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

Ira Rutkow’s “Empire of the Scalpel” is by turns fascinating and ghastly.

EMPIRE OF THE SCALPEL: The History of Surgery, by Ira Rutkow

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 Pare 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-Francois Felix. 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 Felix’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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