Empire of the Scalpel: The History of Surgery

Empire of the Scalpel: The History of Surgery by Ira Rutkow, M.D., Ph.D., M.P.H., chronicles the fascinating evolution of surgery from its Stone Age infancy, when it began as a quasi-religious supernatural craft, to its contemporary eminence as a profession anchored in scientific expertise, technical skill, and ethical acumen. Dr. Rutkow, an accomplished surgeon who developed the PerFix (Bard, USA) mesh plug operation for groin hernia repair, is also an authority on the history of American surgery. The author of seven earlier books on surgical history, Dr. Rutkow is a gifted narrator and raconteur who entertains his readers while educating them.It is astonishing—and humbling—to realize that cavemen practiced neurosurgery, successfully. Indeed, trephination was the earliest operation known to mankind. Skulls have been discovered throughout the globe, many dating back 10,000 yr, to a time when cavemen chiseled holes into the skulls of other cavemen for otherworldly reasons, probably to release evil forces or spirits. However, numerous ancient skulls also display evidence of burr holes created to treat traumatic head injuries. Since these interventions occurred many millennia before the discoveries of anesthesia and antisepsis, these Stone Age humans must have been the most stoic of patients and the most intrepid of "surgeons"!The legendary Hammurabi (c. 1810 BC to c. 1750 BC), ruler of ancient Babylon, wrote 282 laws. A few of these decrees included a code of behavior that regulated the practice of medicine and surgery, constituting mankind's oldest guidelines for any profession. Like those of their Neolithic ancestors, Babylonian medical treatments were "unscientific," based on demons, gods, omens, and sorcery. Importantly, surgeons in Babylon were not considered the equals of priests or physicians, who themselves regarded surgery as exclusively a manual trade, rather than a learned profession. This prejudicial attitude pitted the purportedly uneducated, brash, and crude surgeon against the educated, discreet physician, leaving an indelible stain on the profession that would permeate and tarnish surgery's story for the next 4,000 yr. It was not until the twentieth century that this demeaning attitude was eradicated.Readers will enjoy learning about the contributions of the ancient Egyptians, Greeks, and Romans over many millennia. Notable luminaries include the renowned ancient Egyptian Imhotep (late twenty-seventh century BC), considered the earliest recognized physician or surgeon. Much later, Hippocrates and Galen emerged. In the third century BC, King Ptolemy I (c. 367 BC to c. 282 BC), a classicist and humanist, decreed that all writings on medicine, going back to the Hippocratic teachings of the fifth century BC, be assembled under a single title, the Corpus Hippocratum. This collection of more than 70 works marked the beginning of our enduring medical and surgical literature and exerted a profound influence on Western thought, becoming the most widely quoted surgical literature for the next five centuries.Although what little we know about the life of Hippocrates (c. 460 BC to c. 370 BC) is unsubstantiated, his influence was transformative owing to his conviction that health and illness could be explained through an understanding of nature and imbalance of the alleged four humors. Thus, the Corpus offered a biologic approach to disease, apart from the manacles of religion and superstition.After the fall of Egypt to Julius Caesar, the Roman Empire became the progenitor of Western civilization, and the disparaging attitude toward healers who worked with their hands continued. Galen of Pergamon (c. 129 AD to c. 216 AD) was an insufferably contentious and egotistical physician who lived in an era when Roman law forbade human dissection. Hence, he resorted to applying (often erroneously) animal findings to humans. Nonetheless, the breadth and volume of his writings are astounding. His work influenced the development of anatomy, medicine, pathology, pharmacology, physiology, and surgery. He classified every illness as excesses of Hippocrates's four bodily fluids and championed bloodletting and fluid evacuation to restore humoral equilibrium. Two hundred years after Galen's death, the Western Roman Empire fell and the Middle Ages enshrouded Europe, stagnating surgical progress for more than a millennium. Galen's influence continued, to varying degrees. during the next 15 centuries.Dr. Rutkow next guides the reader through successive centuries when extraordinary advances in anatomy, physiology, pharmacology, and other fields led to an understanding of the human circulation, as well as the importance of hemostasis and prevention of infection. Suffice it to say that the "discovery" of anesthesia was, and continues to be, a linchpin that is foundational to advances in surgery. Innovative developments in immunology enabled organ transplantation, as well as provided additional tools with which to treat cancer. Joint replacements and minimally invasive surgery performed on an ambulatory basis are now virtually routine. Indeed, the list of operations available today is exhaustive, and the respected status of surgeons in the contemporary milieu is undisputed.The author engagingly highlights how the late nineteenth and early twentieth centuries constituted an inflection point when the synergy between science and technology enabled surgeons to explore areas of the body that were previously inaccessible. Equipped with a preoperative diagnosis established with physicist Wilhelm Röntgen's (1845 to 1923) discovery of x-rays in 1895 and, by 1900, the use of electric lighting in operating rooms that greatly enhanced anatomic visualization, surgery ascended to lofty status in the house of medicine. Indeed, from 1890 through 1920, 18 of the 30 men who served as president of the American Medical Association (Chicago, Illinois) were surgeons. No longer exclusively dexterous technicians, surgeons became progressive scientists.The brilliant George Washington Crile (1864 to 1943), founder of the Cleveland Clinic (Cleveland, Ohio) and the American College of Surgeons (Chicago, Illinois), devoted his career to investigating the nature of surgical shock. Considered a pioneer of science-based surgery, Dr. Crile linked the research laboratory and the operating amphitheater. His intrepid step to administer blood transfusions to humans on the battlefield in World War I in an attempt to maintain normotension was the first large-scale use of blood to treat shock. Clearly, World War I catapulted surgery and the treatment of shock forward. Moreover, as a result of the medical and surgical triumphs of World War I, American surgery ascended to a position of international leadership. The war also called attention to the importance of specialty practice to surgical care, emphasizing the vital role that orthopedic surgery, neurosurgery, and plastic surgery have in trauma care. In 1927, the American Medical Association formally declared its support for specialization. The American Board of Surgery (Philadelphia, Pennsylvania), established in 1937, was a major step in upgrading surgical education and training. Currently, the American Board of Medical Specialties (Chicago, Illinois) sets guidelines for board certification in its 24 constituent specialty boards.Just as World War I profoundly changed surgical care, the impact of World War II on surgery was equally transformative and enduring. Charles R. Drew, M.D. (1904 to 1950), an American surgeon and researcher, developed improved techniques for blood storage and established large-scale blood banks early in World War II. Notably, Dr. Drew, an African American, was the first Black surgeon to be offered a fellowship to complete his surgical training at Columbia University and the Presbyterian Hospital in New York, New York. The results of his research on banked blood at Columbia enabled Drew to earn a second doctoral degree, a doctorate of science in medicine (M.D.Sc.). Recognized as one of the nation's most knowledgeable authorities on blood banking and blood preservation, Drew was placed in control of the Blood for Britain project, where he introduced stricter manufacturing criteria, including a 2-week-long bacterial culture quarantine, random checks to monitor for continued sterility, and routine tests for syphilis. He subsequently was appointed administrator of the American Red Cross (Washington, D.C.) Blood Bank and assistant manager of blood procurement for the federally sponsored National Research Council (Washington, D.C.). Despite his success, Drew resigned after 2 months with the Red Cross, and it has been conjectured that an element of institutional racism may have prompted his resignation. Conjecture aside, it is known that the Red Cross, under pressure from the military, blatantly moved to exclude Black donors; this exclusion continued until 1950. After his resignation from the Red Cross, Dr. Drew became chairman of the department of surgery at Howard University Medical School and chief surgeon at Freedman's Hospital in Washington, D.C. The first African American surgeon selected as an examiner on the American Board of Surgery, Drew waged what has been described as a "rather bitter battle" with the American College of Surgeons and the American Medical Association over their unwritten policies barring Black surgeons from membership. Believing that bigotry, including anti-Semitism, permeated the leadership of the American College of Surgeons, Drew never became a fellow of the American College of Surgeons or a member of the American Medical Association. Not until 1968 did the American Medical Association amend its founding documents to explicitly forbid racial discrimination.Dr. Rutkow excels in revealing how cultural and socioeconomic conditions influenced surgery, and vice versa. In addition to the examples cited above, the reader is reminded that the New York Doctors Riot of 1788, fueled by anger about human dissection, involved crowds insisting that surgeons be hanged. This event, which Alexander Hamilton and John Jay attempted to quell, was redolent of the sixteenth century saga of Flemish anatomist Andreas Vesalius (1514 to 1564) in his determination to accurately depict human anatomy while trying to pacify conservative clergy who demanded that he be burned at the stake for studying corpses. Further, Dr. Rutkow adroitly underscores how two linked themes, both reflective of basic human nature, are integral to surgery's complex and thorny story. He reminds us that personal conflicts and rivalries, as happened among physicians, "educated" surgeons, and barber-surgeons, can impede progress. In addition, he emphasizes the almost reflexive tendency to dismiss scientific or technical advances that contradict ingrained, deeply held, and often erroneous views affected the evolution of surgery in important and detrimental ways. This was evident when surgeons, particularly in the United States and England, were slow to adopt the momentous discoveries of the French chemist and microbiologist Louis Pasteur (1822 to 1895) and the English surgeon Joseph Lister (1827 to 1912). As a result of Lister's indefatigable evangelistic promulgation, however, Listerian technique ultimately was widely adopted by the late nineteenth century, rendering it more likely that surgical patients would leave a hospital alive rather than dead.Empire of the Scalpel: The History of Surgery successfully condenses surgery's intriguing story into a single accessible volume. The tome includes carefully researched material, historical photographs and illustrations, extensive notes, a comprehensive bibliography and references, and a detailed index. (My one quibble is that a larger font would be more user-friendly for readers with presbyopia.) Relatively jargon-free, the book is appropriate for a wide audience including nonphysicians with an interest in history, medical students, postgraduate trainees, and attending physicians. One need not be a surgeon to appreciate the author's view that the individual and collective accomplishments of surgeons have been so impactful that his profession "should be regarded as a scientific marvel and societal juggernaut" (author's note). Finally, the author is reverential when he alludes to the enduring bond between surgeons and their patients. As Emily Dickinson (1830 to 1856) admonished,1 and Dr. Rutkow acknowledges:Surgeons must be very carefulWhen they take the knife!Underneath their fine incisionsStirs the Culprit,—Life!