Surgery is nothing short of a stupendous magic act


An excerpt from The Invention of Surgery: A History of Modern Medicine: From the Renaissance to the Implant Revolution.

Johns Hopkins University was unlike anything ever built. Armed with an enormous endowment from a wealthy industrialist, the hospital (and its associated medical school) would be patterned after the German laboratory-centric model, and the clinically-based British model. The founder’s dreams of a scientific hospital staffed by full-time professors was revolutionary, and demanded innovative doctors who would commit their lives to changing the way hospitals operated. Physicians like William Welch and William Halsted.

William Henry Welch, the “American father of pathology,” was the founding physician at Johns Hopkins University. After a Continental tour of the new hospital systems in Europe, Welch returned to New York City, where he oversaw the building of the United States’ first pathology laboratory, at Bellevue Hospital. This new discipline required the latest microscopes and their associated tools, chemicals, and supplies, as well as organized morgues and structured protocols to imitate the very latest in German pathology.

Welch, the luminary in his field in the city, was a celebrated educator among the ambitious medical students looking to supplement their learning. Welch’s intelligence and unsurpassed training greatly accentuated his social standing, but it was his congeniality, borne from a household of generations of Connecticut country physicians, that endeared him to students and patients.

In September 1880, William Stewart Halsted, a commanding and vivacious New Yorker returned home from his own European postgraduate tour of duty, ready to claw and climb and outwork every other surgeon in the city. Where Welch had been tutored by the finest pathologists on the Continent, this former Yale football player had been inculcated by the leading surgeons in Europe and was an enlightened Listerian.

It took little time for Dr. Halsted to make an impact in New York. His enthusiasm, expertise, and panache made an immediate impression; his groundbreaking methods and sheer brilliance fortified his status as one of the medical men of the future, and his zeal led to appointments at multiple hospitals around Manhattan in an era where horse-drawn carriages were the mode of transportation. Halsted’s steel-blue eyes, cosmopolitan manners, and impeccable wardrobe, together with his tony Madison Square address, cemented his reputation as a cultivated physician in a specialty that only recently had risen above the level of derision.

By 1884, Halsted’s dream of a “modern” operating room with comprehensive antiseptic facilities was unmet. Raising money from friends and family, Halsted organized the construction of the most state-of-the-art operating room in the country, an elaborate standalone tent replete with maple floors, skylights, running water, gas for lighting, and sterilization facilities. In 1885, this was likely the most advanced operative theater in the Western Hemisphere.

Halsted’s operating room bivouac at Bellevue Hospital was a utilitarian version of the operative theaters he had seen in Austria and Germany while hovering over the shoulders of luminaries in Vienna, Leipzig, Halle, and Kiel. His most famous exemplar surgeon was the sensitive and melancholy physician-poet Theodor Billroth, the self-styled “sentimental North Sea herring.” For twenty-five years Billroth was professor of surgery at the University of Vienna following his training under Bernhard von Langenbeck in Berlin (1853–1860).

Langenbeck’s clinical career was interrupted several times by war, including the Schleswig-Holstein Wars (1848–1852 and 1864), the Austrian War of 1866, and the Franco-Prussian War of 1870. Battlefield medicine has never changed so dramatically in any twenty-year period; in those two decades, anesthesia was discovered, and antiseptic surgical treatment was introduced. In the Franco-Prussian War, German acceptance of the antiseptic technique was instrumental in vastly superior surgical outcomes among Prussian forces (cared for by Langenbeck and his associates) compared to the old-fashioned treatment rendered by the French doctors. German and Austrian physicians, therefore, became among the earliest and most ardent adopters of Listerism.

Bernhard von Langenbeck was heralded as a humanitarian in the treatment of both allies and adversaries, and as a founding member of both the German Red Cross and the Geneva International Convention, concluded, “a wounded enemy is no more an enemy, but a comrade needing help.”

Langenbeck’s other major contribution was his apprentices themselves; he is credited with training nearly every prominent surgical operator of his time, including Billroth, Emil Theodor Kocher, and Friedrich Trendelenburg. His idea of organized training following medical school, wherein the young pupil would live at the hospital and gradually assume greater responsibility over the course of years, has earned him the sobriquet as the “father of surgical residency.” Theodor Billroth’s Berlin tutelage under Langenbeck (1853–1860) witnessed two of the most powerful surgeons ever to coexist, with Billroth advancing as his most important protégé. Langenbeck was at his pinnacle when antisepsis and anesthesia converged, releasing surgery from its “constraining medieval chrysalis.”

Professor Theodor Billroth was uniquely poised to drive the final stake through the vampire heart of ancient, nonsensical humoral theory and quackery. The amalgamation of chemistry, microscopy, bacteriology, embryology, physiology, and diagnostics heralded a stunning transitional moment in medicine, with Billroth the unquestioned dean of surgeons. “It was a yeasty time for researchers, and the atmosphere of the German hospitals was a ferment of possibilities.” Bloodletting, cupping, purging, leeching, and poisoning were being replaced with careful German laboratory studies and scientific interventions based on organ and cell function. It was the German understanding of disease that enlightened investigators about normal structure and function.

Billroth spent long hours dissecting cadavers and planning on surgical interventions. He was able to pioneer abdominal surgery with careful preparation and strict adherence to meticulous antiseptic technique. Animal experimentation and cadaveric-rehearsed surgery emboldened the Viennese professor; perhaps the abdomen could be entered. Nothing short of a “godlike creative spirit,” as Mukherjee calls it, would suffice when it came to intestinal surgery. Vienna has a centuries’ old reputation for virtuoso performances; with Imperial spirit, maestro Billroth would take his place for master class performances in the greatest theater in the City of Music: the Allgemeines Krankenhaus operative theater.

In 1872 Billroth resected a portion of the esophagus and joined the ends together. In 1873, he performed the first complete excision of a larynx. Even more amazing, he became the first surgeon to excise a rectal cancer, and by 1876, he had performed thirty-three such operations.

What seems commonplace today (abdominal surgery) is nothing short of a stupendous magic act, in reality.

David J. Schneider is an orthopedic surgeon and author of The Invention of Surgery: A History of Modern Medicine: From the Renaissance to the Implant Revolution.

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