Did Stone Age people conduct brain surgery? Medical historian Ira Rutkow points to evidence that suggests they did.
"There have been many instances of skulls that have been found dating back to Neolithic times that have grooves in them where portions of the skull have been removed. And it's evident if you look at these skulls, that this was all done by hand," Rutkow says.
There's no written record of Stone Age neurosurgery, but Rutkow theorizes it may have been conducted by a shaman on patients who were comatose or who had been otherwise injured. What's more, he says, physical evidence indicates that some patients likely survived: "With many of these older skulls, new bone growth had already formed, and bone in the skull can only form if the patient is alive," he says.
Rutkow is a surgeon himself. His new book, Empire of the Scalpel, traces the history of surgery, from the days when barbers did most operations and patients died in great numbers, to today's high tech operations that use robots with artificial intelligence.
He says that when looking back, it's important to keep in mind the body of knowledge that existed at a particular point in history — and to not judge surgeons of yore too harshly.
"People write about medical history and they say, 'Oh, it was barbaric,' or 'The doctors were maltreating,'" he says. "We have to remember at all times that whatever I write about in the past was considered state of the art at the time. ... I would hate to think that 200 years from now, somebody is looking at what we are doing today and saying, 'Boy, that treatment that they were doing was just barbaric. How do they do that to people?'"
Interview highlights
On the four main obstacles for modern surgery
To do an effective and safe surgical operation, there are four elements that are more important than anything else, more important than the mechanistic things that you need to do an operation. And these are an understanding of human anatomy. A surgeon needs a road map. They need to know where things are located. Second thing is how to control bleeding. If there's bleeding going on during an operation, that road map, that roadway gets flooded and the surgeon can't see anything. Third is anesthesia. They had to figure out how to reduce pain on patients. And the fourth is antisepsis. So these four elements — anatomy, bleeding, anesthesia and antisepsis — had to be discovered. They had to be improvised and they had to be worked on.
The four elements, once they came in, were very, very important. But we've undergone a major transformation in surgery in the last 20 to 25 years, meaning ambulatory surgery, where you go home literally hours after the operation, [and] many operations through small incisions and laparoscopic repair, where it's through tubes that they put inside and the surgeon can see with a camera. This is a major revolution and transformation in surgery as large as anything else that's happened in the past.
On surgeon being a low status job in ancient societies
Back in ancient times in Rome and in Greece, in the Middle East with Hammurabi, surgeons were always looked down upon. The priests/physicians were considered the educated elite at the time, and they looked down upon anybody who worked with their hands. Now, of course, what you and I would consider to be surgeons, they were the ones working with their hands: cutting out a boil or removing a bunion. That was what surgery was all about. But there was this very demeaning attitude toward individuals who did manual operations, who worked with their hands. And what happened over the course of time, this demeaning attitude would change. It would not change, however, until the 20th century.
On how the Church influenced surgery in the Middle Ages
The Church really started taking over the care of individuals beginning in the Middle Ages. And what happened was that the monks within the monasteries at the time would render care. When we talk about care, we're thinking of the 21st century, and what we have was nothing like that back then. But the monks were around and they provided whatever care they were able to to individuals. At the same time, there were men, mostly men, who worked with the monks. They were called the barbers. They shaved the monks. They cut their hair. And over the course of time, these barbers were able to do more and more surgery. Now, surgery, of course, was cutting out a bunion or lancing a boil or perhaps doing an amputation of a mangled finger. It's not surgery, as you and I know it today.
They handled the scalpels that existed at the time. The barber/surgeons were the ones who allowed surgery to continue and advance. They were not educated. They passed their traditions and their skills within the family, from son to son, father to son. And this continued for hundreds of years, really, up through the Renaissance, up until the 16th century.
On bloodletting
They would incise a vein and they would allow blood to drip out and they would collect it. And they collected enormous amounts of blood from individuals. We're talking about literally tens of ounces, ten, 20, 30, 40 ounces at a time. The endpoint of bloodletting for many individuals was to faint. So how did all this start? In ancient Greece, there was a theory that all of human disease developed around what they called four humors: yellow bile, black bile, phlegm and blood. And they felt that these humors needed to be in balance for there to be no disease. And amongst their ideas was that blood needed to be taken out of the body. And so bloodletting developed in Greece. And, in fact, bloodletting continued almost up to around the beginnings of the 20th century.
On President James Garfield dying in 1881 after a gunshot wound became infected (by his own doctors)
The doctors come on horseback. They come riding carts. The carts have reins that the horses are wrapped up in, and the reins are on the ground, as they've been for thousands of years. The ground is filled with horse manure and other bacteria. The doctors don't know any better. They pick up the reins. They have manure-covered hands. They go in to see Garfield. The first doctor takes his finger and puts it down the hole where the bullet went and starts to feel it to see if he can feel the bullet. Now, of course, in doing that, he's introducing bacteria, overwhelming numbers of bacteria, into Garfield's wound. He never washed his hands. So this went on for about 80 days with doctors coming in and examining Garfield. The older surgeons would not wash their hands. Garfield develops these huge abscesses throughout his body and eventually succumbs to sepsis, to an infection, as you would expect.
On advancements in robotic surgery
Robotic surgery is increasing in its sophistication and its ability to do operations. Right now, robotics are used because they're so precise in their movements that they're able to get into crevices and corners and other areas that a human hand might not be able to go into. Now, understand that currently the robots are still controlled at a certain level by human beings. They're sitting there at the monitors looking at what's going on. Somebody has to control the robot because if something goes bad, they need to be able to take care of the situation without the robot. Although I read the other day how at Johns Hopkins, my alma mater, they had just invented or were working on a surgical robot that would not need to have any human input. So we're clearly progressing towards that type of outcome, where you're going to have robots that are programmed using AI, artificial intelligence, who are able to do these operations by themselves. Now, is that scary? Yes. Will it work? I suspect that it will work.
Lauren Krenzel and Joel Wolfram produced and edited this interview for broadcast. Bridget Bentz, Molly Seavy-Nesper and Laurel Dalrymple adapted it for the web. Copyright 2022 Fresh Air. To see more, visit Fresh Air.
Transcript :
DAVE DAVIES, HOST:
This is FRESH AIR. I'm Dave Davies, in for Terry Gross, who's off this week. Medical surgery is so common in the industrialized world today that pretty much all of us will have an operation at some time in our lives to deal with an illness or injury. Our guest, surgeon and medical historian Ira Rutkow, says surgeons have been practicing their craft on patients for centuries. But for most of that time, procedures were excruciatingly painful, and great numbers of patients died from the surgery itself. Rutkow's new book chronicles the history of surgery from ancient times, highlighting critical blunders and breakthroughs, and noting how bad ideas could persist for decades or centuries, while game-changing discoveries sometimes had a hard time gaining acceptance. Wars were great incubators of ideas, he notes, since military surgeons often had little choice but to improvise on wounded soldiers. And sometimes, operations on figures as prominent as King Louis XIV and President James Garfield could have a lasting impact or teach important lessons.
Ira Rutkow is himself a surgeon who holds a doctorate in public health from Johns Hopkins University. He's written several previous books on medical history, two of which brought him to the FRESH AIR studios. His latest book is "Empire Of The Scalpel: The History Of Surgery." Well, Ira Rutkow, welcome back to FRESH AIR.
IRA RUTKOW: No, thank you for inviting me.
DAVIES: When we talk about surgery being old, this account dates back to pre-history, Stone Age people who show evidence of a kind of brain surgery. Is this for real?
RUTKOW: Brain surgery as you and I would refer to it, yes. There have been many instances of skulls that have been found dating back to Neolithic times that have grooves in them where portions of the skull have been removed. And it's evident, if you look at these skulls, that this was all done by hand. Now, obviously, there are no eyewitnesses. There is no written correspondence relative to this. But clearly, Stone Age men were performing what you and I would call neurosurgery. And if you think about it, it must have been an unbelievable thing that they had a patient who perhaps was comatose or had been injured or whatever, had bad spirits in their brains, and that the shaman or the surgeon was able to remove a segment of the skull, and that it brought that patient back to health. It must have been fascinating at the time.
DAVIES: And how do we know the patient survived the hole in his head?
RUTKOW: That's a very easy question to answer, even without the evidence being there, in that when a person gets an injury to his skull, there are always jagged edges of bone that are left from the trauma. If you're hit the head, let's say, with a bat or a hammer or if you fracture skull in a car accident, there's always trauma and there's cracked pieces of skull. With many of these older skulls, new bone growth had already formed. And bone in the skull can only form if the patient is alive. So there's evidence that the skull had reformed, and that the patient had survived the operation. So it's all fascinating.
DAVIES: Yeah. Now, we know from modern surgery that the skull can be pierced in order to relieve pressure when there's swelling in the brain. Do we think this might have been a medical procedure or something spiritual?
RUTKOW: I think it's really a combination of both. Clearly, it must have been spiritual because surgery started as a quasi-spiritual endeavor, that they were perhaps people who had mental illness back then, and they were releasing evil spirits from their skull by removing a portion of the skull bone. On the other hand, I'm sure there were instances where a caveman or a Stone Age man might have been injured hunting an animal or whatever, and they suffered a traumatic injury. They were comatose. The skull was pushed in. The shaman or the surgeon removed the portion of the skull that had been injured, and the patient came back to what they considered to be life. So it was an incredible thing when you think about it, that we're talking about 5,000 and 10,000 years ago that, yes, Stone Age men were doing neurosurgery successfully.
DAVIES: Now, ancient societies, you know, the Egyptians, Greeks, Romans - and I think some Mesopotamian societies had writings about medical practices. What kinds of operations were performed then? Any idea what they were doing?
RUTKOW: Really, what a surgeon was doing was looking at something that they could see on the skin, be it a boil that needed to be lanced or perhaps a tumor that needed to be excised or a fracture with a bone sticking out. That's what a surgeon did. They didn't have any capability of operating on the inside, meaning the abdomen or the chest or the lungs. That didn't exist.
DAVIES: Galen was a guy in the second century who - you describe him as a medical superstar of the ancient world. He did a lot of work with injured gladiators in Rome, among other things, and left a lot of writings, you know, knowledge and/or speculation about the human anatomy. What was his impact on medicine in the centuries that followed?
RUTKOW: Galen had an enormous impact. He was a Roman. And he did - the greatest amount of writing at the time - clearly, almost 85% of the writing from that period in time was done by Galen. Problem with Galen was that he didn't really understand human anatomy. Human anatomy was not known back in ancient Rome. They did not dissect bodies, so he dissected animals. And what happened was that he would refer to an animal, let's say a gorilla or a pig, and say that anatomy was the same as human anatomy. Obviously, it wasn't. And so Galen's influence extended way beyond his death. It extended up through the middle of the Middle Ages, almost up to the Renaissance. So for 1,500 years, Galen was out there - his books, his ideas, they encompassed everything in medicine at the time. He was the prophet of medicine. And people listened to what he said. And unfortunately, many of the things that he did was wrong.
DAVIES: As we got to the Middle Ages, you know, the church tended to dominate a lot of society. What was its influence on medicine and surgery?
RUTKOW: Well, church really started taking over the care of individuals beginning in the Middle Ages. And what happened was that the monks within the monasteries at the time would render care. And now, we have to be very careful when we talk about, you know, we always have frames of reference. We talk about care, we're thinking of the 21st century and what we have. It was nothing like that back then. But the monks were around, and they provided whatever care they were able to to individuals. At the same time, there were men, mostly men, who worked with the monks. They were called the barbers. They shaved the monks. They cut their hair. And over the course of time, these barbers were able to do more and more surgery. Now, surgery, of course, was, you know, cutting out a bunion or lancing a boil or perhaps doing an amputation of a mangled finger. It's not surgery as you and I know it today.
DAVIES: Right. They became the surgeons because they handled sharp knives?
RUTKOW: Yes. They handled the scalpels that existed at the time. And they - and, in fact, the barber surgeons were the ones who allowed surgery to continue and advance. They were not educated. They passed their traditions and their skills within the family from son to son, father to son. And this continued for hundreds of years, really, up through the Renaissance, up into the 16th century.
DAVIES: And I gather the surgeons - surgery was seen - was considered distinct from and inferior to medicine, right? There were people who actually considered themselves experts in the practice of medicine.
RUTKOW: It's really the story of surgery as it exists today is really what happened because back in ancient times, in Rome and in Greece, in the Middle East with Hammurabi, the priests' last physicians were considered the educated elite at the time, and they looked down upon anybody who worked with their hands. Now, of course, what you and I would consider to be surgeons, they were the ones working with their hands. Again, you know, cutting out a boil or removing a bunion - that was what surgery was all about. But there was this very demeaning attitude towards individuals who did manual operations, who worked with their hands. And what happened over the course of time, this demeaning attitude would change. It would not change, however, until the 20th century.
DAVIES: We're speaking with Ira Rutkow. He's a surgeon and medical historian. His new book is "Empire Of The Scalpel: The History Of Surgery." He'll be back to talk some more after a short break. This is FRESH AIR.
(SOUNDBITE OF TODD SICKAFOOSE'S "TINY RESISTORS")
DAVIES: This is FRESH AIR. And we're speaking with surgeon and medical historian Ira Rutkow. He's written several books about medical history. His latest is "Empire Of The Scalpel: The History Of Surgery."
You write that before we could get to really effective modern surgery, which essentially was in the 19th century, they had to solve four problems. You want to just explain what the four big obstacles to being really successful at surgery were?
RUTKOW: So to do an effective and safe surgical operation, there are four elements that are more important than anything else, and these are an understanding of the human anatomy. A surgeon needs a road map. They need to know where things are located. Second thing is how to control bleeding. If there's bleeding going on during an operation, that road map, that roadway, gets flooded, and the surgeon can't see anything. Third is anesthesia. They had to figure out how to reduce pain on patients. And the fourth is antisepsis. So these four elements - anatomy, bleeding, anesthesia and antisepsis - had to be discovered. They had to be improvised. And they had to be worked on.
DAVIES: Just to clarify, when you say antisepsis, you're talking about controlling infection in the surgery itself - right? - which can be deadly. Let's consider how some of these things happened. When did scientists begin to get a better understanding of the human anatomy?
RUTKOW: The human anatomy and understanding of it truly began in the 16th century. Prior to the 16th century, there was minimal understanding of the human anatomy. Dissections on cadavers was rarely done. But a man by the name of Vesalius, all of a sudden, when printing started, published a book called "De Fabrica," which was the story of human anatomy. And he had these wonderful illustrations of all the different layers of the human body. This was around - in the middle of the 16th century. And so once this was done, people began to understand anatomy. If you look at Vesalius' book, it looks like a modern-day CAT scan or MRI. He has layers upon layers of human tissue, of human organs, and shows what they were. This is when human anatomy began to be discovered. He wanted people to be able to look at his book and feel as if they were in an operating room, and they were looking over his shoulder when he was doing an anatomical lecture.
DAVIES: And how did he get a better idea of what was underneath our skins?
RUTKOW: Well, because he was allowed to dissect human cadavers. That was something that had not occurred. The church had not allowed it. In ancient Greece and Rome, they had not allowed it. So there had been no dissection, no true understanding, no true learning about human anatomy for literally thousands of years, until around - like I said, around 1600 or so.
DAVIES: And when that information began to be developed, did it contradict some of the beliefs about the human body that had descended from Galen, the physician from the second century who had written so much?
RUTKOW: Vesalius was very specific in saying that he did not believe that Galen knew what he was doing relative to anatomy. And he writes throughout his book that Galen said this, but it's wrong; he says that, and it's wrong. He said Galen never worked on a human cadaver, that all of Galen's thoughts relative to anatomy were on animals.
DAVIES: You write about William Harvey, who figured out how blood circulated through the body, 'cause that was something that Galen had wrong. He had a theory about blood, but it was really based on a misunderstanding, right?
RUTKOW: Yes. Harvey was a gentleman who was - I guess you could almost, to a certain extent, call him the first true scientist. He discovered the circulation of blood. Individuals at the time had no idea where blood went, where blood circulated; the lungs were involved. They had no idea what was going on. But it was up to Harvey, who finally understood the pumping of the heart and the blood circulating throughout the body and it going through the lungs to be oxygenated, coming back to the heart, being distributed through the body. This is what Harvey did. And again, this was in the 16th - early part of the 17th century. He was an important figure, although not a surgeon. Harvey was not a surgeon. He was what you and I would call a physician.
DAVIES: Right. And he figured out the heart was this amazing muscle, this pump that could get blood to the lungs and get it back.
RUTKOW: Absolutely.
DAVIES: It's interesting, though, that even after he developed this idea of - more modern ideas of blood circulation, bloodletting for people with all kinds of maladies continued. Why was that done?
RUTKOW: Bloodletting is exactly what it sounds like. They would incise a vein, and they would allow blood to drip out, and they would collect it, and they collected enormous amounts of blood from individuals. I mean, we're talking about literally tens of ounces - 10, 20, 30, 40 ounces at a time. The endpoint of bloodletting for many individuals was to faint. Well, so how did all this start? In ancient Greece, there was a theory that all of human disease developed around what they called four humors - yellow bile, black bile, phlegm and blood. And they felt that these humors needed to be in balance for there to be no disease. And amongst their ideas was that blood needed to be taken out of the body. And so bloodletting developed in Greece. It was then accentuated by Galen, and it continued with Galen's influence for thousands of years. And in fact, bloodletting continued almost up to around the beginnings of the 20th century. It is obviously a treatment which is no longer used, and it's been - never been shown to help any patient. But bloodletting was around for thousands of years.
DAVIES: You know, you would think empirical experience might raise some questions about this. Losing a lot of blood in addition to whatever else you were suffering can't be good. What was - what were they thinking? What was this doing for the body?
RUTKOW: I always explain this to people when I write that you have to be careful - because I write so much about medical and surgical history. They have to be careful about frames of reference. You know, frames of reference are very important. You need to put yourself in the other person's shoes to understand what's happening. And I find it strange. You know, people write about medical history, and they say, oh, it was barbaric, or the doctors were maltreating, or there was malpractice going on. Well, I think that we have to remember at all times that whatever I write about, you know, in the past was considered state of the art at the time.
When they did an amputation and somebody got infected, that was state of the art back then. I always say that I would hate to think that, you know, 200 years from now, somebody is looking at what we are doing today and saying, boy, that treatment that they were doing was just barbaric. How do they do that to people? What we're doing today is state of the art. What they were doing in 1635 was state of the art. What that caveman was doing was state of the art at the time - at the time.
DAVIES: OK, but what was the thinking? (Laughter) How was...
RUTKOW: (Laughter).
DAVIES: What was - how was letting blood out helping?
RUTKOW: I'll be honest. I have looked at the thinking relative to bloodletting and to the humors that I talked about from ancient Greece. I have tried to understand the thinking. Many historians have tried to understand the thinking. But if you exist in the world of modern medicine and surgery, it's very hard to understand their thinking other than to say, this is what they saw, and this is what they believed. George Washington was bled on his deathbed. Many people think that he was bled so much that it actually attributed to his final death. Now, everybody was.
But William Harvey, the discoverer of circulation, as we just discussed, he had a stroke. That was the end of his life. He had a stroke, and he became aphasic. He was unable to speak. And he motioned to one of his friends that he wanted them to do bloodletting on his tongue, on the veins underneath his tongue to allow out blood, thinking that it would recover his speech. Obviously, it didn't. So this concept of bloodletting and humoral therapy persisted for centuries.
DAVIES: When was anesthesia developed as a reliable method in surgery? When did people learn how to ease the pain of folks undergoing surgery?
RUTKOW: So we have discovered anatomy. We discovered how to stop bleeding, and that is in the 16th century. For the next 300 years, there's virtually no progress in surgery. Anesthesia is not known. It is not discovered until the mid-19th century in 1846. So once anesthesia is discovered - ether anesthesia - patients no longer had pain during an operation. And perhaps America's greatest contribution to the history of medicine was the discovery of anesthesia in Massachusetts.
DAVIES: Now, this was a huge development. If, you know, surgical patients, someone getting an amputation, could actually not feel it so that you didn't have to do it in a big hurry - like, a minute or two - allowed surgeons to do more. Was this widely accepted by surgeons soon? Or was there resistance?
RUTKOW: Anesthesia was not widely accepted initially. Like many things in surgery, there is that conventional wisdom, which has a stronghold on people's opinions. So that conventional wisdom applied to pain in the - during an operation. There were people out there who felt that pain was an important product of an operation 'cause it invigorated the body. The patients were writhing. They would be able to undertake and withstand the operation better. So it's hard to imagine this, but there were people who didn't want to give anesthesia to their patients, absolutely. There are some great quotes in the book. I mean, one man I remembered said, anesthesia is the work of the devil.
DAVIES: Wow. No softies on my operation table, huh?
(LAUGHTER)
RUTKOW: No.
DAVIES: My heavens. Let me reintroduce you. We're going to take another break. We are speaking with Ira Rutkow. He's a surgeon and medical historian. His new book is Empire Of The Scalpel The History Of Surgery. We'll be back to talk more after a short break. I'm Dave Davies, and this is FRESH AIR.
(SOUNDBITE OF WILLIAM SUSMAN AND JOAN JEANRENAUD'S "WHEN MEDICINE GOT IT WRONG: MAKE THEMSELVES HEARD - FROM CHILDHOOD")
DAVIES: This is FRESH AIR. I'm Dave Davies, in for Terry Gross, who's off this week. Our guest is surgeon and medical historian Ira Rutkow. His new book chronicles the growth of surgical knowledge and techniques from ancient times to the present. He focuses on key breakthroughs in scientific knowledge and misconceptions that sometimes held back progress. The book is "Empire Of The Scalpel: A History Of Surgery."
So we were talking about how, you know, modern, effective surgery really relied upon solving some basic problems, you know, understanding the human anatomy, being able to control blood in the course of an operation, getting anesthesia so patients weren't suffering and operations could take longer. The one that still wasn't done as we kind of got through the middle of the 19th century was controlling infection. They just didn't understand the relationship between operations and infections, which were so deadly after these long operations. Louis Pasteur identified bacteria in his work. And then an Englishman, Joseph Lister, is a critical player in this. Explain this for us.
RUTKOW: Lister takes Pasteur's knowledge about bacteria. And Pasteur, his knowledge came from fermentation of wine is how he discovered bacteria. And Lister says, wow - those living organisms, they might be the very reason that wounds get infected and that surgical patients are dying. And Lister proves that. He shows that in wounds, using a microscope and how - whatever he did scientifically, that there were bacteria all over these incisions. And they were the things that were producing pus. OK. That's a great idea. But no one's willing to believe them because he's saying there are these living organisms all over the place. Who's going to believe that there's another form of life out there? Well, Lister proves his point. And he takes a number of evangelistic tours throughout Europe. The Europeans are pretty savvy. They believe him. They believe what Lister is saying.
And he tells them, you've got to wash your hands. You've got to wash the instruments. You have to spray this antiseptic spray all over an operating room and the patient. And it all goes well. 1876 comes. And there's a world's fair in Philadelphia, an international exposition. And there's going to be a huge medical congress that's involved with the world's fair. So this is September of 1876. Literally millions of people are going to the world's fair, which was held in Fairmount Park. And all of a sudden, the Americans decide, hey, we're going to invite Lister over to talk about his discovery. We don't believe him, but we're going to invite him. Lister comes to America. He gives a four-hour lecture in Philadelphia. And the Americans still don't believe him. But there's a line in the sand, a divide in America. And that is the younger surgeons, by and large, believe everything that he said. The older surgeons, that conventional wisdom, they're not willing to buy in to what Lister is promulgating.
DAVIES: Right. Now, I assume that Lister, in his writings, said - had results. Look, folks, we started doing this. And results were much better. Patients recovered. They didn't die.
RUTKOW: Yes. And he showed that the wounds all healed. But it's like anything else in medicine - not every discovery is met with a yes. They're often met with a no, we don't believe even though you're showing us scientific evidence. And they point out the reason why your scientific evidence is no good and not to be believed. And we're just not going to do what you say. It's as simple as that. We're not listening to you.
DAVIES: Then in 1881, President James Garfield is shot in the back, a wound that you say if it - if he had that wound today, he'd be out of the hospital in a few days and recover fully. It didn't hit major organs. But things went badly wrong. What happened?
RUTKOW: So it's a very simple and sad story. So Garfield becomes president in March of 1881. On July 2, he's going to go up to his alma mater, Williams College, in Massachusetts to attend a reunion and also stay at a number of hotels in the Northeast. He's going on a vacation with his family. So he enters the Baltimore and Potomac train depot in Washington. Charles Guiteau meets him from behind and shoots him in his back. Well, of course, you can imagine, the president of the United States is shot. He's lying on the floor, bleeding. All of a sudden, everybody is surrounding him. No one knows what to do. This is now five years after Lister came to America. They immediately call surgeons. They call doctors.
So we have to now think about this. The doctors come on horseback. They come riding carts. The carts have reins that the horses are wrapped up in. And the reins are on the ground, as they've been for thousands of years. The ground is filled with horse manure and other bacteria. The doctors don't know any better. They pick up the reins. They have manure-covered hands. They go in to see Garfield. The first doctor takes his finger and puts it down the hole where the bullet went, and starts to feel - see if he can feel the bullet. Now, of course, in doing that, he's introducing bacteria - overwhelming numbers of bacteria - into Garfield's wound. He never washed his hands.
So this went on for about 80 days, with doctors coming in and examining Garfield. The older surgeons would not wash their hands. No one listened. Garfield develops these huge abscesses throughout his body. And eventually, he succumbs to sepsis, to an infection, as you would expect. The problem was that there were any number of articles that started appearing in the lay press and in the professional press saying, hey, listen; you should have listened to Lister five years before. You should have been washing your hands. You should have been doing this. You should have been spraying his wound with this antiseptic spray. And that is what happened in America in 1881. We lost a president who had a gunshot that, in today's world - the bullet just entered his back and was lodged in a muscle. He died from the treatment that he received from his doctors.
DAVIES: So did that lead to wider acceptance of the, you know, measures to control infection?
RUTKOW: The answer is, yes, it did. And with it, by 1890, you know, a decade later, antisepsis was now being used throughout America. As an interesting aside, Charles Guiteau, the assassin, at his trial, comes up with a brilliant quote. He says, I did not kill the president. He said, the doctors killed the president by not washing their hands.
DAVIES: And there was a case for that.
RUTKOW: (Laughter) There was a case for that.
DAVIES: Let me reintroduce you again. We are speaking with Ira Rutkow. He's a surgeon and medical historian. His new book is "Empire Of The Scalpel: The History Of Surgery." He'll be back after this short break. This is FRESH AIR.
(SOUNDBITE OF THE AMERICAN ANALOG SET SONG, "WEATHER REPORT")
DAVIES: This is FRESH AIR. And we're speaking with Ira Rutkow. He's a surgeon and medical historian. His new book is "Empire Of The Scalpel: The History Of Surgery."
You know, you write about further advances that came as we moved into the 20th century, you know, understanding blood transfusions, eventually heart and lung surgeries, organ transplants, brain operations, as long - as well as, you know, more training and accreditation among surgeons so that there was some consistency in the kinds of treatments. One of the things that struck me is that there's kind of a randomness that affects the way medical knowledge is shared or not shared or distorted over generations. I mean, it just - there are some things that persist that shouldn't and other things that take forever to get accepted, you know, like controlling infections. One of the interesting things you write about is how the use of surgical staples, which were at one point apparently unknown in the United States while they had been in use in the Soviet Union. And the guy who bridges the gap is - was a surgeon named Mark Ravitch. Tell us the story.
RUTKOW: So Mark Ravitch was a surgeon. He had trained at Johns Hopkins, and he had gone to Russia - this was in the 1950s - on a tour of some medical facilities. And while he was there, somebody, a Russian surgeon, showed him this instrument that they had that was literally a stapler, and that they could remove lungs and staple the remaining tissue. They didn't have to sew them with sutures. They could just staple them. Now, of course, this is something that Ravitch had never seen. So he attempts to buy one of these instruments. And I write about the efforts that he did try and buy one of these instruments. And eventually, he buys one, and he brings it back to America. And, of course, the American surgeons again say, no, this - come on. Who ever heard of stapling, you know, organs and tissues? This just can't work. Well, sure enough, it does work.
And that was the beginnings of what you and I see with the laparoscopic revolution, with small incision surgery. It started things. Obviously, it took many decades, but it is the element of what we see today in surgery. And I write that, for me, you know, the four elements, once they came in, was very, very important. But we've undergone a major transformation in surgery in the last - I don't know - I would say 20 to 25 years, meaning ambulatory surgery, where you go home literally hours after the operation, many operations through small incisions and laparoscopic repair, where it's through tubes that they put inside, and the surgeon can see with a camera. This is a major revolution and transformation in surgery, as large as anything else that's happened in the past.
DAVIES: And it's growing, right? I mean, do you see any drawbacks to this? I mean, obviously, it's, you know, much shorter recovery times.
RUTKOW: I don't. I, myself, when I was operating, did hernia surgery. And my patients would come in in the morning. The operation literally was 30 minutes, and they were home in an hour to 2 hours later, having done epidural anesthesia on them, and back to work, the vast majority of them, within a week or two with minimal pain. I rarely gave pain meds after the operation. So what's the importance of all this? We clearly are progressing. The progressing has its fits and starts, its bumps. Yes, we all understand that. That happens all the time. I think the one thing that you have to be careful about in today's climate is that you don't want to introduce a new technology that is more - being done for monetary reasons than for actual patient care. There's this tyranny of surgical technology that I write about, and you must be careful to avoid that. Clearly, the technology is going to be there in the end. You know, whether it's robotic surgery, whether it's artificial intelligence, the technology is taking over, and it's going to be better and more clarified as time goes on. You just don't want to introduce it too early.
DAVIES: You know, you write, as surgery became more advanced in the second half of the 20th century, surgeons over time became among the best paid and most powerful people in medicine, often, you know, occupying senior executive positions at hospital management. But the field wasn't always egalitarian, was it?
RUTKOW: It was far from egalitarian. Certainly when you look at women in surgery, that is something in terms of the - of being able to work within the governance of surgery, being executives within major surgical organizations, that is something that really didn't come about until the 1970s or 1980s. So the fact that over half of the medical school students right now are women, we need to up the number of women in surgical fields, be in orthopedics or, for me, general surgery or whatever it is. Women need to be incorporated more. And they are. I mean, you're seeing more women who are chairmans (ph) of surgical departments. We're seeing that. But it's something which is a relatively new phenomenon. Don't forget, surgery goes back 5,000 years. I think it's important to understand that when you see a surgeon, the knowledge that a surgeon is using on you is really a reflection of hundreds, if not thousands of years of surgical experience.
DAVIES: It also wasn't racially egalitarian. Take a moment and tell us about Charles Drew.
RUTKOW: So Charles Drew was a Black surgeon from North Carolina, Virginia area. And he was just outstandingly trained. He had trained at Columbia University. He had gone to Amherst College. And he not only had an M.D., his medical doctorate, but he got another doctorate at Columbia doing a Ph.D. on blood transfusions. So he was an expert - and we're talking about the time of World War II right now - on blood transfusions. He understood blood transfusions better than anybody. And eventually, he was asked to run any number of organizations at the time to provide blood throughout the theater of the war. But what happened at one point in his life was that the Red Cross had started this program to provide blood for soldiers and all, and they sort of blacklisted Charles Drew, unfortunately. They did not want him to be the top-level executive running their program. And it was clearly a racial insult to Drew with what they did. Now, Drew went on - he tried to join the American College of Surgeons. They did not allow him in, although that's all changed in more modern times.
DAVIES: Why wasn't he admitted to the American College of Surgeons?
RUTKOW: Because the American College of Surgeons up through the - probably the '40s, '50s and '60s, blacklisted individuals. It's as simple as all that. I think they had one or two other Black surgeons. But Charles Drew, for whatever reason, was not allowed in. He never became a member of the American College of Surgeons, even though he was one of the most renowned surgeons at the time. Unfortunately, for Charles Drew, he then became head of surgery at Howard University and, shortly after that, died in a car accident.
DAVIES: There was a story that he was denied treatment because he was Black. This is not the case, you think?
RUTKOW: No. It's become urban legend. In fact, it was a severe car accident. There were, I think, other surgeons involved. They were all treated. The surgeons who were treating Drew, when they brought him to the hospital, were white. They knew who Drew was. They understood how renowned he was. And they did give him blood transfusions. They tried to revive him, but he had serious injuries. He wouldn't have survived no matter what had happened. So he died. So urban legend grew up that this Black surgeon who knew more about blood transfusions than anybody else in the world was denied a blood transfusion on his deathbed. That is all not true.
DAVIES: Let's talk a little bit about what's ahead. I mean, robots are already in use in surgery in some cases, right? What's their role?
RUTKOW: So robotic surgery is increasing in its sophistication and its ability to do operations. Now, right now robotics are used because they're so precise in their movements that they're able to get into crevices and corners and other areas that a human hand might not be able to go into. Now, understand that currently the robots are still controlled at a certain level by human beings. They're sitting there at the monitors. They're looking at what's going on. Somebody has to control the robot because if something goes bad, they need to be able to take care of the situation without the robot. Although I read the other day how, at Johns Hopkins, my alma mater, that they had just invented or were working on a surgical robot that would not need to have any human input. So we're clearly progressing towards that type of outcome, where you're going to have robots that are programmed using AI, artificial intelligence, who are able to do a hernia, who are able to do - you know, whatever the operation is, that they're going to be able to do these operations by themselves. Now, is that scary? Yes. Will it work? I suspect that it will work.
DAVIES: You know, I'm picturing surgery as being - making an incision, getting to the place where there's an issue...
RUTKOW: (Laughter).
DAVIES: ...And then cutting, suturing or stapling. The robot does all that? It feels, it senses where it needs to be to - yeah.
RUTKOW: Yes, and - but that's using artificial intelligence and being able to tell that robot what to do. Now, you got to - you have to understand that they're looking at - you know, we're going to send men to - men and women to the moon. We're going to send men and women to Mars. What's going to happen if you're on Mars and, all of a sudden, you need to have your appendix removed or something happens, you know, that you need a surgical operation? Being able to do a robotic surgery on the battlefield - that is the robotic surgery. That's what they're talking about right now.
DAVIES: Well, Ira Rutkow, thank you so much for speaking with us again.
RUTKOW: Well, thank you again for inviting me. I enjoyed the conversation.
DAVIES: Ira Rutkow is a surgeon and medical historian. His new book is "Empire Of The Scalpel: The History Of Surgery." Coming up, Maureen Corrigan reviews "Young Mungo," the latest novel from Douglas Stuart. This is FRESH AIR.
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