There’s an old joke about different kinds of doctors. An internist, a surgeon and a pathologist go duck hunting. Soon a flock of birds sweeps overhead. The internist pauses. “Those might be ducks, but they could be geese, gulls or herons,” she says. “I’ll have to run some tests. First I’ll see if they respond to my duck call.” Before she can begin, the surgeon lifts a shotgun and fires mid-flock, bringing down a shower of bird parts. The surgeon and the internist turn to the pathologist. “Well,” they say, “Go find us a duck.”

This genre of joke is particularly popular among medical students still figuring out, in vocational terms, who they are: thinkers or doers? Of course, every good doctor can code-switch to some degree, and today the old dichotomies break down. (That Columbia University’s medical school is called the “College of Physicians and Surgeons,” as if they were two different courses of study, is mostly quaint anachronism.) But as Arnold van de Laar reminds us in “Under the Knife: A History of Surgery in 28 Remarkable Operations,” a collection of hypervivid anecdotes and oddities, it was only recently that surgeons were considered the equals of what we would now call internists—doctors who diagnose, prescribe medicine and prognosticate.

Photo: WSJ

Under the Knife By Arnold van de Laar

St. Martin’s, 357 pages, $29.99

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Largely because of the late arrival of antibiotics and anesthesia, for millennia surgery was associated (accurately) with excruciating pain and festering wounds that were as likely to kill as to heal. Its practitioners were often thick-skinned tradesmen, regarded as little different socially from barbers or butchers. Of “stone-cutters,” the proto-urologists of the premodern era, Dr. van de Laar writes wryly, “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.” From the classical age through the Byzantine era, an often-lucrative branch of surgery was that of the castrator, who worked as adjunct to the slave trader to elevate the price of male flesh.

These macabre examples aside, it has been both the bane and the secret glory of surgery as a vocation that it was relegated for so long to the margins of “decent” intellectual or professional life. Its dodgy, outsider status perhaps permitted greater risks and leaps of faith than were available to nonsurgical physicians, who still found themselves making inchworm progress from the dictates of Hippocrates and Galen. Surgeons worked fast to beat pain and gangrene (so fast that in one case, Scottish surgeon Robert Liston cut off a man’s testicles in a rush to amputate his leg). They used whatever materials seemed to make sense—in some cases gold thread, costly but long-lasting; in other cases branding irons.

Surgeons can occasionally get a bit huffy about this traditional distinction between physicians and surgeons, and Dr. van de Laar, a laparoscopic surgeon in Amsterdam, is no exception. (Full disclosure: I am an internist.) Unlike internists, he writes, “once a surgeon is standing at the operating table . . . he is completely alone and everything that he does from that moment, everything that happens to his patient, remains his own, personal responsibility. . . . You do not help your conscience by working on the basis of probabilities.” This seems both a bit melodramatic (what of the small mob of nurses, residents, anesthesiologists and technicians cheek-by-jowl in any contemporary OR?) and an unnecessary dig at the non-surgeon’s attempt to proceed rationally from experimental data.

Dr. van de Laar’s conclusion, however, that any “mutual lack of understanding” is usually caused by the “philosophical distinction between deduction and induction, two ways of discovering the truth,” seems both generous and, on the whole, true. Induction studies the qualities of birds. Deduction shoots the duck.


“Under the Knife” (translated from the Dutch by Andy Brown) is full of startling, occasionally nauseating tales of slicing and stitching. Like many of the classical and medieval medical texts it cites, it can be read out of order or piecemeal, depending on one’s interests and tolerance for gore. Descriptions of tuberculous bone as “Camembert-like” and of the Sun King’s anal fistula are not for the faint of heart. But Dr. van de Laar can be quite funny, too, as when he describes the scene at the deathbed of Queen Caroline of England in 1737. As she lay dying due to surgical bungling, George II, “sobbing and snivelling,” promised that he would never marry again. With remarkable sang-froid, she urged him to reconsider. “No,” he blurted. “I shall have mistresses.” How selfless.

A chapter on obesity races through a greatest hits of the eccentric popes of the Middle Ages and Renaissance. We hear of Pope Innocent VIII, who, once he became too heavy to sit at table, received doctor’s orders to be breast-fed by local women. We also learn of the 13th-century Pope John XXI, a surgeon before assuming the papacy, who published a book called “Thesaurus Pauperum” (“Treasure Chest for the Poor”), which offered medical advice for those unable to meet physicians’ fees. Remarkably for the Vatican, it included guidance on contraception and abortion.

As for John Paul II, shot in 1981 in the abdomen by a man he would visit in prison, he had the wit to remark, when finally rising from his bed after yet another hospitalization, “Eppur si muove” (“And yet it moves”)—the phrase supposedly uttered by Galileo when he defied Church teaching about the Earth’s rotation. “Panta rhei,” Dr. van de Laar writes elsewhere, quoting Heraclitus: “Everything flows.” In surgery and medicine, as in everything else, today’s eccentricity is tomorrow’s commonplace, and some of today’s norms will certainly seem barbaric sooner or later. Perhaps one of the only constants will be our ongoing need “for a man or a woman with a knife to save people’s lives, repair damage, remove cancer and alleviate suffering.”

Dr. Kolbe is a resident physician in internal medicine at Brigham and Women’s Hospital in Boston.