Ira RutkowReseñas

Empire of the Scalpel: The History of Surgery
Ira Rutkow, Mar 2022, Scribner, an imprint of Simon & Schuster
Themes: Medical, History
Tracing the fascinating story of surgery through global history, EMPIRE OF THE SCALPEL shares the key people and breakthroughs that established the foundations for today’s life-saving medical practices.
Take-aways: Educators will find useful examples of how the science of surgery evolved over time. Use these people and practices to demonstrate the importance of ongoing research and perseverance.

Much better at describing the foundations of surgery than later years (say, 1960+), and poor information on 21st century surgical developments. Therefore a lot of the ground covered was familiar. Still, Rutkow tells the story in his own way, and I certainly learned from it.

> The original [Hippocratic] Oath specifically forbade cutting: “I will not use the knife; not even on sufferers from stone, but will withdraw in favor of such men as are engaged in this work.” The proscription established an unmistakable division between Hippocratic-influenced physicians and the class of individuals who performed surgical operations. Like that of their Babylonian predecessors, who consigned surgery to a lesser standing within Medicine, the Greeks left the craft and its work of the hand to itinerant craftsmen and roustabouts

> As the first major medical author writing in Latin, Celsus translated hundreds of Greek medical terms into the language of ancient Rome. Many of these words remain in modern professional usage. I recall, fifty years ago as a freshman medical student, memorizing the four cardinal signs of inflammation enunciated by Celsus, ones that he urged every surgeon to be on the lookout for: “calor, dolor, rubor, tumor; calor, dolor, rubor, tumor.” This assonant phrase, with its English rendition—“heat, pain, redness, swelling”—is tattooed onto every surgeon’s psyche.

> In the sixteenth century, Vesalius and Paré created a revolution in anatomy and surgery: the former, by demonstrating that knowledge of human anatomy can only be gained through the hands-on dissection of cadavers; the latter, by showing how to control bleeding during an operative procedure.

> "All his profession would allow him to be an excellent anatomist, but I never heard of any that admired his therapeutique ways. I knew severall practisers in London that would not have given 3 ducats for one of his bills." Favoritism or not, Harvey’s middling work as a physician should not be conflated with his astounding accomplishments as a researcher. During Harvey’s early years of practice, no one knew that he was investigating the action of the heart and the movement of blood. … What Harvey could not explain was how the arteries and veins were connected to one another to complete the circular pathway. He was unable to visualize the capillaries, the arterial-venous go-betweens, because they were microscopic sized. Proof of their existence would wait several decades until the microscope was invented

> In early 1865, his approach changed when he read a newspaper account of how engineers at a nearby sewage plant used carbolic acid (aka phenol, a derivative of coal tar) to reduce the smell of cesspits. Lister deduced that the carbolic acid killed the microorganisms in the refuse … Joseph Lister joins the elite list because of his notable efforts to introduce systematic, scientifically based antisepsis in the treatment of wounds and the performance of surgical operations.

> In 1686, the surgical treatment of Louis XIV’s anal fistula required construction of a handmade, three-pronged, metal retractor that allowed his surgeon to adequately view the king’s anal canal. The success of the operation demonstrated the curative powers of a knife bearer’s scalpel and brought about a key shift in how the public viewed the craft of surgery.

> Railway accidents in the nineteenth century were so common and catastrophic they brought about the long forgotten specialty of railway surgery. It was America’s earliest large surgical specialty with its own journals, textbooks, and local, state, and national societies. However, railway surgery ultimately failed to gain recognition within mainstream Medicine and suffered a precipitous decline.

> Charles Drew was a celebrated African-American scientist and surgeon. His research in the area of blood banks and techniques for blood storage led to the large-scale use of blood transfusions during World War II.

> Surgeons could not repair major cardiac defects without a way to stop the heart from beating while ensuring that the patient’s blood was still oxygenated. John Gibbon, with the assistance of his wife, Mary, developed the heart-lung machine and their success meant that heart surgery, an elusive vision in 1950, became practical and routine by 1960.

> In 1954, the world’s first successful transplant of an organ, a kidney, changed surgery in profound ways. It broke a psychological, perhaps spiritual, barrier that viewed the human body as a sacrosanct object able to receive care but not designed to provide it. An individual’s body could now provide a cure, along with drugs, minerals, and plants.

Although Rutkow's depiction of Civil War medicine does not focus on nurses, he does make some valuable points about Civil War nurses. On page 168 he reminds the reader that no programs in nursing education existed in the country at the time, and although some Catholic orders did train nuns as nurses, the training was not of the "Nightingale School" ie cleanliness, diet, drainage, light, quite and warmth and adequate ventilation; but rather caring for patient's emotional needs, providing clean clothing and linen and regulating what the patient could eat. This is the first book I've read that discusses in detail the type of training received by nursing sisters. It also discusses the Catholic church's initial reaction to the nun's nursing for the Army which was unfavorable. The book also contains an excellent discussion of why Victorians found the idea of women nurses so unpleasant, and discusses the contributions of such nurses as Hannah Ropes and Lousia May Alcott. The author explains more about the background and character of Hannah Ropes than one can get from her diary (which we have) and also does a great job explaining the motivations of Dorothea Dix. The story of Dix's attempts to hire only middle-aged, plain women is well known, what is not known was why. Initially Army doctors objected strenuously to almost all the women nurses, criticizing some for laziness and other for working too hard and insisting on cleanliness. The real problem of course was that few doctors wanted the women there at all! The only women, Dix believed, who could get along with doctors were "women of bad character" because these became the doctor's mistresses! Thus she began to insist on plain women...

The first half of this book offers a short biography of the little-remembered President, and the second half is made up of a detailed account of the shoddy medical care which he received after his shooting. This portion of the book incorporates a digression into the state-of-the-art of American medicine at the time, with emphases on the slow and grudging acceptance of Lister's sepsis discoveries, the absence of a nursing profession, and the rivalry between homeopaths and allopaths to become the prevailing approach for American clinicians. The author is hardly the first individual to state that physicians killed Garfield, not an assassin--indeed, assassin Chas. Guiteau said as much in his courtroom defense, but he does deploy some truly excruciating examples of poor practice to strengthen his case. Unfortunately, his antipathy toward the physicians in charge leads him into expressing a rather odd sympathy for homeopathy. A fascinating epilogue sketches the medical care and overnight stay in the hospital Garfield would have received had he been shot a century later when Dutch Reagan was shot. The book is unspectacular but consistently interesting and informative.

Did I miss something, or did the end of the Civil War not mean that the country was reunited? For a book purporting to be an account of American medicine during the Civil War, it is unfortunately only a documentation of Union medical development during that era. Exactly ONE Confederate case--that of Stonewall Jackson's agonizing death after what should have been a survivable wound--is mentioned, and that only fleetingly. The author clearly spent much time at the Army Medical Museum*--I must get up there some day and visit Dan Sickles's pickled leg--would it have killed him to have gone one hundred miles down the road to visit the medical museum on the site of Richmond's Chimborazo hospital? I was interested to discover if Chimborazo, the largest Confederate hospital, really did serve as the model for pavilion hospitals on both sides of the conflict, and I was hoping to find out how the Confederate medical staff coped with medical shortages due to the blockade, or how they dealt with the continual insistence from fundraisers that money and material donated go only to the wounded from an earmarked state. And didn't the Confederacy start the first proto-MASH units, too? I would have liked to have read about that, as well. Alas, my curiosity remained unsatisfied. For a book entitled "Blue" AND "Gray", this lapse was inexcusable.

Harrumph. Well, as a history of Union medical practices, this book isn't bad. Rutkow writes with some verve; his thumbnail sketches on the querulous and paranoid Stanton, the imperious Hammond, and the energetic man-of-all talents Olmstead are especially good. Even more gripping are his accounts of the slow deaths of several soldiers whose excised wounds ended up in the specimen jars at Walter Reed; these are particularly difficult for a modern reader to follow, as the great advances in bacteriology came just a few years too late for these hapless men. And I enjoyed the accounts of the backstabbing amongst the paper-shufflers. There's a bit too much of that, however, as the author circles back (and circles back) to his obvious greatest interest, the establishment of the Union Ambulance Corps, and the turf struggles between the Quartermaster Department (to whom it originally belonged, when the department belatedly decided the Union Army needed one) and the Surgeon General and Dr. Letterman, who were of the opinion that said department was too lackadaisical by half. Indeed, the author would have been better to have organized his book in strict chronological order, or to have picked an area of medicine (nursing, surgery, etc.) for each chapter, as that would have cut down on much redundancy. It is still a fascinating look at an era when man's technological ability to wield destruction outstripped his capability to cure it.

* While writing this review, I spoke to someone whose husband works at the now renamed National Museum of Health and Medicine; she believes the museum, relocated in Silver Spring, is inferior to the old one near Walter Reed as the display area is somewhat diminished, and many of the preserved medical specimens have been tucked away. The moral: always visit when you can.

This is a short biography. It's too bad it couldn't be one part of a three- or four-part biography.

James A. Garfield was very likely the smartest man ever to be President of the United States. He is the only President to have invented an independent proof of the Pythagorean Theorem. He spoke multiple languages -- one story says that he could write Greek and Latin simultaneously, one with each hand. When he was elected President, it was said that he was able to do all the jobs of his cabinet secretaries, so great was his understanding.

But he was not good at decisions. Some of his social interactions were odd. As a leader, he wasn't much.

Reading about him, I couldn't help but think that he really sounds as if he had Asperger's Syndrome. Both the brains and the oddities fit. So it would be nice to have a biography by a psychologist.

It would be nice to have a biography by a student of elections, too, to study his strange rise. And a biography by a military historian, who could look at his Civil War record.

But it's also nice to have this biography, which looks at his long, sad death at the hands of incompetent surgeons. If the rest of Garfield's biography is slighted in this short book, we certainly get a good look at how medicine was changing, and failing, in the late nineteenth century.

I enjoyed this book. But it left me wanting more. Garfield probably deserves more biographies than he has received.½

Rutkow's biography is less a biography than retelling of Garfield's near-assassination and subsequent medical mistreatment leading to his death. As such, it's not what I hoped for when I picked it up. The medical story was pretty interesting in it's own right, though.

It was a quick read, but not terribly informative about the subject at hand. Guardedly recommended for those interested in late 19th century American medicine.½

Ira Rutkow. James A. Garfield. New York: Times Books, 2006. 139 pp. $22.00.

Ira Rutkow is a clinical professor of surgery and the author of several books including Seeking the Cure: A History of Medicine in America and Bleeding Blue and Gray: Civil War Surgery and the Evolution of American Medicine.

James Garfield was America's 20th President for 200 days, 79 of which were spent dying of a gunshot wound. Thus, Garfield only functioned as the President for 121 days (the last of our 'born in a log cabin' presidents). Rutkow notes Garfield was "the most well-educated congressman of [his] era" and points out "he signed out more books and spent a greater amount of time [in the Library of Congress] than any other congressmen. Visitors to the house in Washington always remarked on the size of Garfield's study...Garfield always made certain that he had books with him when he traveled" (45). Yet, it is not true he could write Greek and Latin simultaneously.

This book is a brief biography of Garfield's life. By page 55 James has won the Republican nomination and by page 62 he and Chester Alan Arthur have won the 1880 presidential election, beating Winfield S. Hancock by less than 2,000 votes (the closest popular vote in American history). Less than ten pages later we first meet Charles Julius Guiteau, a mentally unstable self-educated lawyer seeking an appointment from Garfield.

Despite the fact Lincoln had been assassinated only sixteen years earlier, American presidents still had no bodyguards and security was generally not a major concern. Furthermore, newspapers printed the president's daily schedule (in 1963 JFK's Dallas route was printed). Likewise, White House doorkeepers unwittingly gave out information on the goings and comings of the president. Such lack of concern would result in the assassination of a second president.

Guiteau purchased a .44-caliber to carry out what he perceived to be the will of God. On June 12 Charles Guiteau followed James Garfield to the Disciples of Christ Church on Vermont Ave. There he plotted to kill the man who rejected him for the consulship in Paris.

While the first 81 pages focus on Garfield's journey into the White House, the last 58 focus on the shooting and the medical care (or lack thereof) of which Garfield received. Here, Ira Rutkow is at his best. The 55-year-old Doctor Willard Bliss is more the villian in this tragic tale. In fascinating detail Rutkow documents the consistently poor decision-making abilities of Bliss and his team. Bliss claimed, "If I can't save [Garfield], no one can" as infighting worsened between himself and his colleagues over what constituted proper treatment.

Rutkow ably explains in layman's terms how two medical worldviews were clashing in 1881. Unfortunately, Bliss did not put much value in the findings of Joseph Lister who claimed, in the mid-1860s, germs on wounds create deadly infections. Listerism is a system of sanitizing hands, instruments and skin. Numerous physicians stuck their unwashed fingers and uncleaned instruments into the back of the president. Furthermore, they believed pus was the sign of a healthy wound. The unfolding of the medical malpractice surrounding Garfield is jaw-dropping. Weaving historical 'firsts' into the plot only enhances the story's telling (I would love to divulge here, but do not want to spoil the fun).

The moral of the story: America's best doctors killed our nation's 20th president!

Unfortunately, the book has only one picture. Likewise, it is unfortunate the reader is never informed of what happened to Charles Guiteau--he was sentenced to death by hanging which occurred on June 30, 1882 in Washington D.C.

An enlightened reader,
A Ramey½

A brief overview of Garfield. There is some value to be found in the chapters on the state of medicine and surgery at this time in history. Otherwise, a disappointment.