ECHOES FROM THE OPERATING ROOM

Trafford Publishing

Contents

1. A Moment in Montgomery....................................................12. Hippocrates of Cos: The Most Famous Physician.............................53. Mythology and Medicine: The Symbol of Medicine............................94. Mythology and Medicine: Achilles and Medusa...............................115. The Barber Surgeon and the Barber Pole....................................136. The Patron Saints of Surgery..............................................157. A Brief History of Cesarean Section.......................................178. Andreas Vesalius: Human Anatomy Redefined.................................199. William Harvey: The Circulation of Blood Described........................2110. A History of General Anesthesia..........................................2311. The First Use of Ether for Surgical Anesthesia...........................2512. Wash Your Hands..........................................................2713. The Birth of the Germ Theory and Bacteriology............................3114. The Discovery of Antisepsis..............................................3315. A Brief History Blood Transfusion........................................3516. The First Laparotomy.....................................................3717. The First Gastrectomy....................................................3918. The History of Appendectomy..............................................4119. Advances in Appendectomy.................................................4320. Pancreaticoduodenectomy..................................................4521. The First Perineal Prostatectomy.........................................4722. The Use of Rubber Gloves in Surgery......................................4923. The White Coat...........................................................5124. The History of Surgical Attire...........................................5325. The History of the "Scrub Tech"..........................................5526. The History of Surgery on the Mayo Stand.................................5727. The Father of Surgical Education: William Halstead.......................6328. The Father of Modern Hernia Surgery: Eduardo Bassini.....................6729. The Father of Neurosurgery: Harvey Cushing...............................6930. The Father of Pediatric Surgery: William Ladd............................7131. The Father of Modern Orthopedics: Willis Campbell........................7332. The Father of Cardiac Surgery: Michael DeBakey...........................7533. The Father of Modern Gynecology: J. Marion Simms.........................7734. The Blue Baby Turns Pink.................................................7935. John H. Gibbon: The Birth of Open-Heart Surgery..........................8336. A Button and the Surgical Clinics of North America.......................8737. Surgeon Nobel Laureates..................................................9138. Electrosurgery and a Man Named Bovie.....................................9739. Johns Hopkins and the Four Physicians....................................9940. The Mayo Clinic and the Mayo Brothers....................................103I George Washington, President 1789-1797.....................................107II James A. Garfield, President 1881.........................................109III Grover Cleveland, President 1885-1889, 1893-1897.........................111IV Dwight Eisenhower, President 1953-1961....................................113V Ronald Reagan, President 1981-1989.........................................115References...................................................................117

Chapter One

I think I should begin by telling you, the reader, a little about my own surgical history and why I wrote this book. I was twenty years old when I walked into my first operating room at St. Margaret's Hospital in Montgomery, Alabama. After graduating from high school, I lived at home in Louisville, Kentucky in order to attend the University of Louisville. But after eighteen months of very little study, my two major interests were rock and roll and Kentucky bourbon. At the end of a late night of too much of both, the Beatles blared out from the radio in my 1957 Chevy, cutting through my aimless adolescent confusion, and told me with their song's title that I was a "Nowhere Man". This unlikely instance of clarity suddenly took my life in a different direction. That same morning I joined the United States Air Force in order to grow up and to help my country, or so I thought, in Viet Nam. It was 1966 and the war was escalating rapidly to its peak. The recruiter assigned me to be a medic. After basic training, and then medic school, I was told I was to be an operating room technician. I was stationed in Montgomery, Alabama for training. After a week of learning the names of the instruments, the correct way to fold linens, and the details of sterile technique, Master Sergeant Cartledge sent me downtown to St. Margaret's to watch surgery for the first time.

The head nurse, who was a tall imposing Catholic nun, told me to go to room two, stay out of the way, and just watch. Doing as I was I found operating room two and pushed open the two half doors that hung in mid-air from each side frame much like the old bar room doors in a Roy Rogers western movie. The moment I stepped into that small operating room in Montgomery, Alabama, my life was changed forever. The surgeon was making an incision into a young man's knee. I knew at that second what I would do for the rest of my life. I had never seen anything so exciting, so interesting, so precise, and so meaningful. I knew I had to do it. That moment in Montgomery hit me like a thunderbolt from Zeus. I hurried back to my sergeant to tell him that I finally knew what I wanted to do, so he could let me go back to the University of Louisville and I could become a surgeon. Upon hearing this, after his laughter had stopped, he assured me that I had four more years to serve in "this man's Air Force" and that if I lived through Viet Nam then I could try college again.

I spent three more years in Air Force operating rooms with one of those years being stationed in Southeast Asia at U-Tapoa Air Force Base in Thailand. The horrible injuries and wounds I saw there did not deter me but further reinforced my desire to be the one making the decisions and doing the dissection. When I came home and was discharged, I immediately returned to the University of Louisville and started college all over again. I had but one goal and that was to become a surgeon, not a doctor, but a surgeon. After graduating college, the University of Kentucky accepted me into medical school and gave me the chance to get a M.D. degree. Then five years of intense training in surgical residency followed, and now some 30 years as an attending professor of surgery has passed since that fateful day in my first operating room. I have had the privilege of operating on many thousands of patients and the opportunity to teach hundreds of young men and women the satisfaction of caring for patients in and out of the operating room.

When I returned home and reentered college, I worked as a scrub technician for a truly talented surgeon named Benjamin B. Jackson. He had trained under the great professor of surgery Robert Ritchie Linton at Harvard and the Massachusetts General Hospital.

Every day, as we operated, Dr. Jackson recounted the Greek myths and told story after story about the great surgeons of the past. I was always quizzed the next day on the details of that day's history lesson. He instilled in me a love for both Greek mythology and surgical history. He was my first surgeon mentor and had a great impact on me. My son bears his name and, in a way, he is partly responsible for this book.

This book is dedicated to the ones that came before and is for those who will come after. It is written for those young men and women who have allowed me to teach them and in return have taught me even more. The appreciation of the history of surgery is not just for old surgeons. It adds a foundation, understanding, and a certain grace to the practice of all of those involved in a profession that is itself ageless.

Every day in every operating room throughout the world the same names are spoken over and over again. These names are the names of the great surgical innovators and teachers of the past. These men have become eponyms. Surgeons call out for Kocher clamps and Deaver retractors. They perform Billroth gastric resections and Bassini hernia repairs. Those names and all the others have echoed from the bright clean environment of operating rooms for over a hundred years. This little work attempts to tell their stories in an educational and entertaining way while at the same time honoring those names and their contributions that formed the basis of modern day surgery.

As the years pass by, I increasingly think of the skill and courage of those that came before me. I know that they too must have felt the weight and loneliness of life and death decisions. I know that they too experienced the quiet and inward exhilaration of the operative procedure completed perfectly just as planned and without complication. But I can only imagine the courage and brilliance it took to take that next innovative step into the unknown and do it with the patient's life in the balance.

Even today as I finish scrubbing my hands, when I back through that operating room door and step into the sanctum of I can hear those echoes of the past and feel their presence. Even now at the close of my career, it is still the same excitement for me and still the same thunderbolt as it was that moment in Montgomery.

A Short History of Medicine

2000 B.C.—"Here, eat this root."

1000 B.C.—"That root is heathen, say this prayer."

1850 A.D.—"That prayer is superstition, drink this potion."

1940 A.D.—"That potion is snake oil, swallow this pill."

1985 A.D.—"That pill is ineffective, take this antibiotic."

2000 A.D.—"That antibiotic is artificial. Here, eat this root."

Anonymous

Chapter Two

Hippocrates

Ancient Greek mythology told of Asklepios the great healer. The God Apollo and a mortal named Coronis had a son named Asklepios. Coronis was unfaithful and Artemis, the sister of Apollo, killed Coronis with her bow and arrow. Just before Coronis died, Apollo rescued his unborn son by cutting him from the womb of Coronis. Asklepios there received his name meaning "to cut open." The Centaur named Cherion raised him. Asklepios had a daughter named Panacea (universal cure), a daughter named Hygeia (health and beauty), and two sons who were battle surgeons. Asklepios became a great healer. He was so good that Hades, the god of the underworld, complained that not enough people were dying so he demanded that Zeus kill Asklepios. With his mighty thunderbolt Zeus did as his brother Hades requested. However, the Fates returned Asklepios to Mount Olympus and Asklepios became deified as the god of healing.

On the Island of Cos off the southwest coast of Turkey, a sect called Asklepiads worshiped Asklepios and practiced mystical religious-based teachings in temples devoted to him. The snake was felt to be sacred and the priests interpreted the dreams of the patients. Unlike the priests, the lay healers outside the temples used observation of results in their practice and had strong family traditions. In 460 B.C., Hippocrates was born into such an Asklepiad family. Hippocrates disassociated medicine from religious mysticism. He crystallized the existing knowledge into a systemic science. He was also the first to make physicians realize their high moral obligations to their patients.

Hippocratic physicians believed that nature needs to maintain equilibrium and if anything is out of balance disease results. They thought there were four fluids, or humors, that were the cause of certain emotions and behaviors: blood, yellow bile, black bile, and phlegm. Blood imparted energy, while yellow bile was choleric and made one quick to anger. Black bile was melancholic and introverted, and phlegm meant the brain was quiet and relaxed. Balance was health and an imbalance was the cause of disease. Because they kept accurate records of observations, this allowed them to make predictions or give a prognosis to the patient, and their reputation grew and grew.

Ptolemy I collected the entire medical works of the Hippocratic physicians under one title the Corpus Hippocraticum. In 1525, Pope Clement the VII compiled the first complete printed edition, which contained 70 different texts and was made up of writings before and after the death of Hippocrates. This work details the use of observation and record keeping, as well as the removal from medicine the notion of the supernatural. Also included is the famous Hippocratic Oath, which was the first ethical code of conduct for physicians. By swearing the Oath, the physician promised to hold his teacher as important as his parents, to teach his sons the art, and to keep his patients from harm. He swears that he will give no deadly drug, perform no abortion, and that he will not cut for stone. He also swears to visit the patient for their benefit only and to not have sex with the patient. Finally, he vows to keep matters confidential and act in a moral way. Some form of this oath is still taken by a great majority of doctors graduating from medical school today. Hippocrates remains the most famous and well-known physician even now some 2,500 years after his death.

"Life is short, the Art is long, opportunity is fleeting, experience is delusive, and judgment is difficult."

Chapter Three

The symbol of Asklepios was his staff. The staff was a single knotty rod with a single serpent entwined about it, often with a Hippocratic saying.

The origin of the staff is probably related to a practice of the Jews in the desert who would occasionally accidentally step on the parasite named Drancunulus Medinensis, a one and a half foot long worm. They removed the worm through the wound in the foot by wrapping it around a stick. Also the shedding of the skin by the snake symbolized the process of renewal and regeneration.

The caduceus, which is often thought to be the symbol of medicine, is two serpents entwined on a staff with wings at its top.

The caduceus is really the symbol of Hermes (Roman name—Mercury). Hermes was the winged foot messenger of the Gods and the symbol of commerce. A Swiss printer of medical books, Johan Froben, always used the caduceus on his frontispiece and so it became associated with medical books. The United States Military Corps mistakenly adopted the caduceus as its symbol in 1902 at the insistence of a single officer. Currently 70% of medical companies use the caduceus and 40% of medical professionals do as well.

The symbol of medicine is the staff of Asclepius not the caduceus.

"Good surgical judgment comes from bad experiences. Wisdom then comes from the experience of bad surgical judgment."

Anonymous

Chapter Four

The Heel of Achilles

The Achilles tendon is the tendinous extension of the two calf muscles in the lower leg: the gastrocnemius and the soleus. The tendon passes posterior to the ankle. It is the thickest and strongest tendon in the body. It is about six inches long, and is inserted into the middle part of the posterior surface of the heel bone, the calcaneus.

The term Achilles heel is a deadly weakness, either literal or figurative that in spite of overall strength can potentially lead to downfall. The mythological term suggests a specific physical vulnerability, while today the term is used as a metaphor for attributes that can lead to failure. For example, "His pride was his Achilles heel."

Achilles was a Greek hero who was the central figure in Homer's Iliad. His mother Thetis wanted to make her baby son immortal and invulnerable so she held him by the heel and dipped him into the river Styx. The river Styx surrounded Hades and was the boundary between Earth and the Underworld (Hell). The Trojan named Paris killed Achilles. Paris shot an arrow that struck Achilles in the heel, his only vulnerable spot, and the great warrior Achilles died as a result of the injury.

The Head of Medusa

Medusa was a beautiful maiden who was the only mortal of the three sisters known as the Gorgons. One story has it that she lived far in the North and wanted to see the sun. She asked the goddess Athena for permission to visit the South and see the sun, but Athena refused. Medusa became angry and told Athena the reason she had refused her was that Athena was jealous of her beauty. Athena became incensed and punished Medusa by turning her hair into snakes and made her so ugly that anyone who looked upon her turned into stone.

Patients with cirrhosis of the liver can have increased resistance to blood flow through the portal vein, which increases the portal venous pressure. Portal hypertension then causes the portal venous blood to be shunted away from the liver into the systemic veins of the abdominal wall. These veins become engorged with blood, dilated, and appear as large varicosities around the umbilicus. They resemble the snakes on the head of Medusa. Caput is the Latin word meaning head. So the presence of dilated veins around the umbilicus is indicative of portal hypertension and is called the caput Medusa, or the head of Medusa.

"Abdominal Surgery—It is safer to look and see than to wait and see."

Sidney Cuthbert Wallace

Chapter Five

In Medieval Europe surgery was not generally done by physicians, but by barbers. During the early Middle Ages, most healing arts (both medical and surgical), were practiced by members of the clergy. However, concern a rose about the shedding of blood by these religious men and the Pope decreed that monks and priests should not and could not perform surgery. Therefore, the barbers who had experience with razors, in cutting the monks' hair, were chosen to perform the operations. The academic and social status of these barber-surgeons was much lower than that of physicians. Medicine was considered a profession practiced by doctors trained at a university. Surgery was a trade, sometimes carried out by the uneducated lower class.

Around the 13th century, guilds of barber-surgeons began appearing in Europe. In London, separate trade guilds for barbers and surgeons began as early as 1308, the two largest being the Company of Barbers (later known as the Barber-Surgeons' Company), and the much smaller but better educated Fellowship of Surgeons.

At the end of the fifteenth century, the two guilds had begun to work together on the licensing of surgeons, and in 1540 an act of Parliament combined the two guilds into one. They made certain laws, one of which prohibited surgeons from practicing as barbers and barbers from practicing surgery, with the one exception of the pulling of teeth. This association endured for two hundred years. It was ended in the 18th-century by surgeons across northern Europe who began to disassociate from their hair-cutting colleagues.

In 1745, London surgeons formed their own Company of Surgeons, which would evolve into the Royal College of Surgeons of England. As an interesting and lasting vestige of their history, today throughout the United Kingdom, surgeons are referred to as "Mister" and physicians are called "Doctor."

The red and white barber pole was associated with bloodletting and represented blood soaked bandages wrapped around a pole. The original poles had washbasins at the top and bottom: the leeches were placed in the upper basin and the bottom basin received the blood. The actual pole was the staff that the patient held onto during the bloodletting procedure. The United Barber Surgeons Company in England required a blue and white pole to be used by the barbers, and surgeons were required to use a red and white pole. Some would say the red of the barber pole represents arterial blood, the blue represents venous blood, and the white depicts the bandage.

"The fact that you do not know what to do does not mean that you have to do something."

Anonymous

(Continues...)

Excerpted from ECHOES FROM THE OPERATING ROOMby Carl R. Boyd Copyright © 2013 by Carl R. Boyd . Excerpted by permission of Trafford Publishing. All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
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