get out easily. It was not until sterility could be assured that the customary wound infections could be prevented and wounds could be closed up immediately after the operation had been completed. Hygiene is thus not the only new element in surgery; stitching up wounds is also a relatively recent development.
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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.
When they operate, surgeons literally become part of the treatment of their patients, after all, their hands and their skills are the instruments. When that is the case, you have to be sure of yourself if problems arise. You ask yourself if they happened because of your personal contribution to the treatment, or whether the problems were caused by something else. After all, we never know how any medical complaint will turn out, no matter how good the treatment. Problems may also arise during the course of the disease itself. But, as a surgeon, you have to justify that course for yourself, more so than doctors, who do not use their own hands to influence it. You ask yourself whether you have done your best and done the right thing. Most surgeons conceal that perpetual doubt behind an air of self-confidence. That attitude has always determined the image of a surgeon as omnipotent and untouchable. Yet, even among the most self-confident of surgeons, this is only a front, to allow them to bear the responsibility and keep the latent feeling of guilt at a distance. Just get on with it, that is their motto.
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. It is a little like a train driver who hits someone on the line, but couldn’t do anything about it. The trains have to keep running. Patient deaths are dramatic events and some are easier to get over than others, depending on the circumstances, and the reasons for the operation. If the patient has cancer or has suffered a serious accident, you have no choice other than to operate. If it was elective surgery, an operation for which there was also a non-surgical alternative, or if the patient was a child, it is more difficult.
Naturally, your experience also makes a difference. It matters whether you have performed an operation five or five hundred times. Every procedure has a learning curve; there is a greater chance of complications the first few times you perform it, but that risk decreases as you gain more experience. Every surgeon has to go through this learning curve, there is no way of getting around that. In the seventeenth century Charles-François Félix de Tassy was by no means a novice, but he had never performed an operation to cut open an anal fistula when Louis XIV consulted him about this complaint. So he asked the king to give him six months and first performed the operation on seventy-five patients before daring to try it on the king. I wonder whether my first patients were aware of my comparative lack of experience when I was just beginning as a surgeon.
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.
Fortunately, the setbacks and the less pleasant aspects of the work are compensated for by the gratitude of patients and their families, and the great pleasure of doing surgical operations more than makes up for the hard work. Performing an operation is complex, but it is also enjoyable. Most of the things a surgeon has to do are quite basic and require skills you learn at nursery school, such as cutting, sewing and doing everything neatly. If I had never played with Lego as a child or enjoyed making things, I would never have suited being a surgeon. There is something else that makes surgery enjoyable: the detective work, finding out what is wrong with the patient. Looking for the underlying problem and discussing the best solution with your colleagues are welcome distractions.
The surgeon’s job may seem magical for people who have nothing to do with surgery: the responsibility, skills and knowledge of a person who can save lives. That is why surgeons were often treated with great respect, even awe, portrayed as heroes who, in the face of adversity and appalling working conditions, tried to save their patients with their scalpels. But this image is often distorted. Surgeons were often indifferent, naive, unclean, clumsy and bent only on money or fame.
In this book, I recount some of the stories of my profession and look at a number of famous patients, renowned surgeons and extraordinary operations. That is not simple, as surgery is not only an interesting and exciting job, but is above all very technical. Surgery is concerned with the complex details of the functioning of the human body, and uses jargon that is almost incomprehensible to outsiders. Readers without a surgical background will have no idea what we mean, for example, by an ‘acute abdominal aortic aneurysm’, a ‘sigmoid perforation’ or a ‘B-II resection’. Surgical concepts therefore need to be explained, so that everyone can understand the point of these stories. Consequently, they are not only about the history of surgery but also about how our bodies work and what a surgeon can do to make sure they keep working.
Some surgical terms may require further explanation. The words ‘incision’ and ‘resection’ come from the Latin and mean literally ‘cut into’ and ‘take away’. ‘Trauma’ comes from Greek and means ‘injury’ or ‘wound’. A trauma can be psychological, in the sense of suffering a trauma after a bad experience, but in surgery it means that something is physically damaged. ‘Indication’ means ‘the reason for an operation’, while a ‘complication’ is an undesired development or a calamity. Other terms can be found in the Glossary at the back of the book.
The various stories do not offer a complete history of surgery, but they do give an impression of what it was – and still is – about. What is surgery? What was it in the past? What happens during an operation? What do you need to perform one? How does the human body respond to being attacked by a knife, a bacterium, a cancer cell or a bullet? What are the principles of shock, cancer, infection and the healing of wounds and fractures? What can be repaired by an operation and what cannot? Why did the most common operations arise and who thought of them? Most of the chapters describe operations on famous figures and contain interesting details. Did you know, for example, that Albert Einstein lived much longer than was actually possible, Houdini gave his final performance while suffering from acute appendicitis, Empress Sisi was stabbed at the age of sixty, John F. Kennedy and Lee Harvey Oswald were operated on by the same surgeon, or that a man from Amsterdam cut a stone out of his own bladder? Did you know that you have an electrical current passing through your body during an operation, and that surgeons did not start washing their hands before an operation until 150 years ago?
Some of the stories are especially dear to me. Jan de Doot, the man with the bladder stone, is a favourite because I live in Amsterdam myself, not far from where he operated on himself. And the story of the gluttonous popes also intrigues me, because I have a special interest in operating on people with obesity problems. Then there are the stories about the Shah of Persia, as I had the pleasure to be surgeon to his charming widow; and Peter Stuyvesant, because I worked for some years as a surgeon on the beautiful Caribbean island of St Martin; and the one about keyhole surgery, because I was present when my boss performed the first remote surgical procedure in history. Lastly, long ago, another surgeon from Amsterdam also wrote a book of observations on surgical practice. He was Nicolaes Tulp, portrayed by Rembrandt in his painting The Anatomy Lesson of Dr Nicolaes Tulp. He concluded his Observationes Medicae with a chapter about a chimpanzee. I follow in the footsteps of my fellow-Amsterdammer and also devote the last chapter to a special animal.
Nicolaes Tulp dedicated his book to his son. I dedicate mine to my children, Viktor and Kim, whom I have to abandon so often in the evenings or at weekends to work at the hospital.
Arnold van de Laar
Amsterdam, 2014
Copyright © 2018 by Arnold van de Laar
Translation copyright © 2018 by Andy Brown
