Revolutions and Enlightenment
The American Revolution, the French Revolution, the Industrial Revolution, and so many more followed the “Rebirth.” And with it came the progress of new knowledge. Louis the XIV, the Sun King, led a life at the height of opulence and glory. He lived in luxury at Versailles, surrounded by art, beauty, culture, and wealth. Were it not for a pain in his buttocks, things would have been perfect. He had a “fistula in ano,” an abnormal connection from the inside of the rectum to the skin outside. It frequently got infected causing swelling, pain, and pus to discharge. He consulted his physician and surgeon, Charles-François Felix. Unfortunately, his learned adviser didn’t have the slightest idea what to do for this humbling and agonizing problem. So, he did what doctors often do, stall. He told Louis that he must do sitz baths for a year before he could treat him. In the meantime, he went to the Bastille, the central prison in Paris, and found 72 prisoners who had the same condition. For the next year, he experimented with different treatment options to see what worked best. Felix found that unroofing the fistula, just slicing it open worked well. Finally, the year was up, and it was time to treat the King. The King reluctantly agreed to have the surgery Felix advised, as he saw no improvement, and had no other choice. No anesthesia was available. The King assumed the undignified position for the surgeon to approach the fistula, and Felix went to work. The records at Versailles indicate that the operation was a three-hour ordeal, but the King did not scream once. He did say, “Oh, Mon Dieu” twice, roughly translated as OMG. Felix crafted a knife that had a leading blunt probe that was inserted through the fistula track, and had a sharp portion that was then used to transect the fistula, and overlying anal sphincter. It is on display at Versailles in a glass case and named the “bistouri royal.”
The operation was a success, and the surgeon was well rewarded. He received 15,000 Louis d’ Or approximately $5,000,000 in today’s currency. Additionally, there was a chateau in the south of France, and the title of Baron, that came with the fee. Compare that to today’s Medicare reimbursement for a fistulotomy, the kingly sum of $436.87!
Although not in historic proper timeline order, it seems appropriate to mention David Henry Goodsall at this point. He does not come on the scene until 1900 when he was able to correctly describe the path of an anal fistula, a frequent question on surgery in-training exams.
Goodsall’s rule states that if a line is drawn through the middle of the anal ring parallel to the floor, the internal opening of the fistula will be in direct opposition to the external opening on the skin. If the external opening is posterior to that line, the internal opening will follow a curving path to the dorsal midline. The exception to the rule is, if the external opening is more than 3.75 cm from the anal verge, the path may curve to the posterior midline regardless of where it is.
Appendicitis was almost always a fatal condition, as that, too, had no known treatment, and the surgeon did not have the luxury of trying out different procedures for a year.
The very first successful removal of the appendix was done at St. George’s Hospital in London, in 1735, by a French surgeon, Claudius Amyand, on an 11-year-old boy. He described the operation, which he presented to the Royal Society.
St. George’s Hospital< Hyde Park Corner
Amyand had to wait for the proper credit, as many were accorded that honor erroneously, not knowing he preceded them by 150 years. Charles McBurney wrote about “the McBurney” incision in 1894, actually 1st described by another surgeon, Louis L. MacArthur.
Although the pathophysiology was not well understood at that time, it was a Harvard pathologist, Reginald Herbert Fitz, who described it accurately in 1886, 150 years later. He wrote a paper entitled: “Perforating Inflammation of the Vermiform Appendix; With Special Reference to Its Early Diagnosis and Treatment,” as the little worm-like projection from the cecum, that was the cause, and not what was thought to be a process that involved the entire cecum, called typhlitis or peri-typhlitis.
John Hunter is considered to be one of the early “Fathers of Modern Surgery.” He was a man who would not accept any idea that he himself had not thoroughly vetted. He was a scientist that depended on direct observation, trial and error, and experimentation to prove a theory. He
was considered to be a surgeon, and he felt himself a surgeon, although he saw the shortcomings of the craft of surgery. He tacitly acknowledged that surgery had its flaws, “It is like an armed savage who attempts to get that by force which a civilized man would get by stratagem,” he said. Surgery was a treatment option when other, less invasive measures failed. He was known to collect everything that moved, and even plants, a total of 14,000 exhibits at the end of his life. One of his prize specimens was the skeleton of a giant man (7’7”), who specifically left a will which refused any part of him to be used in one of Hunter’s exhibits, but Hunter bribed one of the morticians. The skeleton is now on display at the Hunterian Museum in London. What would the legal and ethical implications of that be in our time? Hunter came by his “trade,” not through any academic route, he was an assistant to his brother who taught an anatomy course for eleven years, then assisted a surgeon for one year. Subsequently, he was an army surgeon for three years. He was appointed to be the Surgeon to King George III, (yes, that George, against whom we fought the Revolutionary War).
He published several scholarly books on venereal diseases, the development of human teeth, inflammation, blood, and gun-shot wounds. He was an ardent supporter of learning by doing; surgery was not something that could be taught only by reading. He died at the age of 65, on October 16, 1793, immediately after a fierce argument with his hospital’s Board of Directors, who did not want him to bring medical students to observe operations (a discussion we still have today).
His death mask, to the right, shows a man with determination and wisdom. He was described by one of his assistants, “as a man, warm but impatient, readily provoked, and when irritated, not easily soothed,” a character trait common to many surgeons. His house in London had two entrances, one for the family, and one on a different level, the entrance for his macabre laboratory, where he prepared many of his exhibits for display. The house became immortalized, and Hunter, himself, was thought to be the most likely inspiration for Robert Louis Stevenson’s novel, The Strange Case of Dr. Jekyll and Mr. Hyde.
|Sir Astley Cooper|
Operating on the crowned heads of the European Empires was quite rewarding. Sir Astley Cooper, a student of John Hunter, was Surgeon to George IV. His aristocratic title was bestowed on him by George IV for removing a huge mass on the King’s head.
Cooper has several anatomic structures named after him; the most remembered today are two ligaments: the suspensory ligaments of the breast are Cooper’s ligaments, as is the thickened periosteum, just above the superior pubic ramus, the ligament of Cooper. It is Cooper’s ligaments in the breast that cause the skin to give the “peau de orange” appearance with underlying cancer, plugging the lymphatics causing swelling of the skin, but Cooper’s ligaments tug on and create the fine dimpling of the skin that gives it that orange peel appearance. The other Cooper’s ligament provides the strong anchoring structure in the pelvis for the Mc Vay hernia repair. His contributions to surgery were diversified, from ligating the aorta for aneurysms, the study of the cerebral circulation, anatomy of the inner ear, and more practical applications, such as hernia repair, and treating breast diseases. Cooper’s published works include anatomy of hernias, breast, and thymus, as well as lectures on surgery, and treatment of fractures.
Sir Astley Cooper has a special place in the education of women surgeons. The fact is that women were not accepted into medical schools in that era, much less becoming surgeons. The strange story of James Barry changed that. James was actually a female who very much wanted to be a surgeon.
She dressed as a boy, and entered the medical school in Edinburgh, Scotland where she came under the influence of Sir Astley Cooper, and eventually became a very talented, capable, and accomplished surgeon. Her real name was Miranda Steuart. She continued to dress and appear as a man; she also joined the British Army and fought in the Crimean War. By that time, she had attained the rank of General, because she was an outstanding surgeon.
She gets the credit for performing the first successful Cesarian section, where both mother and child survived! Being from Edinburgh, which had a reputation for hygiene concerns, she was very meticulous about sanitation during the execution of surgery, long before Lister came up with his carbolic acid spray. She got into a knock-down-drag-out fight with a fellow army surgeon who was less interested in cleanliness. Miranda was court-martialed for behavior “unbecoming an officer and a gentleman.” But she prevailed both in the fight, and the court-martial. When she died, it was discovered at her post-mortem exam that she was, in fact, a female. Also elucidated was that she had had a child, which she obviously hid from society.
Florence Nightingale worked with Dr. Barry in that war, but the two did not get along. There were nurse-surgeon hierarchical issues, something that remains a point of contention at times, even today.
Wars have always advanced the surgical sciences, because with war comes trauma, which usually requires intervention to stop the bleeding, cut off the mangled extremity which would only get infected, and eventually kill its owner, extract the bullets, dress the burns, etc. Dominique Jean Larrey was Napoleon’s surgeon, and whatever battle, whatever country Napoleon went to, Larrey was sure to follow.
He made the astute observation that the sooner the surgeon gets to the injured soldier, the better the outcome. With that as his leading theme, and observing how quickly the French “flying artillery” crisscrossed the battlefield, he adapted it, and “Voilá,” came up with the “flying ambulance.” It may have been a bit overstated, as it was just a horse-drawn cart, but it served its purpose, getting the fallen soldier off the battlefield, and into the surgeon’s tent. He created the rule for triage we still use today, treating the wounded according to the seriousness, and urgency, without regard for rank, or nationality, of the injured.
The concept of early intervention would be copied, and improved by another icon of surgery, Michael DeBakey, in the 1950s, during the Korean Conflict, where the Mobile Army Surgical Hospital (MASH) was set up right in the conflict zone. Only this time the horse and buggy “Flying ambulance” was replaced by a real flying machine, a helicopter, dubbed the “Angel of Mercy” by the soldiers on the battlefront.
Edward Jenner studied anatomy and surgery with John Hunter at St. George’s Hospital in London. Jenner took Hunter’s advice, a well-known philosophy among the intelligentsia of the Age of Enlightenment, “ Don’t think, try!” In 1796 he noted that milkmaids that contracted “Cowpox” did not get Smallpox, a disease that wiped out one in five inhabitants in the villages in Briton. He experimented by inoculating his gardener’s son and even his own son with pus he had collected from the pustules of infected cow’s udders. Although the children had a mild febrile illness with skin lesions, they were immune to the lethal form of the disease. He coined the word vaccine from the fact that it came from vaca, the Latin for cow. Jenner has saved more lives than any individual in human history including today. It was in 1970 that the World Health Organization declared Smallpox eradicated, in no small part due to vaccination.
In 1822 Alexis St. Martin was shot, by accident, in the left lower chest. A Surgeon, doctor William Beaumont, was called to attend to him. Beaumont did not think that St. Martin would survive, but he did. Beaumont took the opportunity to study him, becoming the father of gastric physiology. He put bits of meat on a string, and placed it through the skin opening into the stomach, but retrieved it periodically, to see what the stomach acid did to it. Alexis attempted to escape from Beaumont, but was caught, and returned to him for further study.
Louis Pasteur was a brilliant chemist, who came up with the germ theory of diseases, that ended the popular idea of so-called spontaneous generation as a reality. Pasteur discovered the etiology of TB, rabies, as well as cholera, smallpox, anthrax, and made vaccines to block rabies, smallpox, and Anthrax. He ascertained that most bacteria were killed by the heat generated with the process of Pasteurization, a life-saving discovery that saved, perhaps millions, through the ages, and still does.
He contributed to a variety of industries, among them the fermentation of grape juice, and silk manufacturing. He recognized that virulence is variable. Less virulence allowed vaccination, while more virulence led to epidemics.
He is also responsible for giving us the understanding that many chemicals have a mirror image form, each with different characteristics. Although he was not a physician, without him, we would all be ignorant of microbiology, the cause of all bacterial and viral diseases.
The implementation of Pasteur’s discoveries, however, took a while to permeate all of the medical community. The Viennese obstetrician and surgeon, Ignaz Semmelweis, wrote a paper explaining the cause and prevention of the dreaded Puerperal Sepsis (Kindbettfiebers). He noticed that in his hospital, the Allgemeines Krankenhaus, in the city of Vienna, the service of the professors had a much higher maternal mortality than the women who were delivered by midwives. The professors would do the autopsies on the women who died, and then proceed into the delivery room, often not washing their hands, or changing clothes. Semmelweis believed in Pasteur’s work of tiny plants that cause disease, but the professors in Vienna didn’t. They laughed at Ignaz. “Tiny plants growing on your hands … Ridiculous!”
All he wanted was for us to wash our hands between patients! He lost his job, but continued railing against his colleagues in the newspapers, claiming that they were killing women… which indeed they were. To stop him, they had him committed to an insane asylum, where he died, a broken, discredited man, with the knowledge that he was right.
ROBERT KOCH 1843-1910
Robert Koch was a Surgeon during the Franco-Prussian War, and later led the battle against ignorance of the denial of microbes. Koch’s postulates helped in convincing the world of the truth of Pasteur’s theories:
- The bacteria must be present in every case of the disease.
- The bacteria must be isolated from the host with the disease, and grown in pure culture.
- The specific disease must be reproduced when a pure culture of the bacteria is inoculated into a healthy susceptible host.
- The bacteria must be recoverable from the experimentally infected host.
The above are the four famous Koch’s Postulates that prove the etiology of a disease.
He identified the bacteria that caused anthrax, cholera, and tuberculosis. He also developed the PPD (Purified Protein Derivative), the still-used test to determine if the tubercle bacillus has infected an individual.
He did not patent it, as he wanted it available to all for study, and disease prevention, thus giving up all royalties that could have made him a rich man. He discovered Agar, (a product of red algae), still used today to grow bacteria. He garnered the Nobel Prize in 1905 for his achievements.
Joseph Lister listened to Pasteur. He believed that the little plants do cause infectious diseases. Pasteur advised the railroad builders that if the railroad crosstie timbers were soaked in creosote, they would not rot nearly as quickly as when untreated. Lister used the phenol extracted from creosote and devised an atomizer that sprayed the phenol (carbolic acid) into the air. He used it to spray into operating rooms, and soaked his hands in carbolic acid before surgical procedures, and also dressed wounds in bandages soaked in it. Lo and behold the infections all but disappeared! That too took a while to sink in, with no help from literature. The Lancet, which was and remains a respected journal, warned the profession against these “progressive ideas”! Something they failed to do when they promoted hydroxychloroquine for Covid.
The above is Lister’s invention that made a vapor of the phenol that was sprayed around the operating theater.
I visited Lord Lister’s home on June 7, 2005, to pay my respects, about135 years after he lived in Edinburgh, Scotland, with his wife Agnes, daughter of James Syme, the innovator of the Syme amputation (cutting half the foot across the metatarsals). Lister eventually replaced Syme as Chair of Surgery.
Lord Lister (center with his hands clasped) surrounded by all his residents at the Old Royal Infirmary of Edinburgh 1855.
In eighteen-forty-six, William Morton, a dentist, gave a public demonstration on the effects of Ether at the Massachusetts General Hospital. The operation was to be the removal of a neck tumor. He used a device that contained a sponge soaked with Ether. He had learned about Ether when he was a medical student at Harvard, from his chemistry professor. Much of the rest of his life was spent in trying to profit from this drug and trying to claim credit for its discovery.
Morton’s tombstone reads, “Science has control over pain.” Shortly after Morton’s public display, a Scottish obstetrician, James Y. Simpson, introduced Chloroform in 1847, which had a much quicker onset but was more of an explosive risk than Ether. Queen Victoria made Chloroform popular when she used it for the delivery of Prince Leopold.
Wilhelm Conrad Röntgen was a German physicist who was experimenting with cathode tubes, and noted that a strange and eerie glow was coming from them in the dark. He surmised that they emitted some kind of energy, that he named the X-ray. He exposed his wife’s (cleverly not his) hand to it, placed a photographic plate underneath it, and there were her bones and wedding band, the first X-ray. X-rays revolutionized diagnosis, and consequently, treatment. Without X-ray, we would literally be in the dark!
BERNHARD RUDOLF KONRAD von LANGENBECK 1810-1887
Langenbeck was a German surgeon who gained much of his surgical training courtesy of numerous wars against Denmark, Austria, Prussia, and France. After the various wars, his hospital was Charité in Berlin where he became acquainted with Rudolf Virchow, “the Father of Modern Pathology,” (whose name is memorialized in the Virchow’s Triad and also Virchow’s node). They are both honored by a building dedicated to educational purposes and a meeting place for physicians – the Langenbeck -Virchow- House in Berlin. Langenbeck invented a variety of instruments, especially retractors that still grace surgical trays in every operating room. He is perhaps best known for creating the method of training surgical residents, and is considered the “Father of the Surgical Residency.” The term “resident” derives from the fact that Langenbeck insisted that the surgeon in training would reside at the hospital 24/7. Hence he or she is a “resident.” The famous surgeons that were part of his house staff read like a Who’s Who in surgery: Billroth, Kocher, Bassini, Esmarch, Trendelenburg, and even Halsted spent a short time with him.
Mary Edwards Walker 1832-1919
The only woman ever to receive the Congressional Medal of Honor was for her services above and beyond the call of duty during the US Civil War. She was the first woman surgeon in the Union Army, and was captured by the Confederates, and treated as a spy. She was raised on the family farm in New York state. From that time on, she wore men’s clothing, as it did not restrict her ability to work alongside her brothers in the heavy labor farm work required. Her medical education was at Syracuse Medical College. She was an active surgeon during the war and participated in numerous battles including Manassas, Fredericksburg, Chattanooga, and Chickamauga.
Even when captured, she helped Confederate doctors perform amputations. During her imprisonment, she suffered neurologic damage, for which she received a military pension after the war. She lectured and was active in women’s rights movements that made her popular among feminists and female physicians. She died in 1919, one year before the 19th Amendment to the Constitution passed, which guaranteed women the right to vote.
Theodor Billroth 1829-1894
Langenbeck’s illustrious protégé, went on to found his own school of surgery, the Vienna School, that in-turn produced more famous surgical icons, with many firsts: Wölfler- gastroenterostomy, Czerny- vaginal hysterectomy, Mikulicz- the pyloroplasty, Eiselsberg- the founder of neurosurgery and creator of the ER, and William Halsted- the radical mastectomy.
Billroth was an amateur musician and had mastered the violin and the piano. He had also bought the former home of Ludwig van Beethoven, and often Billroth would host musical evenings with Johannes Brahms, the composer considered by many to be Beethoven’s successor. Billroth often invited his resident, Jan Mikulicz, an accomplished pianist, to play quartets, and the like, in Beethoven’s former residence. Jan became one of the great surgeons in his own right.
Robert Virchow 1821-1002
Virchow, although not a surgeon, was crucial for surgeons to do their work. He was the “Father of Pathology.” He produced volumes of scientific articles in excess of 2000, introduced the microscope for use in pathology, and developed many principles of the medical sciences. Omnis cellula e cellula– all cells (come) from cells. He coined words and christened multiple diseases, such as spina bifida, amyloid degeneration, leukemia, chordoma, embolism, thrombosis, parenchyma, osteoid, and many more. He is the sole inventor of the modern autopsy, a systematic investigation into a deceased individual’s journey from birth to death. His work at Charité in Berlin influenced many surgeons, including Kocher, Langenbeck, and Bergman. He ventured into a diverse variety of fields in addition to medicine: anthropology, forensic criminology, and politics among others, vehemently disputing that Aryans can be identified as a single race, much less be superior to other races. “Medicine is a social science, and politics is nothing else but medicine on a large scale,” he remarked. Virchow’s strong opinions inevitably led to a confrontation with the most powerful politician of the time, Otto von Bismarck, Chancellor of the German Empire. Robert got under Bismarck’s skin to such an extent that Bismarck challenged him to a duel. By the rules, the challenged chooses the weapons. Virchow brilliantly chose Kielbasa, Polish sausages, filled with Trichinella Spiralis, the cause of Trichinosis (also his discovery). Bismarck turned him down as the duel was undignified and furthermore Bismarck thought it too risky.