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

As Rutkow observes at the beginning of his book, it is a “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 (due to retinal detachments), walk with a limp (due to a complex ankle fracture) and possibly be dead (due to urosepsis) without the help of my fellow surgeons. Yet until 150 years ago, as Rutkow explains, surgery was limited to the external parts of the human body, such as trauma amputations. The only internal surgery was the occasional incursion into the bladder for bladder stones and trepanation of the skull. Indeed, skulls have been found all over the planet, dating back thousands of years, with deliberately made holes that had been covered with new bone, meaning the patient survived the procedure. But no one knows if the first trepanation was performed to release a traumatic blood clot from inside the skull, or to release an evil spirit responsible for epilepsy or a similar misunderstood disorder.

As Rutkow writes, the emergence of surgery from its barbaric past rested on four pillars: understanding anatomy, controlling 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 just plain wrong when it came to human anatomy. His writings were transmitted 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 on the dissection of the dead. The Flemish physician Andreas Vesalius, the greatest of the early anatomists, performed his dissections on the corpses of executed criminals, often surreptitiously removed from the gallows at night. Surgeons like Ambroise Paré in France, working on battlefield wounds, devised ways to control bleeding – by tying off blood vessels, for example, rather than using red-hot irons and dipping the stump of an amputated limb in boiling oil.

But the biggest change came in the middle of the 19th century, with the use of ether as an anesthetic and Joseph Lister’s work on antisepsis. This was based on the work of Louis Pasteur showing that infection was caused by living microbes, and not (as previously thought) by odors and stale air. And yet, as medical historian David Wootton pointed out in his book “Bad Medicine”, the Swiss physician Paracelsus used ether to anesthetize chickens in the 16th century and Antonie van Leeuwenhoek had discovered bacteria, using of a microscope of his own making (though of a rather clumsy design), in the 17th century. German-Hungarian obstetrician Ignaz Semmelweis has shown that handwashing makes a huge difference in the incidence of fatal postnatal infections in women. It was 20 years before the work of Lister and Pasteur, yet Semmelweis was fired by his colleagues and died in obscurity. The history of surgery, especially up to the modern era, is as much one of physicians’ innate conservatism as one of innovation.

It is, however, ultimately a story of triumphant progress – but not without dark episodes, such as the abuse of psychosurgery in the mid-twentieth century.