Gowns, Germs and Steel

Ernst von Bergmann performing a leg amputation at the Charité Hospital in Berlin, 1897.

By WILLIAM BYNUM

Invasion of the Body: Revolutions in Surgery
By Nicholas L. Tilney 
Harvard, 358 pages, $29.95



Most of us have had close encounters with a surgeon. One of my earliest memories is of the ether mask putting me to sleep before my tonsils were lopped out. I remember also the sore throat afterward, but not the ice cream that was supposedly always given. (click below to read more)


I went under the knife of a modern surgeon, but surgery has changed dramatically since then (the late 1940s). In fact, it has probably changed more than it had in the preceding hundred years, which saw the introduction of two of the preconditions for modern surgery, anesthesia and antisepsis. Anesthesia was first demonstrated publicly in 1846, at the Massachusetts General Hospital. It allowed surgeons the luxury of operating more carefully, without conscious patients struggling in pain. The increased exposure time of the surgical wound, however, raised the chance of postoperative infection, with fatal consequences often following.
That problem was addressed by antiseptic surgical procedures, introduced in 1867 by the British surgeon Joseph Lister. Lister soaked his dressings and instruments in carbolic acid to disinfect the surgical wound; he had been inspired by Louis Pasteur's researches on microorganisms. By the 1880s, antisepsis had been superseded by asepsis, which involved the scrupulous attention to maintaining sterile operating conditions. As one surgeon remarked, the best antiseptic is life itself, since the blood and living tissues are naturally free of microorganisms, and if none are introduced, the tissues will stay that way.
Major surgery was further facilitated by the development of safe blood transfusion, following Karl Landsteiner's identification of the major human blood groups in 1901. War often provided the theater for surgical innovation: Blood transfusion, trauma management and orthopedic and neurosurgery all matured materially during World War I. The development of penicillin during World War II added the last "A" to modern surgery's triad of anesthesia, asepsis, and antibiotics.
Nicholas Tilney's "Invasion of the Body" chronicles these and other landmarks on the way to contemporary surgery. His historical account is always entertaining, if marred by occasional errors of time, place and person. René Laennec invented his stethoscope in 1816, not 1819; the discoverer of X-rays, Wilhelm Roentgen, worked in Würzburg, in Bavaria, not Paris, and Joseph Lister was English, not Scottish.

But Dr. Tilney's analysis of surgical developments during his long career—he graduated from medical school in 1962—is little short of brilliant. He focuses on his own hospital, the Peter Bent Brigham, one of Harvard's teaching hospitals. He served on its house staff and for many years directed its renal transplant program, whose founder, Francis Moore, was a pioneer of transplant surgery. The Brigham has an even longer history of surgical innovation, beginning with Harvey Cushing (1869-1939), probably the most important neurosurgeon of all time.
Cushing operated without diagnostic aids such as CAT scans, but as Dr. Tilney beautifully shows, surgeons nowadays rarely open a body without a pretty good idea of what they will find, so precise are preoperative imaging techniques and the battery of blood tests patients routinely undergo. Gone are the days of speculative operations on the abdomen undertaken to find out what was wrong, in the hope that the surgeon could do something positive rather than simply closing up and telling the patient that nothing could be done.
The range of conditions amenable to surgical correction has also expanded dramatically during the past half-century. Dr. Tilney's own field of transplant surgery was primitive and experimental when he was a medical student. Now kidneys, hearts, livers, lungs and even faces can be transplanted. Heart surgery itself is also a product of the past 50 years or so. The pioneering work in the 1940s of Alfred Blalock of Johns Hopkins University on "blue babies," children with congenital malformations whose blood wasn't properly oxygenated, was important, but it was still done without the crucial operating time that modern heart-lung machines give to the surgeon.
Dr. Tilney provides full accounts of both the science and practice of cardiac and transplant surgery, with their backgrounds in basic immunology and the technology of the heart-lung machine. He illustrates his narrative with vivid examples of real operations, including some from his own surgical experience. In the mid-1960s, for instance, he assisted Francis Moore in one of the first successful kidney transplants not using an identical twin as the donor. As the patient's new kidney started working a few days later, Dr. Tilney "became a believer" in the power of transplants to save lives. He has a wonderful capacity to describe what surgeons actually do when they are operating, why they do it and why it sometimes ends in failure. His description of removing a bullet from the chest of a young man brings the middle-of-the-night experience to life: "He was ashen and barely breathing. His shirt was soaked with blood. . . . Blood was welling from a single bullet hole in the front of his chest." The operation was successful: "For years, I received a Christmas card from him."
Dr. Tilney analyses the changes wrought in surgical practice by advances like "keyhole" surgery, in which instruments are threaded through an extremely small incision. He also describes robotically assisted surgery and the introduction of artificial materials, such as are used in hip repairs, cataract replacement or vascular patching up. Surgery is increasingly becoming an outpatient specialty, and surgeons are feeling the competition from other branches of medicine, such as cardiology and gastroenterology, which are themselves becoming more hands-on. Surgeons used to perform all cardiac catheterizations; now cardiologists do many of them. Dr. Tilney freely admits that a few surgeons fight this encroachment by doing unnecessary (and lucrative) operations. Still, he is generally proud of the standards of his discipline, but frustrated that it is bound by the cumbersome bureaucracy that surrounds medical care in the United States. For a country that spends more than any other on health, it is chilling to learn that 27% of its costs are administrative (the figures for Canada and the U.K. are 3% and less than 10%).
Dr. Tilney is concerned, as every American citizen ought to be, with the chaotic state of American health care. His last chapter contains a great deal of wisdom (and documentation) about the problems of spiraling costs, inequality of access and the pernicious ways in which the market drives decisions about how much and what kind of treatment a patient receives. Affirming that health care is a right, Dr. Tilney concludes that "The marketplace may not be an appropriate venue for the social mission of medicine." He has made a shrewd diagnosis of the lack of system in American health care, and politicians would do well to take his critique seriously.
—Dr. Bynum is professor emeritus of the history of medicine at University College, London.