'Under The Knife' book review: On the cutting edge

Under The Knife

The History of Surgery in 28 Remarkable Operations

Arnold Van De Laar

Hachette

357 pages; Rs 699

 

If you are reading this review over a cup of morning tea, you might want to put it down. For in Under The Knife, surgeon Arnold Van De Laar has shared stories from surgery’s bloody past and (somewhat) cleaner present, and no amount of dithering over delicacy can prevent some mention of the frankly gory procedures he describes in the book.

 

The very first chapter, “Lithotomy”, describes the surgery Dutch blacksmith Jan de Doot performed on himself in 1651 to get rid of a bladder stone. This was after he had visited surgeons of the day who had been unsuccessful in relieving him of the “excruciating pain” and “unbearable discomfort”. Bladder stones were a common problem at the time, due to poor hygiene brought about by wearing thick clothes and not bathing for days on end.

 

When the surgeons could not help him, de Doot fashioned a knife, sent his wife away to run errands and got his assistant to hold his scrotum while he gashed three cuts into his perineum and pushed his hand inside to retrieve a stone as large as a chicken’s egg. Mercifully, Dr Van De Laar provides no further details of what must have been an intensely painful and bloody operation.

 

Each of the 28 chapters in the book focuses on one or the other ailment and describes how surgery advanced through a mix of luck and pluck to its current avatar, where surgeons minimise invasive operations through keyhole surgery in an antiseptic environment where the patient is anesthetised. Some of the revelations are so jaw-dropping that they can confound the modern mind.

 

Speaking of anesthesia, the book informs that the practice was not widely adopted until the 1850s when it was popularised by Queen Victoria who refused to undergo delivery until she was relieved of the cramps. Before this, surgeons in Europe operated while the patient was held down by an army of helpers, and the surgeon had to finish the operation in the time it took for the patient to wrest himself free. Surgeons even prided themselves on how quickly they could complete the task and thought of anesthesia as a “waste of time”.

 

It was John Snow, an amateur anesthesiologist and the designer of a mask to administer chloroform, whose services helped Queen Victoria deliver her eighth child with relative ease. The news of the success travelled throughout Europe and what was known as “Yankee humbug” was quickly adopted on the continent.

 

Dr Van De Laar’s focus on celebrity to explain advances in his discipline extends to other ailments. Most notable is the chapter on John F Kennedy’s killing which was mired in conspiracy for many years. One reason for this is that the autopsy conducted on the president failed to detect the exit wound for a bullet, leading to speculation that the murder was not a lone man’s job but a keenly planned exercise.

 

The straightforward reason for the missing bullet wound was revealed later. When a sinking Kennedy was brought to Parkland Memorial Hospital in Dallas on that day, Dr Malcolm Perry performed a tracheotomy on the president by making an incision at the exact spot where the bullet had exited. In fact, Perry widened the bullet wound horizontally to insert the tracheostomy tube into the windpipe.

 

Incidentally, Dr Perry also performed surgery on Lee Harvey Oswald, Kennedy’s assassin, two days later when the patient was brought before him with a gunshot wound. That operation also failed — and Dr Van De Laar provides a detailed account of the procedure that dovetails into a stimulating discussion of the complications of surgery.

 

Other chapters detail why Louis Auguste and Marie Antoinette failed to have a child for so long (a tight foreskin), how Harry Houdini died of appendicitis, and why obesity is not the real reason so many popes have had trouble concentrating (the culprit is sleep apnoea). Some, such as the one on stomas, explain the origins of a procedure that is now a life-saver for patients of, say, colon cancer. Others, such as the chapter on castration, are largely anecdotal.

 

For all the grimness of the subject matter, Dr Van De Laar’s style is bracing, even bordering on the comic. He finishes the book with a list of the top 10 surgeons from the arts, tipping his hat to such cultural icons as Victor Frankenstein and Stanley Kubrick. His mention of Luke Skywalker’s mechanical arm is a reminder that the superhero genre would not be what it is without its wholesome lifting of surgical practices.

 

Finally, Under the Knife is a reminder that all medical knowledge, not just in surgery, is a result of unexpected hits and misses. At one time, for example, it was common for medical students to return from dissecting bodies to helping senior surgeons in the operating room without washing their hands. It was only after new mothers started dying of childbed fever that the practice was introduced. Dr Van De Laar’s ability to shock us remains uninhibited to the last page.