"Ira Rutkow’s “Empire of the Scalpel”
is by turns fascinating and ghastly.
I find it difficult to imagine being
a surgeon in the conditions in which my predecessors had to work — gloveless,
covered in blood, with patients physically tied down and screaming in pain, not
to mention a postoperative mortality of almost 50 percent. And yet in “Empire
of the Scalpel,” Ira Rutkow quotes the 18th-century English surgeon William
Cheselden, who wrote of himself:
“No one ever endured more anxiety
and sickness before an operation, yet from the time that I began to operate,
all uneasiness ceased … [I was] never ruffled or disconcerted and [my hand] …
never trembled during an operation.”
I can identify with this sentiment
across the centuries, despite all the changes since Cheselden’s time. It
expresses exactly what I and other surgeons — or “scalpel wielders,” as Rutkow
calls us in his somewhat florid style — experience when operating. We have to
make a strange transition as we enter the operating room — from caring about
patients as fellow human beings to seeing them as objects, albeit living
objects with anxious relatives waiting outside. It is a difficult balancing act
between empathy and detachment, and the intense self-belief that surgery
involves can lead us to become very fixed in our opinions. We feel threatened
by any suggestion that there are better ways of doing things than the ways that
have served us well for many years.
Perhaps this explains why progress
in surgery has sometimes been erratic. Rutkow quotes surgeons in the mid-19th
century who argued against anesthesia on the outrageous grounds that pain was
necessary for healing. But many others adopted anesthesia very quickly,
including Robert Liston, a leading surgeon in London. In order to minimize the
suffering of his un-anesthetized patients, he had perfected the art of
amputating a leg in minutes. It is said — although this might be apocryphal —
that he had once accidentally severed his assistant’s fingers along with the
patient’s leg, both the assistant and the patient dying afterward from
postoperative sepsis (as well as a spectator who died from shock).
As Rutkow observes at the beginning
of his book, it is a “reasonable certainty that no one in the industrialized
world will escape having an illness for which effective treatment requires a
surgical operation.” I myself would probably be blind in at least one eye (from
retinal detachments), walk with a limp (from a complex ankle fracture) and
possibly be dead (from urosepsis) if not for the help of my surgical
colleagues.
Yet until 150 years ago, as Rutkow explains, surgery was
limited to the external parts of the human body, such as amputations for
trauma. The only internal surgery was the occasional foray into the bladder for
bladder stones and trepanning of the skull.
Indeed, skulls have been found all
over the planet, dating back thousands of years, with deliberately made holes
that had healed over with new bone, meaning that the patient survived the
procedure. But it is anybody’s guess as to whether the earliest trepanning was
done to release a traumatic blood clot from inside the skull, or to release an evil
spirit responsible for epilepsy or some similar, misunderstood disorder.
As Rutkow writes, the emergence of surgery from its barbaric
past rested on four pillars — the understanding of anatomy, the control of
bleeding, anesthesia and antisepsis.
The story, however, is not one of
steady, rational progress. The surgeon Galen, working in the second century
A.D., wrote extensively on anatomy; some of his experience came from treating
wounded gladiators but much of it was based on dissecting animals, and was simply
wrong with respect to human anatomy. His writings were passed down by the
Andalusian physician Abu al-Qasim al-Zahrawi, among others, to become dogma in
the Middle Ages.
The first breakthrough came more than a thousand years later
with the Renaissance, and the relaxation of taboos about dissecting the dead.
The Flemish physician Andreas Vesalius, the greatest of the early anatomists,
carried out his dissections on the corpses of executed criminals, often removed
surreptitiously from the gallows at night. Surgeons such as Ambroise Paré in
France, working on battlefield injuries, established ways of controlling
bleeding — tying off blood vessels, for instance, rather than using red-hot
irons and plunging the stump of an amputated limb into boiling oil.
But the greatest change came in the mid-19th century, with
the use of ether as an anesthetic, and Joseph Lister’s work on antisepsis. This
was based on Louis Pasteur’s work showing that infection was caused by living
microbes, and not (as had been previously thought) by smells and foul air.
And yet, as the medical historian
David Wootton has pointed out in his book “Bad Medicine,” the Swiss physician
Paracelsus was using ether to anesthetize chickens in the 16th century and
Antonie van Leeuwenhoek had discovered bacteria, using a microscope of his own
making (although of rather an awkward design), in the 17th century.
The German Hungarian obstetrician Ignaz Semmelweis showed
that hand-washing made a massive difference to the incidence of fatal postnatal
infections in women. This was 20 years before Lister’s and Pasteur’s work, yet
Semmelweis was dismissed by his colleagues and he died in obscurity.
The history of surgery, especially until the modern era, is
as much about doctors’ innate conservatism as it is about innovation.
It is, however, ultimately a history
of triumphant progress — although not without dark episodes, such as the abuse
of psychosurgery in the middle of the 20th century.
Rutkow discusses at great length the
evolution of surgery as a separate specialty, and the rivalry between surgeons
and other medical practitioners. But even here, in the rather tedious detail,
there are human stories.
In 17th-century France, for instance, the granting of a
royal charter to surgeons was accelerated by the successful operation on Louis
XIV’s anal fistula by Charles-François Félix. Surgeons pride themselves on
operating on celebrities — it marks their successful ascent of the professional
ladder. But it comes at the price of considerable anxiety. I greatly admire
Félix’s bravery, but he did spend six months practicing on less exalted
patients before he felt able to tackle the royal anus.
Rutkow is a surgeon, but freely
admits he has always been more drawn to the history of surgery than surgery
itself, and he confines his own surgical practice to relatively simple cases.
Readers of the book looking for the blood and drama that is such a vital part
of surgery will not find much of it. Instead, they will learn that the history
of modern surgery is the history of the rise of the modern world, with all that
has involved — not just science and technology but also politics, architecture,
demographics and institutions. Rutkow includes some important chapters on the
past prevalence of antisemitism in American medicine, and on the difficulties
faced by members of other ethnic minorities and women in gaining entrance to
the profession (a problem not confined to the United States). This has changed
profoundly in recent years, but there is still progress to be made. It shows how
the history of surgery is about so much more than just science and new surgical
procedures. All human life is there.
Henry Marsh is a neurosurgeon and
the author of “Do No Harm” and “Admissions.”
EMPIRE OF THE SCALPEL: The History
of Surgery, by Ira Rutkow | Scribner | 381 pages
| $29.99"
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