Empire of the Scalpel

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  For Alex and Benjamin, two A²G²s.

  May your futures be filled with happiness, health, love, and success

  AUTHOR’S NOTE

  Why is the amphitheater crowded to the roof, by adepts as well as students, on the occasion of some great operation, while the silent working of some well-directed drug excites comparatively little comment? Mark the hushed breath, the fearful intensity of silence, when the blade pierces the tissues, and the blood of the unhappy sufferer wells up to the surface. Animal sense is always fascinated by the presence of animal suffering.

  Henry J. Bigelow, An Introductory Lecture, delivered at the Massachusetts Medical College, 1849

  Surgeons must be very careful

  When they take the knife!

  Underneath their fine incisions

  Stirs the Culprit, — Life!

  Emily Dickinson, Poems, 2nd series, 1891

  This book is about the history of surgery and examines the relationship between my profession and society. The clearest indication of modern surgery’s impact on our lives is the reasonable certainty that virtually no one in the industrialized world will escape having an illness for which effective treatment requires a surgical operation. This extraordinary fact is supported by a recent World Health Organization report that estimates the global number of surgical procedures at hundreds of millions per year; in America alone, tens of millions are performed annually.1 Indeed, a case can be made that many aspects of modern surgery, such as breast augmentations, cataract removals, gender reassignment operations, heart transplants, hip and knee replacements, and procedures for obesity, have become mainstream cultural benchmarks. That few of us pause to think about the magnitude of these statistics, that we have such inherent faith in this mystifying branch of the medical world, is nothing short of remarkable.

  There is no denying that the rise of surgery and confidence in its practitioners is among the most profound of changes that separate current existence from past eras. Yet, despite the debates, the headlines, and the table talk that surround surgical operations, most of us have no idea how surgeons arrived where they are or of the ins and outs of what they do. None of this is surprising, because surgery’s inner sanctum is closely guarded. After all, surgery began as a quasi-religious, supernatural craft, as intriguingly admired as it was singularly feared (it still is in many cultures); there are not many events in life that are as simultaneously life frightening and lifesaving as a surgical procedure.

  Few would disagree that surgery is concealed from the world by its jargon and rituals. For instance, to simply enter an operating room necessitates an act of supplication to the surgical gods. Surgeons must first put on a cap and mask to separate themselves from the outside world. If the patient is to be closely approached, then an anointing wash of antiseptic soap and cleansing water followed by the sliding on of sterile rubber gloves and the donning of a germ-free gown (the surgeon’s priestly robe?) are required to further isolate and purify the encounter. Nonphysicians seeking entry into this mysterious realm and its secrecies are usually met by locked doors.

  Empire of the Scalpel addresses this glaring silence and tells surgery’s story; from its subjective Stone Age origins to its objective roots in the classical world of Europe and finally its rise to scientific and social supremacy in the United States. No other approach captures the growth of surgery in all its dramatic and gory complexity. I devote attention to European surgery because its evolution, from Greek and Roman Antiquity to the rise of barber-surgeons in the Middle Ages, followed by the emergence of centers of surgical excellence in England and France during the seventeenth and eighteenth centuries, and concluding with Germany’s predominance at the end of the nineteenth and beginning of the twentieth centuries, developed in ways that served as the wellspring of modern surgery.

  European surgery’s dominance arose from the technical expertise of its practitioners, the credibility of their professional organizations, and the perception that surgical therapies worked well. Its status as the international leader in surgery ended with the First World War. The conflict destroyed much of the Continent—if not its physical features, then a large measure of its finances and passion for scholarly and scientific pursuits. The result was a global vacuum in surgical education, research, training, and therapeutics. It was only natural for surgeons from the United States, the industrialized nation least affected physically and psychologically by the war, to fill the void.

  Over the last century, the rise of surgery is intimately bound up with the United States’ development as an international leader in cultural, political, socioeconomic, and scientific affairs. I have little doubt that the world would not have surgery as it presently exists, with its triumphs, tragedies, and contradictions, without modern America and, quite possibly, vice versa. Moreover, given that I was born and live and work in the United States, it only seems natural that my history of surgery reflects an American tilt. None of this is to suggest that each nation in the world does not have its own fascinating, unique, and worthy surgical story to tell. The reality is that what began as the surgery of Europe and became the surgery of America was transformed into the surgery of the globe.

  I focus on “Western” Medicine because its relationship to surgical illnesses evolved in ways that made it successful and worldwide in appeal. “Eastern” Medicine, exemplified by Indian practices, enjoyed numerous surgical achievements, especially plastic and reconstructive procedures, including development of a renowned method to reconstruct the noses of individuals who suffered a traumatic injury. However, these successes did not markedly sway the overall organizational, scientific, and technologic developments of Western surgery that became the global norm. Surgery in China did not flourish due to Confucian tenets that concerned the sacredness of the human body along with restrictions against human anatomical studies. As late as the nineteenth century, human anatomy was still being taught by means of diagrams and artificial models rather than cadaver dissection. Japanese aversion toward the performance of surgical operations surpassed that of the Chinese. Once the religious stigmas attached to caring for the bleeding, the wounded, and the dying were overcome, Japanese surgeons were able to develop their craft. However, as in China, this progress occurred much later than in Western civilization.

  Condensing surgery’s story into a single, accessible volume is a challenge. Surgeons are detail oriented. You want your surgeon to be somewhat obsessive-compulsive. Orderliness and perfectionism are necessary because a steadfast attention to specifics can spell the difference between surgical success and surgical failure. Similarly, Empire of the Scalpel must pay close attention to a myriad of facts and, at the same time, be reasonably concise. In no way is this book the complete story of surgery; it is not a tell-all account of every well-known knife bearer of the past. A balancing act is called for.

  On one hand, the history of surgery is a series of awe-inspiring discrete triumphs. These include the unanticipated discovery of anesthesia in 1846 and, a century later, the Nobel Prize–winning, seemingly impossible feat of transplanting a kidney. Many of the singular breakthroughs are worthy of their own books, tales of men and women standing on an intellectual and technologic precipice as they conquer the surgical unknown. On the other hand, surgical advances often mo
ve in slow, almost imperceptible steps. The rise of the profession as a recognized specialty and the growth of organized surgery with its accompanying societal concerns of credentialing, education, and licensing took centuries to achieve. Neither of the accounts—the distinct or the gradual, the scientific or the socioeconomic—is complete without the other. They must be grafted together to convey the complexity, genius, and vibrancy of surgery’s development.

  Similarly, two overarching and linked themes, both reflective of basic human nature, are also central to surgery’s story. The first is antipathy toward a contemporary and/or rival, noted by the conflicts between the public and physicians, physicians and surgeons, and surgeons and surgeons (these types of disagreements date back to Antiquity and continue through the present). The second theme is an inclination to dismiss scientific or technical advances that contradict deeply held, often-erroneous views. Whether caused by economic concerns, ego gratification, social disparities, or other competing interests, these disputes and jealousies impacted the evolution of surgery in ways that cannot be disregarded.

  An additional admonition concerns the fact that the history of surgery has been largely dominated by white men. There is no disputing that, as far back as the Middle Ages, there were women who had a role in providing surgical services for their households or the poor. However, with the growth of the male-dominated Catholic Church in the sixteenth century and their care of the sick, females were forced aside and discouraged from performing any form of surgical therapy. Even with the beginnings of modern surgical training at the start of the twentieth century, the road for female surgeons remained difficult. Nevertheless, the opening of the Woman’s Medical College of Pennsylvania and the London School of Medicine for Women provided fresh opportunities in surgery. Yet, despite the increasing presence of female surgeons, few held positions of authority or leadership or exerted any semblance of control over the governance of surgery until the mid-1970s.

  Empire of the Scalpel is meant to be a comprehensive and revelatory history, one that is educational and entertaining and showcases the development of the profession within the rich tapestry of human life in which it evolved. As a popular narration, it is intended for a wide audience, laypersons and physicians alike—since surgical terminology can act as a barrier to the uninformed, this book is as free of the surgeon’s tongue as possible. Its words inform readers as to what scalpel wielders have accomplished, individually and collectively, the impact of their thoughts and actions, and why my profession should be regarded as a scientific marvel and societal juggernaut.

  Plainly stated, Empire of the Scalpel aims to change the way people think about surgery by helping them understand its character while exposing its conduct. I say this with the firm conviction that surgery has played a major and, certainly in the Western world, expanding role in human society, one that will, figuratively and literally, shape future generations. For this reason, the many interfaces between surgery and other spheres of human endeavor need to be examined to reveal how cultural and socioeconomic conditions have influenced surgery and vice versa; events in literature and theater, music and the visual arts, sports and recreation, and philosophy and religion are important adjuncts to this narrative. The interweaving of such nonsurgical historical facts with the main body of information imparts a greater sense of timeliness to the writing.

  To the extent that my own experiences and perspectives shape the narrative, I offer the following. I have devoted my adult life to Medicine,I as both a surgeon and a historian. I believe that my understanding of the subject (the combination of a surgeon’s skills and a historian’s scholarship) has given me unique insights to tell surgery’s story. When trained historians deal with this material, albeit skillfully, their perspective is necessarily limited by their “outsider status” and not having toiled in surgery’s vineyards. Conversely, I remain in awe of the expertise of scholars who have studied the many epochs and subjects covered in this book. Their historical insights and writings aided me in synthesizing surgery’s tale since I freely admit to not having in-depth knowledge of more than a few eras and themes.

  Lastly, I confess to being an inveterate storyteller; more precisely, a “surgical raconteur.” History provides an explanation for past behaviors and my approach is to let those who have died speak for themselves—the living will not be found in these pages. I am neither a critic, moralist, philosopher, nor soothsayer. Similar to one of my boyhood heroes, Sergeant Joe Friday on the 1950s and 1960s TV series Dragnet and his signature businesslike catchphrase, I am interested in “just the facts.” I am a sleuth, a surgical private eye. I enjoy relating anecdotes about my profession and the individuals who have populated it, their whys and wherefores, their sense of self, and, most important, their decencies and deficiencies.

  Empire of the Scalpel is the result of five decades of learning and listening and attempts to show how every surgeon, knowingly or unknowingly, reflects a testimony to their profession’s past. In addition, I hope this book is meaningful and relevant to the lay reader, even more so to those about to confront a surgeon and his or her scalpel. Most importantly, my research and writing has furthered my optimism about the future of surgery and the enduring bond between surgeons and patients. The essential quality of this relationship is an abiding interest in mankind, and all that it entails in caring for another human being.

  I. Throughout Empire of the Scalpel, I use “Medicine” to signify the totality of the profession and “medicine” to indicate internal medicine as differentiated from neurology, obstetrics, pediatrics, radiology, surgery, et cetera.

  PRELUDE

  As no man can say who it was that first invented the use of clothes and houses against the inclemency of the weather, so also can no investigator point out the origin of Medicine—mysterious as the sources of the Nile.

  Thomas Sydenham, Medical Observations, 1676

  If there were no past, science would be a myth; the human mind a desert. Evil would preponderate over good, and darkness would overspread the face of the moral and scientific world.

  Samuel D. Gross, Louisville Review, 1856

  On the evening of July 4, 1975, John Quigley, a forty-three-year-old salesman from Southie, a working-class Irish community in Boston, was out on the town with his wife, Maureen. They were celebrating John’s recent promotion and had driven toward the city’s Esplanade, where they joined the crowd of 170,000 who watched Arthur Fiedler conduct the Boston Pops on America’s “birthday.” It was a balmy fun-filled evening of fireworks, Frisbees, music, picnics, and swaying bodies. Afterwards, the Quigleys were driving home when their car was hit by a drunk driver. Although their injuries seemed minor, the Quigleys were taken by ambulance to nearby Boston City Hospital.

  An urban emergency room on a Friday night, especially at the beginning of a holiday weekend, can be a gritty and hectic place. Doctors and nurses scramble about while the flashing lights, the bloodstained bandages, the stretchers askew, and the half-eaten pizzas lay bare the chaotic atmosphere. Life and death hang in the balance as the staff determine which individuals might die if care is not immediately given versus those who can wait with less threatening situations. For the Quigleys, this meant an hour or so of passing the time before they would be fully evaluated. In a bare, curtain-enclosed side cubicle, John quietly lay on a stretcher. Maureen sat beside him. Together, they listened to the sounds of Medicine at work.

  Around midnight, a doctor poked his head in and told the Quigleys he was there to examine them. “I’m fine,” Maureen said. “I feel okay.” Physicians are taught to observe, to listen, and to pay attention to words and actions. In Maureen’s case, the doctor agreed with his patient. Other than her being upset by the ordeal, Maureen’s examination was unremarkable.

  John’s situation was different. The ambulance driver mentioned that when John was first seen he was out of sorts—“groggy” was the description—and may have suffered a brief loss of consciousness. John’s version of the events was not the same.
“It wasn’t much of an accident,” he related, “just us getting bounced around. Nothing bad. Maureen was okay, but I hit my head and cut my scalp. Before I knew it, an ambulance was there.” On the ride to the hospital the attendant said that John regained his senses and joined in the conversation.

  John’s vital signs, his blood pressure, breathing, pulse, and temperature, were all normal. The doctor examined his ears, eyes, and neck, listened to his heart and lungs, felt his abdomen, and flexed his extremities. John’s hearing, seeing, smelling, tasting, and touching were unremarkable. The same was true of the neurological evaluation that tested his brain, the spinal cord, and the nerves that arose from these areas. The doctor assessed John’s mental status and found that he spoke clearly and knew where he was as well as the date and time. John’s balance was fine; he easily stood up and walked up and down the corridor without assistance. Nothing was out of the ordinary. “Other than a little headache, I’ll be okay,” John said.

  Everything about John appeared normal except for a nasty-looking 2.5-inch gash on the right side of his scalp. Dried blood matted John’s hair and the tissue surrounding the laceration was swollen and tender. The doctor parted the wound to see whether he could feel an underlying skull fracture. The bony surface was smooth with no evidence of breaks, roughness, or splintering. To complete the evaluation, the ER physician ordered routine blood tests, an electrocardiogram, a urinalysis, and X-rays of John’s chest and head—computerized axial tomography (CAT) or magnetic resonance imaging (MRI) scans were not yet available. As a matter of precaution, John was admitted to the hospital’s neurology service for an overnight observational stay. While he waited to be transferred to a room, the neurosurgical service was asked to send someone to repair his scalp.