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
Jan Jansz. de Doot with his bladder stone and his knife, by Carol van Savoyen, 1655.
1
Lithotomy
The Stone of Jan de Doot, Smith of Amsterdam
‘AEGER SIBI CALCULUM praecidens’ – literally translated is ‘a sick man cutting out a stone from the front himself’ – is the title of a chapter in a book by Nicolaes Tulp, master surgeon and mayor of Amsterdam in the seventeenth century. Tulp describes a wide variety of disorders and other medical curiosities he encountered in his practice in the city. They include ‘a twelve-day attack of hiccups’, ‘the mortification of a thumb after blood-letting’, ‘a rare cause of objectionable breath’, ‘a pregnant woman who ate 1,400 salted herring’, ‘piercing of the scrotum’, ‘daily urination of worms’, ‘pain in the anus four hours after defecation’, ‘pubic lice’ and the rather macabre ‘a hip burned off with red-hot iron’. He wrote the book Observationes Medicae in Latin to be read by fellow surgeons and doctors. But it was translated into Dutch without his knowledge and became a bestseller among non-medical readers. His description of the smith Jan de Doot, who had cut out his own bladder stone, must have been a favourite, as Jan was portrayed in action on the title page of the book.
Jan de Doot lost all confidence in Tulp’s profession and literally took the matter into his own hands. He had suffered from the bladder stone for many years and had twice looked death in the face as a surgeon tried and failed to remove it. This operation is known as a lithotomy, literally ‘stone-cutting’. In those days, the mortality rate of a lithotomy – that is, the odds that you would die from it – were 40 per cent. One of the most important attributes of a successful stone-cutter’s practice was a good horse, so that he could get as far away as possible before the victim’s family could call him to account. The profession of stone-cutter was therefore – like that of tooth-puller and cataract-pricker – by nature a travelling occupation. The advantage of this nomadic existence was that there were always poor wretches in the next village who were suffering so much from their ailments that they were willing to take the risk – and pay for it, too.
De Doot had twice survived the 40 per cent odds of dying under the knife – a combined risk statistically speaking of 64 per cent. So it was pure luck that he was not yet dead. The pain was excruciating, his discomfort unbearable and his nights sleepless. Bladder stones have occurred throughout human history. They have been found in ancient mummies and there have been reports of stone-cutting since time immemorial. Bladder-stone pain was an everyday complaint, like scabies and diarrhoea, and so ubiquitous that you could compare it to present-day ailments like headache, backache or irritable bowel syndrome.
Bladder stones are caused by bacteria and are a direct result of a lack of hygiene. It is a misconception that urine is by nature dirty. In normal circumstances, the yellow fluid is completely free of any kind of pathogens from its origin in the kidneys to its discharge through the urethra. Bacteria in the urine are therefore not normal. They cause blood and pus in the bladder, which can create a gritty sediment. You don’t feel it at all, as long as it is still small enough to discharge in the urine. But if you have a succession of bladder infections one after the other, the sediment may become so large that it can no longer find its way out. Then it forms a stone. And, once a stone has formed in your bladder that is too big to be discharged, that tends to generate new infections. So once you had one, you could never get rid of it and, with each infection, it would get bigger. Bladder stones therefore have a characteristically layered structure, like an onion.
Why did people in the seventeenth century get bladder stones so easily, while today they are very rare? Houses in cities like Amsterdam were cold, damp and draughty. The wind blew through the cracks in the doors and window frames, the walls were wet from rising damp, and the snow came in under the front door. There was little to be done about it, so people always wore thick clothing, day and night. Rembrandt’s portraits show people in fur coats wearing hats. In those days people were not able to take a daily bath in clean water. The water in the canals was sewer water. Dead rats floated in it, people defecated in it and threw their waste into it, and tanners, brewers and painters discharged their waste chemicals in it. The canals in the Jordaan district of the city were little more than extensions of the muddy ditches that passed through the surrounding pasturelands, so that cow manure flowed slowly into the River Amstel. You couldn’t take a decent bath in the waters of the river, or wash out your underwear, and toilet paper had not yet been invented.
Consequently, the groins and private parts of these thickly clothed people were always dirty. The urethra, the tube for discharging urine from the body, presented only a small obstacle to bacteria entering the bladder. The best remedy from this external assault was to urinate as much as possible to rinse the urethra and the bladder clean. But that meant drinking a lot and clean drinking water was hard to come by. The water from the pump was not always trustworthy. The best way to ensure it was safe was to make soup from it. Wine, vinegar and beer could also be kept much longer and, around 1600, the average Dutch citizen would drink more than a litre of beer a day. As this did not apply to children
, bladder infections often started during childhood, giving the stones plenty of time to grow.
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Hippocrates and the stone-cutter
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). According to Hippocrates, stone-cutting did not fulfil these requirements. In his oath, he urges doctors to leave the cutting of stones to others. Today, this specific passage is interpreted as an appeal to refer patients to a specialist if you cannot treat them yourself, but that is actually nonsense. Hippocrates meant exactly what he said and firmly placed stone-cutters outside the boundaries of medicine, with tooth-pullers, fortune-tellers, poison-mixers and other charlatans. In his time, there was probably good reason for this. No matter how much a bladder stone could make your life a misery, the chances of dying from having it cut out were probably quite high. Since then the risks of operations have been reduced a hundredfold. The fear of surgery is no longer justified, not even in the case of health problems not life-threatening. Hippocrates could only have dreamed of a time when surgical operations not only saved but also improved the quality of lives.
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Any bladder infection will give three unpleasant complaints: pollakisuria (abnormally frequent urination), dysuria (pain when urinating), and urgency (a compelling urge to urinate). Since Tulp described Jan de Doot’s deed as an unprecedented tour de force, Jan’s bladder must have been causing him terrible pain to make him cut himself open. What complaints, in addition to those of a normal bladder infection, did the smith suffer to drive him to such desperation?
At the exit to the bladder, at the bottom of the urethra, there is a kind of pressure sensor. The sensor is stimulated when you have a full bladder, so that you feel the need to urinate. But a stone lying on the bottom of your bladder will give you the same urge, whether your bladder is full or not. And if you then try to urinate, the pressure will cause the stone to block the exit from the bladder, so that almost nothing comes out. Furthermore, the stone will press even harder against the sensor, increasing the urge. That will cause more pressure, less urine to come out, and a greater urge to urinate – enough to drive you crazy. We know that the Roman emperor Tiberius ordered his torturers to tie up their victims’ penises, which of course led to such complaints. If you suffered in this way day and night, whether your bladder was full or empty, what did you care about a 40 per cent chance of survival?
For anyone who has never had a bladder stone, it must be difficult to imagine where you would need to make an incision to get the thing out. But because a stone closing off the exit from the bladder is pushed downward by the pressure, a sufferer like Jan de Doot would know exactly where it could be reached: between the anus and the scrotum. This area is called the perineum. But anyone who is familiar with the human body would never start cutting it open down there – there are too many blood vessels and sphincters in close proximity. It would be easier to access the bladder from above but that is, in turn, dangerously close to the abdomen and the intestines. Because stone-cutters were not anatomists, but crafty conmen with little understanding of what they were doing, they cut into the body from below and went straight for the stone, taking little account of the damage they could be causing to the functioning of the bladder. Most victims who survived the stone-cutter’s work became incontinent.
In Jan de Doot’s time, there were two ways to remove a bladder stone: the ‘minor’ operation (using the ‘apparatus minor’) and the ‘major’ operation (using the ‘apparatus major’). The first method was described in the first century AD by the Roman Aulus Cornelius Celsus, but had already been applied for many centuries. The principle of the ‘minor’ operation is simple. The patient lies on his back with both legs in the air, a position still called the lithotomy position. The stone-cutter then sticks his index finger into the patient’s anus. This enables you to feel the stone in the bladder in the front, through the rectum. You then pull it towards you with your finger, in the direction of the perineum. You ask the patient – or someone else – to hold the scrotum up, while you make an incision between the scrotum and the anus until you can get at the stone. Then you get the patient to press it out like a woman pushing out a baby. Someone can help him by pressing on his abdomen, or the stone-cutter can pull it out with a hook. If that all works, you then have to stop the patient from bleeding to death by applying considerable pressure to the wound for as long as possible.
It was an operation that could only be performed on men and then only up to the age of about forty. Around that age, a gland swells up that gets in the way of the incision. For that reason, the gland was called the prostate, based on the Latin pro-status, meaning ‘standing in front of’.
The ‘major’ operation was described in 1522 by Marianus Sanctus Barolitanus, a new method devised by his master Joannes de Romanis of Cremona. Instead of bringing the stone to the instrument, the instruments were brought to the stone. The ‘Marian operation’ required the use of a large number of instruments, hence the term ‘apparatus major’. The sight of all these metal tools was often enough to make the patient faint or change his mind. The ‘major’ operation was also conducted in the lithotomic position, but the scrotum did not need to be lifted out of the way. A bent rod was inserted into the bladder through the penis. A scalpel was used to make a vertical incision in the direction of the rod, between the penis and the scrotum, along the centre line of the perineum. A ‘gorget’, a grooved instrument, was then inserted into the bladder, through which the stone could be crushed and removed in fragments, using spreaders, forceps and hooks. The advantage of the ‘major’ operation was that the wound was actually smaller, reducing the risk of incontinence.
De Doot did not have access to all these complicated instruments, so had no choice other than to keep it simple. He only had a knife and performed the ‘minor’ operation by making a large, crossways incision. The smith had made the knife himself and before getting down to work – not unimportantly – had concocted an excuse to send his wife (who suspected nothing) to the fish market. The only other person present during the operation, on 5 April 1651, was his apprentice, who held his scrotum up out of the way. Tulp writes ‘scroto suspenso a fratre uti calculo fermato a sua sinistra (the brother held the scrotum up so that the stone was held in place with his left hand). From his pidgin Latin, however, it is difficult to determine which of the two men had their left index finger in Jan’s rectum. Perhaps Jan tried to do everything himself and his assistant simply observed the ‘operation’ with growing amazement. Jan made three cuts, but the wound was still not wide enough. So he stuck both his index fingers (one of which was obviously his left one) into the wound and tore it open wider. He probably did not suffer a lot of pain and loss of blood, as he went through the scar tissue resulting from the operations he had undergone when he was younger. By pressing vigorously and, according to Dr Tulp, more by luck than judgement, the stone finally emerged, with a lot of crunching and cracking, and fell on the ground. It was larger than a chicken’s egg and weighed four ounces. The stone was immortalised in an engraving, along with Jan’s knife, in Tulp’s book. The drawing clearly shows a longitudinal groove in the stone, probably caused by the knife.
The wound was enormous and eventually had to be treated by a surgeon, and continued to fester for many years. Carel van Savoyen’s portrait of Jan, painted four years after his heroic act, shows the smith standing (not sitting!) with a bitter smile on his face and holding both stone and knife.
Not long after Jan de Doot’s act of desperation, the primitive incision in the centre of the perineum would be replaced by other methods. Unfortunately, these were not without risk. In the year Jan cut the stone out of his own bladder, a man called J
acques Beaulieu was born in France. Under the name Frère Jacques, Beaulieu travelled around Europe performing the ‘major’ operation through an incision from the side a few centimetres off the midline. In the early years of the eighteenth century he made a name for himself performing the operation in Amsterdam. As fatalities and complications after the operation decreased, the incision became smaller and the stone could be extracted with greater precision. In 1719, John Douglas performed the first sectio alta, the ‘high section’ through the lower abdomen. This access route had always been taboo because of a warning by Hippocrates, who believed that a wound on the upper side of the bladder would always be fatal. But he was proved wrong. In the nineteenth century, lithotomy was rendered almost completely obsolete by transurethral lithotripsy, a difficult term for pulverising (-tripsy) the stone (litho) via (trans) the urethra. Narrow, collapsible forceps and files are inserted into the bladder through the penis, and used to break the stone into small fragments. In 1879, the cystoscope was invented in Vienna; this is a small visual probe that can be inserted directly into the bladder through the urethra, making it much easier to pulverise and remove stones. Prevention, however, remains the best treatment. The discovery of daily clean underwear has meant more in combating this great tormentor of mankind that any new operating method. As a consequence, genuine lithotomies are rarely performed now, and never via the perineum. Furthermore, the operation is no longer the domain of the surgeon, but the urologist.
For anyone who is still curious about how a lithotomy between the legs must have felt, the French composer Marin Marais set the ‘major’ operation he had himself endured in 1725 to music. The piece, for viola da gamba in E minor, is called ‘Tableau de l’opération de la taille’. It lasts three minutes and describes the operation’s fourteen stages from the perspective of the patient: the sight of the instruments, the fear, bracing oneself and approaching the operating table, climbing onto the table, climbing off again, reconsidering the operation, allowing yourself to be tied to the table, the incision, the introduction of the forceps, the extraction of the stone, almost losing your voice, the blood flowing, being released from the table and taken to bed.
Under the Knife Page 2