Surgeons get no respect. Or, at least, they didn’t use to.
I learned this surprising fact when I began dating the (originally British) woman who would become my wife, who explained that, in the U.K., surgeons, unlike physicians, are referred to as “mister,” not “doctor.”
This distinction, the surgeon and historian Ira Rutkow tells us in “Empire of the Scalpel,” his illuminating account of surgery’s origins and development, dates as far back as the Hammurabi code, which punished unsuccessful surgeons—but not flawed physicians, who formed part of the priestly class—by cutting off their hands. “It was a prejudicial attitude,” he writes, “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.”
Surgery’s etymology reflects this distinction. The word derives from the ancient Greek cheiros, or hand, and ergon, or work, later becoming chirurgia in Latin and chrirurgien in Old French before its modification into “surgerie” in Middle English. Meanwhile, “medicine” comes from the Latin medicus, for a learned physician.
But as Rutkow tells us, surgical practice began even earlier. In the 19th century, archaeologists in France discovered a Stone Age human skull with precise, curved indentations surrounding a sizeable hole. This prehistoric “trephination,” subsequently found in other skulls, is believed to have been a treatment for traumatic head injuries. As Rutkow notes, “of the numerous achievements that make up surgery’s story, perhaps none is more astonishing that the realization that cavemen practiced neurosurgery, successfully.”
Yet ancient surgeons never managed to overcome their reputation as glorified handymen. Egyptian and Greek societies devalued them relative to physicians, as the Roman historian Celsus observed when he lamented how “that part of medicine which cures by hand…although very ancient…was unwisely separated from the rest of medicine”—a separation readily espoused by the renowned (if overrated, in Rutkow’s eyes) Roman physician Galen.
The Muslim Golden Age eschewed surgery and banned human dissection altogether, while the medieval church proved not much more hospitable. This suspicion spurred the 11th-century emergence of “barber-surgeons,” or literal barbers who slowly expanded their repertoire to include bloodletting, bunion-trimming, and boil-lancing, later graduating to tooth extractions and even amputations. Thirteenth-century France saw a parallel evolution of educated surgeons, prompting the inauguration of royally recognized surgical colleges within the University of Paris and stirring rivalries with both the uneducated barber-surgeons and the oh-so-superior physicians.
As the Renaissance dawned, knife-bearers (Rutkow’s favored nickname for his colleagues) of various stripes slowly came to master the four fundamentals of surgery: understanding human anatomy, controlling bleeding, reducing pain, and minimizing infection.
The 16th-century Belgian scholar Andreas Vesalius improved upon Galen’s primitive understanding of human anatomy by initiating the practice of cadaver dissection and by commissioning skilled artisans to illustrate it. Along the way, Vesalius bemoaned that “the art of medicine was torn in pieces long ago, when one of its basic instruments, the technique of surgery, fell into neglect and was … handed over to laymen and people with no knowledge of the discipline.”
Around the same time, Ambroise Pare, a Frenchman indentured to barber-surgeons, fashioned a method of treating gunshot wounds that relied on “yolks of eggs, oil of roses, and turpentine” instead of the prevailing—and mostly harmful—practice of cauterizing tissue and applying hot oil. He also contrived a predecessor of forceps to enable tying off bleeding arteries with ligatures. But despite his groundbreaking advances, Pare was only grudgingly admitted to the Parisian college of surgery, where he clashed for years with his more well-read, but less successful, colleagues.
Several centuries would pass before the third fundamental—anesthesia—would emerge, in Boston, when a dentist named William Thomas Green Morton perfected a metal-and-glass mouthpiece that osmosed ether to put patients to sleep. Morton’s first administration on October 16, 1846, which resulted in successful, pain-free surgery, prompted newspaper headlines and widespread professional acclaim. Rutkow characterizes anesthesia as “America’s greatest contribution to the art of healing and one of its most important gifts to the whole of mankind.”
Antisepsis, the final step in surgery’s maturation, arrived in 1865 at the hands of Joseph Lister, a British surgeon who had carefully studied Louis Pasteur’s groundbreaking discovery of the germ theory of disease and began experimenting with carbolic acid. He applied it successfully to the shattered lower leg of an 11-year-old boy, later mixing the highly caustic substance with linseed oil and other solutions and immersing in the mixture all body parts and tools that would come into contact with the human body during an operation. While an older generation of surgeons initially expressed skepticism toward Lister’s breakthrough, it rapidly took hold across the world.
Rutkow also chronicles the advances of prominent modern surgeons such as William Halsted, the cocaine- and morphine-addicted Johns Hopkins scalpel-wielder (another of Rutkow’s euphemisms) who became “American surgery’s Adam”; George Washington Crile, the founder of the Cleveland Clinic and the American College of Surgeons, who during World War I established field hospitals in Europe that saved thousands of lives; Harvey Cushing, the Pulitzer Prize-winning biographer who pioneered neurosurgery; Charles Drew, the African-American surgeon who overcame terrible discrimination to spearhead the mission-critical Blood for Britain effort—the “world’s first successful mass donor procurement program”—at the outbreak of World War II; and John Gibbon, who in 1953, with assistance from IBM, built the first heart-lung machine to enable open-heart surgery. Nowadays, the automation revolution has come to threaten the future of the profession, as laparoscopic techniques and robotic surgery supplant traditional methods.
Rutkow’s prose occasionally meanders into relatively uninteresting waters, such as the concoction of an alphabet soup of surgical specialty boards and certification agencies, and his narration flags a bit as it advances into the 20th century. In addition, at the beginning of the book he nicely interweaves his own fascinating operating room stories into the historical narrative, but he mostly abandons this personal approach as the story wears on.
But in the end, Rutkow’s thorough treatment of surgery’s evolution over the course of thousands of years triumphantly fulfills his central goal: “to change the way people think about surgery by helping them understand its character while exposing its conduct.” We should give respect where it’s due, and professional knife-bearers more than deserve their fair share.
