Review: “Empire of the Scalpel”, by Ira Rutkow

As Rutkow notes at the beginning of his book, there is “reasonable certainty that no one in the industrialized world will escape a disease for which effective treatment requires surgery.” I myself would probably be blind in at least one eye (from retinal detachment), limping (from a complex ankle fracture), and possibly dead (from urosepsis) if I didn’t have the help of my surgical colleagues. But 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 an occasional incursion 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 with new bone, meaning the patient survived the procedure. But it’s a mystery whether the earliest trepanning was done to release a traumatic blood clot from the skull, or to release an evil spirit responsible for epilepsy or a similar, misunderstood condition.

As Rutkow writes, the rise 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 AD, 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 regard to human anatomy. His writings were passed on by the Andalusian physician Abu al-Qasim al-Zahrawi, among others, and became dogma in the Middle Ages.

The first breakthrough came more than a thousand years later with the Renaissance and the loosening of taboos about dissecting the dead. The Flemish physician Andreas Vesalius, the greatest of the early anatomists, performed his dissections on the corpses of executed criminals, who were often surreptitiously removed from the gallows at night. Surgeons such as Ambroise Paré in France, working on battlefield injuries, developed ways to control bleeding — for example, by closing blood vessels instead of using red-hot irons and soaking the stump of an amputated limb in boiling oil. to dip.

But the biggest change came in the mid-1800s, 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 previously believed) by odors and foul air. And yet, as medical historian David Wootton has noted in his book “Bad Medicine,” in the 16th century the Swiss physician Paracelsus used ether to anesthetize chickens and Antonie van Leeuwenhoek had discovered bacteria using a microscope of his own making ( though of quite a clumsy design), in the 17th century. German-Hungarian obstetrician Ignaz Semmelweis showed that hand washing makes a huge difference in the incidence of fatal postnatal infections in women. This was 20 years before Lister and Pasteur’s work, but Semmelweis was fired by his colleagues and died in obscurity. The history of surgery, especially up to modern times, is about the innate conservatism of doctors as well as innovation.

However, it is ultimately a history of triumphant progress – though not without dark episodes, such as the abuse of psychosurgery in the mid-20th century.

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