Empire of the Scalpel

The History of Surgery

Ira Rutkow

• Publisher: Scribner
• Year: 2022
• ISBN:
  9781501163760
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

From an eminent surgeon and historian comes the "by turns fascinating and ghastly" (The New York Times Book Review, Editors' Choice) story of surgery's development—from the Stone Age to the present day—blending meticulous medical research with vivid storytelling. There are not many life events that can be as simultaneously frightening and hopeful as a surgical operation. In America, tens-of-millions of major surgical procedures are performed annually, yet few of us consider the magnitude of these figures because we have such inherent confidence in surgeons. And, despite passionate debates about health care and the media's endless fascination with surgery, most of us have no idea how the first surgeons came to be because the story of surgery has never been fully told. Now, Empire of the Scalpel elegantly reveals surgery's fascinating evolution from its early roots in ancient Egypt to its refinement in Europe and rise to scientific dominance in the United States.From the 16th-century saga of Andreas Vesalius and his crusade to accurately describe human anatomy while appeasing the conservative clergy who clamored for his burning at the stake, to the hard-to-believe story of late-19th century surgeons' apathy to Joseph Lister's innovation of antisepsis and how this indifference led to thousands of unnecessary surgical deaths, Empire of the Scalpel is both a global history and a uniquely American tale. You'll discover how in the 20th century the US achieved surgical leadership, heralded by Harvard's Joseph Murray and his Nobel Prize–winning, seemingly impossible feat of transplanting a kidney, which ushered in a new era of transplants that continues to make procedures once thought insurmountable into achievable successes.Today, the list of possible operations is almost infinite—from knee and hip replacement to heart bypass and transplants to fat reduction and rhinoplasty—and "Rutkow has a raconteur's touch" ( San Francisco Chronicle ) as he draws on his five-decade career to show us how we got here. Comprehensive, authoritative, and captivating, Empire of the Scalpel is "a fascinating, well-rendered story of how the once-impossible became a daily reality" ( Kirkus Reviews, starred review).

PART I BEGINNINGS

1. GENESIS

Those about to study medicine and the younger physicians should light their torches at the fires of the ancients.

Karl von Rokitansky, Handbuch der Pathologischen Anatomie, AD 1846

Then give place to the physician, for the Lord hath created him: let him not go from thee, for thou hast need of him. There is a time when in their hands there is good success.

Ecclesiasticus 38:12

The history of surgery begins not with Mesopotamian cuneiform script or Egyptian hieroglyphic writing, nor with Greek and Latin words, but with holes, holes in ancient human skulls that tell extraordinary tales of pain and suffering and healing and recovery. The skulls are found throughout the globe, many dating back ten thousand years, to a time when Stone Age humans roamed the earth. The startling thing is that these holes were man-made. Of the numerous achievements that make up surgery’s story, perhaps none is more astonishing than the realization that cavemen practiced neurosurgery, successfully.

In 1865, a physician with an interest in medical archeology was exploring a megalithic tomb in the Massif Central region of southern France, when he made a fascinating discovery. There, in the mountainous countryside, lying half-exposed, alongside one of the grave’s vertical stone supports, was a human skull that was missing a large section of its cranium. Finding ancient bones among the ruins was not unusual, but something about this noggin seemed off. Despite the hole in his head, there was no evidence that this individual had sustained a violent death-wielding blow—no jagged splinters of bone protruding from a viciously punched-out hole were anywhere to be seen. Instead, deep and precise grooves, and other curvilinear indentations, suggested that the missing piece had been somehow purposely detached, as if removed by hand. The mystery deepened when the doctor noticed that a segment of the hole’s edge was smoothed over with a polished sheen. He had never come across anything like this and speculated that the skull was used as a drinking cup, perhaps in religious or spiritual ceremonies. Over time, suggested the physician, the bone edges had been worn smooth by the lips and teeth of the multitude who drank from it.

The doctor showed the skull to several of his colleagues who had more expertise in bone pathology. One pointed out that the shiny area was actually new bone growth, the result of an effort by the skull to heal and seal itself. More importantly, explained the specialist, bones that make up the skull develop slowly and cease growing once an individual dies. This was no Neolithic chalice meant to soothe those who imbibed an ancient elixir. Instead, whoever this Stone Age human was, he had survived for several years following the intentional removal of a large portion of his skull.

The finding was met with amazement and doubt. At a time when surgeons were first beginning to understand the complexities and dangers of modern neurosurgery, it did not seem possible that a Stone Age caveman could have undergone a successful neurosurgical operation. Yet a growing number of similar prehistoric trephined skulls, found in other parts of the world, soon corroborated this theory.

The medical communities were abuzz with the news. The most renowned physicians and surgeons of the day voiced their opinions as to what the skull revealed. How did Stone Age humans, thousands of years prior to the discovery of anesthesia and antisepsis, successfully perform such complicated surgery? A number of methods were suggested, all of which, undoubtedly, required the most stoic of patients and the most brazen of “surgeons.” First, the patient had to have his or her hair and skin scraped away before the Stone Age equivalent of a modern knife bearer started to bore into the skull. The simplest and crudest technique would have been to scratch a hole in the cranium, using a sharpened rock or shell. Or perhaps the surgeon had furrowed or scored the skull in a tic-tac-toe intersecting pattern with a sharpened flint stone, thus freeing the segment of center bone. If these practices were not harrowing and painful enough, a crude hammer and chisel could have been used to fashion a series of small holes that were then connected by grooves, allowing the loosened middle section to be lifted out.

One thing is certain: despite the crudeness of the procedure and lack of pain relief and cleanliness, having part of one’s skull cut away, thousands of years ago, did not necessarily condemn an individual to death. The critical question is why: Why would a prehistoric man have a hole created in his head and what motives guided the hand of a Neolithic surgeon? Was there a therapeutic basis or religious and spiritual reasons? Was the operation meant to benefit the patient in this life or the one that followed? And who was responsible for performing such surgical procedures? What was his or her psychological makeup?

Much that is written about the ancient skulls is pure conjecture. There are no eyewitness accounts of a prehistoric trephination. Despite all the suppositions, one thing is fairly certain: religion and spirituality went hand in hand with actual therapy in prehistoric times. After all, the idea that evil life forces can exist in one’s head is an ancient superstition. In primitive times, a hole created in the skull could have been perceived as an escape route for magical and sinister spirits. The weak and infirm might have submitted to trephination as a way to relieve disabilities thought to reside in the head; in present-day terms, treatment for convulsions, epileptic fits, mental illness, migraines, or other neurological maladies.

Trephination for solely magical or spiritual reasons is certainly antiscientific. However, it appears that, distinct from those whose craniums were opened for mystical purposes, some seriously injured individuals were truly aided by the Stone Age surgeon’s use of trephination. Numerous ancient skulls show evidence of burr holes created as treatment for traumatic head injuries. Coma, the major consequence of an acutely fractured skull, could have been reversed by removal of pushed-in bone fragments and wounded brain tissue. For the Neolithic surgeon, to bring the near dead back to life would have been a commanding show of competence and power.

Everything has a beginning, a birth from which its story emerges. For surgery, prehistoric surgeons and their trephinations represent the naissance, the Big Bang of its evolutionary tree. And, much like our ancestors’ DNA determines who we are as human beings, vestiges of the caveman’s surgical essence—his authority, his derring-do, his psyche, and his skills—course through every modern surgeon’s body.

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In room 3 of the Richelieu wing, on the ground floor of the Louvre Museum in Paris, stands one of the most revered objects in all of surgery: a seven-and-a-half-foot-tall black basalt stele, shaped like a huge index finger, on which are engraved 282 laws promulgated by the legendary Hammurabi, ruler of the Amorite dynasty of ancient Babylon. With its inscribed and sculptured surface, this stone slab, dating back thirty-eight hundred years, is not only a work of art and history but also the most complete legal compendium of Antiquity, and has been called “one of the most important artifacts in the history of humans.”¹ To put its age in perspective, the pillar was carved hundreds of years before Moses and the laws of the Bible, twelve centuries before the birth of Buddha and Confucius, and two and a half millennia prior to when Muhammad founded Islam.

Hammurabi was a fearsome warrior king who united the many small kingdoms that made up the Fertile Crescent of Mesopotamia, the lush region in the Middle East bounded by the Tigris and Euphrates rivers. Hammurabi’s code formalized laws that regulated individuals and their society and recognized the concept of obligations and privileges such that the strong should not oppress the weak and wrongs must be made right. The decrees also included a code of behavior that regulated the practice of Medicine—mankind’s oldest written guidelines for any profession.

In 1901, during an archeological dig at the site of ancient Susa in present-day Iran’s Khuzestan Province, this relic was found, broken in several pieces. Cleaned and reassembled, the stone was soon displayed in the Louvre. This final welcoming journey was far different from the column’s troubled past. After Hammurabi had his legal code inscribed in Akkadian cuneiform—Akkadian was the daily language of Babylon—the structure was placed in the center of one of the city’s public squares. Like an incessant wagging digit, the stele’s admonishments were not easily overlooked or dismissed. For over five hundred years the pillar survived in Babylon, but in the twelfth century BC it was plundered and taken to Susa, where it was defaced and flaunted as a trophy of war. Thirty-one centuries later the stone relic was unearthed and brought to Paris.

Like their Neolithic ancestors, Babylonian medical treatments were “unscientific,” based on demons, gods, omens, and sorcery. This belief system presented the surgeon, or at least those individuals who wanted to practice the craft of surgery, with a major dilemma. The priestly class, which included physicians, appealed to various gods to cure the ill through the casting of magical rites and supernatural spells. The opposite was true of the surgeon who looked mostly to his crude instruments to heal. Once they relied on man-made probes, saws, and scalpels, the surgeon was considered to have lessened his dependence on soothsaying and the gods.

In the eyes of Babylonian society, the surgeon was tainted as a healer, not fit to be included in the priestly caste, and relegated to a much lower social standing. One result of this downgrading was the notion of caveat chirurgicus, “let the surgeon beware.” As written in Hammurabi’s code—of the stele’s 282 decrees, numbers 215–223 relate to surgery—to risk failure meant the knife bearer would suffer physical and financial consequences:

218. If a surgeon has treated a gentleman for a severe wound with a bronze lancet and has caused the gentleman to die, or has opened an abscess of the eye for a gentleman with the bronze lancet and has caused the loss of the gentleman’s eye, one shall cut off his hands.

219. If a surgeon has treated a severe wound of a slave or a poor man with a bronze lancet and has caused his death, he shall render slave for slave.²

Notwithstanding Hammurabi’s regulations, little is known of Babylonian surgical techniques. What constituted a “severe wound” or an “abscess of the eye” is open to wide speculation. Whether other types of surgical operations were performed also remains a matter of guesswork. Surgeons in Babylon might not have been considered the equals of priest/physicians, but these knife bearers and their procedures were not easily dispensed with. Then again, the severity of punishment meted out for an unsuccessful surgical case must have made the individuals who practiced surgery circumspect in their choice of operations.

Priest/physicians regarded surgery as strictly a manual trade, rather than a learned profession; a less cultured task and something unbecoming. The lesser respect that Babylonians accorded surgeons, the notion that they were baser individuals who worked with their hands, in contrast to pious and thoughtful physicians, left an indelible mark on Medicine for millennia to come. Why is easily explained, and the consequences far-reaching. It was a prejudicial attitude that pitted the brash surgeon against the discreet physician, the doer versus the thinker, the uneducated versus the educated, and would underscore surgery’s story for the next four thousand years.

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In 1858, Edwin Smith, an American expatriate and antiquities dealer, settled in Luxor, site of the ancient Egyptian city of Thebes. He was an interesting blend of Egyptologist and entrepreneur who combed the stalls of the area’s antiques sellers looking for the next great find. Four years later, he bought a tattered fifteen-foot-long papyrus covered in black and red ink with hieratic, a form of cursive Egyptian hieroglyphs. Smith was told that the roll had been lying in a noble’s tomb for over three thousand years and was newly discovered. More likely, it had been plundered by local thieves who made their livelihood ransacking pharaoh-era grave sites. Smith knew enough hieratic to recognize the papyrus as a medical treatise, but despite his attempts to translate the text, nothing came of it.

A half century later, following Smith’s death, his family presented the document to the New York Historical Society, where it would lay forgotten. That is, until 1930, when James Breasted, the widely respected director of the Oriental Institute of the University of Chicago, published a translation of the entire papyrus (in 1948, the scroll was donated to the New York Academy of Medicine, where it remains today). He found the crumbled manuscript to be more than just a simple treatise on health care. In fact, Breasted proclaimed the now-named Edwin Smith Papyrus to be the world’s “earliest known scientific [surgical] document,” one that illustrated how, for the first time, “the human mind peered into the mysteries of the human body, and recognized conditions and processes due to intelligible physical causes.”³

When Breasted translated the Smith text he found that the scroll, although written by a scribe around 1600 BC, appeared to be a copy of a manuscript authored several centuries earlier. The most fascinating aspect of the Smith Papyrus is what it does not contain. There are no farfetched charms and jumbles of prayers. Instead, the facts are presented in a forthright and practical manner. Just as intriguing as the want of the supernatural was Breasted’s “conjecture”⁴ that a surgical treatise of such obvious importance may have been composed by or directly reflected the views of the renowned Imhotep.^I And it is through the clarity of an ancient surgeon’s thinking that modern surgery’s story takes shape.

In a world reliant on the occult, Imhotep, or whoever the author was, wrote about the brain and skull, ears and face, neck and throat, arms and shoulders, and ribs and spine in an impassive and impersonal voice. What makes the Smith Papyrus truly unique is that it reads like a modern textbook, an all-in-one surgical encyclopedia of dos and don’ts. Babylonia and Hammurabi provided rules that governed surgical engagement, but Egypt and the pharaohs supplied surgeons with day-to-day working instructions.

The primitive anatomical observations in the Smith Papyrus are apt and colorful. For the first time, the word “brain” appears. The undulating grooves on the surface of the brain (known as the sulci) are likened to “those ripples that happen in copper through smelting.” In a fractured skull, the pulsations of the exposed brain are said to “throb and flutter under your fingers like the weak spot of the crown of a boy before it becomes whole for him”⁵—thus demonstrating a clear understanding of the fontanelles, the gaps in a child’s skull that close by adulthood. But it is not only the anatomical observations that are remarkable for their surgical wisdom. Explanations of physiological conditions are revealed with surprising clarity. The strength of the pulse and its rate were used as an indicator of a patient’s well-being. Strokes are detailed along with an awareness of the relation between the location of a brain injury and the side of the body involved. A fracture of the neck with damage to the spinal cord is linked with paralysis, involuntary urination, as well as priapism, the persistent erection of the penis.

What the Smith Papyrus makes obvious is that surgery and magic did not share common ground. The individuals in ancient Egypt who treated surgical problems saw what needed to be fixed (e.g., superficial abscesses, broken bones, bulging tumors, grievous injuries, necrotic fingers and toes, rotten teeth, et cetera) and treated them in as objective a manner as the times permitted. This contrasted with those who practiced medicine, a field still mired in prescientific subjectivity. It is impossible to treat illnesses such as cancer, heart failure, gastrointestinal conditions, and respiratory disorders when there is no insight as to what causes them.

For thousands of years, the healing arts in Egypt were unaffected by foreign influence. The rational and the supernatural held sway, but around 500 BC Greek physicians came to Egypt. Under their influence, Egyptian Medicine was replaced by different ways of thinking, including the beginnings of evidence-based therapies as well as speculative mumbo jumbo. Before long, little was left of the ...

Table of contents

• Cover
• Title Page
• Dedication
• Author’s Note
• Prelude
• Part I: Beginnings
• Part II: Foundations
• Part III: Revolutions
• Part IV: Baptisms
• Part V: Triumphs
• Part VI: The Present and the Future
• Photographs
• Acknowledgments
• About the Author
• Notes
• Bibliography
• References
• Index
• Photo Credits
• Copyright