Too Short for a Blog Post, Too Long for a Tweet 445

 

Here are a few excerpts from a book I recently read, "Empire of the Scalpel: The History of Surgery," by Ira Rutkow.

What is significant is the Hippocratic-based conviction that health and illness can be explained through an understanding of nature, apart from the shackles of religion and speculation. Pre-Hippocratic Greek healers regarded disease as being of supernatural origin, caused by angry gods or demonic possession. The underlying concepts in the Corpus opposed these beliefs. There is not a single mention of evil spirits in the entirety of the writings. Instead, what the Corpus offered was a biologic-based approach to disease. 

The followers of Hippocratic-style medicine believed that ill health was not a punishment brought by angry gods but the consequence of lifestyle choices, environmental issues, and other mitigating factors including mind-set and social class. They called for an analytic approach to healing, one independent of dogmatism and hearsay and, instead, based on inspection and observation.

The original Oath set Medicine’s moral high ground. At the same time, it sowed confusion, as its prohibitions against performing an abortion and assisting a suicide conflicted with the fact that some Hippocratics engaged in those activities. This ambivalence broadened when it came to the practice of surgery. The original Oath specifically forbade cutting: “I will not use the knife; not even on sufferers from stone, but will withdraw in favor of such men as are engaged in this work.”

The proscription established an unmistakable division between Hippocratic-influenced physicians and the class of individuals who performed surgical operations. Like that of their Babylonian predecessors, who consigned surgery to a lesser standing within Medicine, the Greeks left the craft and its work of the hand to itinerant craftsmen and roustabouts. This clear-cut separation is reflected in the etymological derivation of the words “surgery” and “medicine.” “Surgery” originated from the ancient Greek cheiros (hand) and ergon (work) and was then modified into the Latin chirurgia, which led to the French chirurgien and finally the English “surgerie.” In contrast, “medicine” is derived from the Latin medicus, meaning “a learned physician.”

Despite surgery’s imperfect knowledge and hard-nosed amputation/extirpation approach to disease, much like a broken clock that shows the correct time twice a day, surgeons occasionally cured, always with brutal self-confidence. What surgery needed for its further advancement was the elucidation of four basic but crucial clinical fundamentals: 1) an understanding of human anatomy; 2) the ability to control bleeding; 3) minimizing the risk of infection; and 4) reducing pain. Taken together, these four issues were more critical than advancing the mechanics involved in a surgical operation. Without these foundational elements, mere technical improvements in surgical technique were doomed to failure. And, like Alexandre Dumas’s musketeers’ creed, “All for one and one for all, united we stand, divided we fall,” the four fundamentals had to work in concert for an operation to succeed. None could stand alone.

For doctors-to-be, their first encounter with a cadaver (I had never seen a dead body before) can be a time of high anxiety. After all, to willfully take apart a human body is far from normal. From the psychological concerns that accompany the dismemberment of a human being to the distinctive odor of the chemicals that preserve cadavers—fruity and foul, somewhere between spoiled juice and stale urine (vestiges of the smell are imprisoned in my olfactory nerves)—medical students routinely name their cadavers as a way to deflect the strangeness of the situation. In Walter’s case, a nickname was not necessary. A paper tag that provided his identity and told of his medical woes had been inadvertently left dangling from one of his toes. Walter was his real name and his life must not have been pleasant. He suffered from alcoholism, cirrhosis, emphysema, and heart disease and had died eight months earlier in one of Missouri’s old soldiers’ homes.

Up to the time of Cheselden, lithotomy was a gruesome procedure and sufferers from bladder stones only submitted to it when the agony of their condition made life insufferable.II The ghastly operation involved a deep and lengthy incision in the perineum (the area between the anus and scrotum or vulva), the passage of a metal rod through the penis or vagina into the bladder to serve as a guide, and the extraction of the stone with a forceps inserted through the incision and pushed into the bladder. The whole process often took more than an hour, and without anesthesia, plus the always-looming problem of infection, it was a horrific ordeal. 

Through extensive research on the anatomy of the perineum and lower abdomen, Cheselden revised the placement of incisions for lithotomy such that blood vessels, intestines, and the prostate were less likely to be injured. Utilizing these modifications, Cheselden was able to complete the operation in one to two minutes, compared with one to two hours, and reduced the complication rate from over 50 percent to under 10 percent. Cheselden’s almost sleight-of-hand operative dexterity was astonishing and his ability to nimbly deliver a bladder stone within seconds of making an incision brought him worldwide acclaim.

Hunter’s belief that gonorrhea and syphilis were caused by the same agent or toxin was based on the long-established attitude that two diseases could not exist in an individual at the same time. Hunter knew that the clap and pox had different symptoms and thought gonorrhea represented the local expression of the disease while syphilis emerged once the illness spread throughout the body. Since the ever-curious Hunter could rarely resist the challenge of studying an ailment ripe for scrutiny, he determined to inoculate a person with gonorrhea and monitor him for the onset of syphilis. If, as Hunter postulated, symptoms of gonorrhea were followed by symptoms of syphilis, then the two diseases were one and the same. Contrariwise, if no suggestion of syphilis emerged, then they were separate entities. What he needed was an individual willing to be infected and a donor with severe enough gonorrhea to provide the sickening pus. 

Not surprisingly, the search to find a suitable volunteer proved fruitless. Hunter then made an expeditious and pragmatic decision: he would serve as the experimentee. Hence, in the spring of 1767, Hunter smeared a lancet with gonorrheal pus from one of his patients and inoculated himself by puncturing the foreskin and head of his penis. Within days, a gonorrhea-like discharge oozed from Hunter’s urethra. Two weeks later, a syphilitic chancre appeared on his prepuce. Hunter was ecstatic. As far as he was concerned, the experiment was decisive; the two illnesses were one, merely appearing in different states in the human body. “[The research] proves that matter from a gonorrhea will produce chancres,” wrote Hunter, “and opens fields for further conjectures.”8 There was one major flaw—Hunter’s findings were erroneous. He did not know that the anonymous penis he used as a source of gonorrhea also harbored syphilis. Hunter had unintentionally infected himself with both diseases.

Most professions have a watershed moment, a time after which things will never be the same. For surgery, its turning point began in 1846 with the discovery of anesthesia and ended in 1867 with the development of antisepsis. The availability of anesthesia and antisepsis to control pain and infection—the last of four crucial fundamentals essential for the performance of effective and safe surgical operations (the first an understanding of anatomy and the second the capability of controlling bleeding)—dramatically transformed the experience of patients. Yet the introduction of these two epochal innovations was contentious, marked by profound debates concerning life, death, suffering, and the very nature of human existence.