The History of Surgery: How We Got to Where We Are Today
Today, surgical breakthroughs have been as astonishing as heart transplants and face transplants, and even keeping people alive with the help of technology. But, what was life like for surgeons before this emerging science? In this interview, Richard Hollingham, author of “Blood and Guts: A History of Surgery,” take us back in time when medicine was the Wild West of experimentation and shocking decisions. Learn more about your ad-choices at https://www.iheartpodcastnetwork.comSee omnystudio.com/listener for privacy information.
He had a milk pump used to carry milk around dairy to connect these tubes, which were actually the same tubes you'd use for beer.
So in a bar to bring up the beer from the cellar, he used those beer tubes and a milk pump and connected a parent to a child.
So when he cramped off the child's heart, it was the parent who was doing the breathing for the child.
Hey everyone, I'm Dr. Oz, and this is the Dr. Oz Podcast.
We're joined by a colleague, a writer from Great Britain, who's written a wonderful book called Blood and Guts, A History of Surgery.
Richard Hollingham is a science journalist, author, and a BBC radio presenter, so he's well-versed with the art of radio.
He's joining us today to talk about the blood and guts.
Richard, thank you for joining us.
No, you're very welcome.
Thanks for inviting me on your excellent show.
Well, you're very kind.
Now, we live in a time when surgery has become pretty routine, and that's a pretty recent development.
Until probably 1900, most folks who went to the hospital did not expect to survive the visit.
You actually went back even further and started around 1850 with a description of an amputation.
Just get everyone up to date on what surgery was like 150 years ago.
Well, let me tell you about just a few years before that, so about 1842, something like that.
And imagine you're in a city like New York or London, one of the modern cities of the industrial age.
And the operating theatre, well, it's a bit like a theatre if you're going to see a play.
There's these steps where surgical colleagues could look down on the operation.
Then there's the operating table, which was, well, just a table, but stained with blood, sawdust on the floor too.
To catch the blood from the operations themselves.
And no anesthetic.
So the patient would be probably dragged in screaming normally because they really did not want this excruciating, awful, appalling procedure.
They'd be strapped down to the operating table and then it was all about speed.
So the surgeon with their Fock coat encrusted with the blood and pus of previous operations.
I mean, they didn't want to get their street clothes dirty.
They would...
Just work as quickly as possible.
Apply a tourniquet to the top of the leg, say for a leg amputation, slice through the flesh, pull it back, saw through the bone and then stitch up the blood vessels, release the tourniquet and that was it.
They could do it in 30 seconds.
They could remove a leg which would be just drop into the sawdust on the floor.
You can just I don't think you can actually.
I don't think I can imagine the horror of that, of watching that, or we're still experiencing that.
What were the types of operations?
You mentioned amputations, which I can sort of imagine, although it's difficult having done them in the modern era, what kind of other procedures would folks willingly have done?
I mean, you say they're dragged in, they're not wanting the surgery, but they had to consent, I gather, right?
Yeah, it's one of those awful decisions you would have had to make.
Do you have the surgery and live?
Or not have the surgery and almost certainly die.
So no antibiotics, no understanding really of disease or infection.
So if you had a compound fracture, that's when the bone would come up through the leg side.
Let's talk about a leg amputation.
It gets infected, you get blood poisoning, gangrene.
The only way to survive is to remove the leg.
So that's your choice.
Operate a reasonable chance of living, depending on how good the surgeon is, or not operate and almost certainly die.
So really it's surgery of last resort.
So no brain surgery, no heart surgery, nothing where you cut into the body, because if you cut into the body, a good chance you'll introduce infection and the patient will die.
What percentage of people would die with surgery anyway?
Well, it sort of depends on the surgeon.
One of my favorite surgeons is a British surgeon.
Very tall, arrogant man.
Arrogant is a word you associate with surgeons over the years, no offense.
Nugdagan.
And botched is another one.
But Robert Liston was...
He was a great surgeon, and only about one in six of his patients would die.
He operated very quickly, very efficiently, very cleanly.
But other surgeons, I mean, you have to imagine that surgery wasn't really...
They weren't...
That well trained, some of them.
And becoming a surgeon was often about knowing the right people.
So some of the surgeons were shocking.
I mean, awful.
And you really would be better not having the operation than with them.
And they killed almost all of their patients.
Because it's like the Chi-Chi joke, you can either die or you can have death or death by Chi-Chi.
It's like you have the torture and then you die instead of just dying with the surgery.
Well, exactly.
These are all terrible choices that you have to make, and particularly in the 19th century where you've got this industrialization, you've got factories, you've got trains, you've got trams, all these things, and there were more and more nasty accidents, and amputation was becoming more and more common.
You mentioned surgical training not being ideal.
How were surgeons trained?
And I'm at Columbia University, so it's called the College of Physicians and Surgeons.
And I know in Great Britain, the surgeons are not called doctors, they're called misters.
So were surgeons trained at completely different institutions?
Yeah, I mean, you know, doctors didn't really like surgeons.
Doctors were considered, well, doctors, physicians were considered professionals, very high standing in society.
Whereas surgeons, well, they come from the barber-surgeon tradition.
So you go to the barbers and have your shave, your hair cut, they would also do amputations.
So that became a craft.
Surgery was a craft rather than a profession, if you like.
So, you know, surgeons were almost considered like carpenters or blacksmiths.
And it was only really around the 19th century they started to get any respect, which is strange, really.
The doctors, they didn't know anything.
I mean, the surgeons could actually...
Save people's lives, whereas doctors did all sorts of weird stuff and bloodletting and all sorts of odd potions that were ineffective.
Well, Volterra spoke frequently about the role of medicine in the 18th century.
It wasn't much better than the 19th century, I guess.
So in any case, we've got these surgeons.
They're not that well-trained.
They're not doctors, but that may not be a bad thing 150 years ago.
And they're doing fairly urgent procedures, nothing really of the nature that we talk about in surgery today.
And just to be clear on this, there was no anesthesia, right?
To my recollection, anesthesia didn't really even exist until the initial use of ether around that time.
About 1846, it was an American invention, a guy called, well it's still slightly controversial, but it's accepted really that it's a guy called William Morton, who was a dentist.
So you had ether and then the Brits.
We didn't like the fact that this was an American invention.
They called it a Yankee Dodge.
So they came up with chloroform.
So you had ether and chloroform, and both had their advantages and disadvantages.
I mean, the big disadvantage of ether was it was highly flammable.
So you're operating in these grimy operating theaters under gas lights, and you're introducing just a few inches away from the gas light This highly flammable ether, that was a recipe for disaster.
And then chloroform, they were just applying it to rags and sticking it over people's faces to knock them out.
And it turned out that often when you did that, you killed the person you were trying to knock out.
You've got to get the balance exactly right.
It was very imprecise.
But obviously, you know, suddenly you can do surgery without the pain.
What a wonderful thing for surgeons.
The trouble is, they hadn't It worked out anything about infection or disease.
So they were doing all these operations.
They thought for the first time, we could cut into the body, we could remove an appendix or fiddle around.
And more patients were dying as a result of introducing anaesthetics than before they had the anaesthetics.
But they used to have parties, didn't they?
Ether parties and all kinds of other crazy get-togethers?
Oh, yeah.
This is what passed for rigorous experimentation at the time.
Ether, the surgeons would have their friends around and visiting dignitaries and the like, and they'd pass the ether around, and people would laugh at the people as they sprawled out on the floor.
Chloroform was a particularly dangerous anesthetic.
A guy called James Simpson in Scotland, he'd experimented all sorts of amounts on himself.
He had parties, his niece parked out on the sofa describing herself as an angel.
It was like a parlor game, a party game, but these things were really dangerous.
Well, I guess, would the surgeon's assistant give the anesthesia?
Who would actually do the administration if that's where most of the risk was?
Yeah, there was no anesthetist, no one who would actually do this stuff.
I mean, either the surgeon or one of the assistants.
There are quite a few assistants you'd have with the surgery.
Because it had come up through this tradition of being quick and fast, you needed everyone to do everything right, like a military operation.
And that was one of the other things that anesthetics enabled surgeons to do was to slow down a bit.
It didn't have to go quite so fast.
But again, by slowing down, they increased the risk of infection.
And there was some transition, obviously, they had to have been, otherwise we wouldn't be able to do surgery that we can do today.
So what was the major change that allowed anesthesia to become safer and more broadly applicable?
I think the big change was not so much with anaesthetics.
I think there was a period, really, in the middle of the 19th century where they understood how the body fitted together.
They could stem blood loss, so in an operation, if they were lopping off an arm or a leg, they could tie it off.
They could tie off the blood vessels.
They could control pain, so people weren't enduring this awful agony.
But they were still dying because they didn't understand infections.
If you like, if there was a big surgical breakthrough, it wasn't anesthetic.
Although, you know, we think, well, pain relief, surely that's a big deal.
It wasn't that.
It was understanding infection.
And this guy, Joseph Lister, who really...
Put the bits together and worked out what was causing all these patients to die despite successful surgery.
And that was bacteria getting into the wounds.
It was this idea of germs and infection.
And that really, I mean that then, From the end of the 19th century, when surgeons started washing their hands using clean gowns, it just seems extraordinary that they were to me.
And then eventually gloves and masks, that's when really things could take off.
And I gather...
By the way, before I even leave anesthesia for one second, because I was curious about this.
If you're using a gauze to put people to sleep, doesn't that gas slip into the operating theater and anesthetize the surgeon as well?
Yeah, they did have this.
Not so much with the chloroform, but more with the ether when you're administering this gas.
Actually, later on, with sort of facial reconstructive surgery, the early plastic surgery they were doing in World War I to cope with some of the terrible injuries that were coming from the trenches or from modern warfare.
And, well, the surgeon had to was bending over in the operating theater, over very close to faces, where you got this mask of ether.
And surgeons were just keeling over, knocking themselves out with the gas that was meant to be knocking out their patients.
We have a lot more to talk about, but first, let's take a quick break.
What's the case?
So we've survived anesthesia.
We've got this huge advance in infections.
And I gather part of that was through the whole understanding of germ theory.
And much of that came from Semmelweis' work.
Can you walk our audience through that a little bit?
Yeah.
What I find extraordinary and incredibly frustrating when you look at the history of surgery...
How long it took surgeons and the medical profession, if you like, to make the connection between what was killing their patients, the diseases killing their patients, and germs, and that it was some sort of bacteria, microorganisms, because microorganisms were discovered way back in the 1700s, so they didn't make any sort of connection.
There was this A surgeon, Semmelweis, who was working in Vienna, and he worked in this woman's hospital.
So women come in, deal with pregnancies.
So he was coming in.
The women were coming into this hospital, and they go into one of two wards.
They go into a ward which was looked after by the surgeons, the cream of the Austrian medical profession, or they could go into one that was overlooked by midwives.
The midwives, they were considered by surgeons as kind of, you know, the lower ranks, if you like.
So, you know, surely it'd be best to be in the ward with the doctors and the surgeons.
But what they were finding is that the patients that came in and were looked after by the doctors, about one in five, one in six, were dying.
And they were getting this awful, this awful disease.
I mean, it's called childbed fever.
It's essentially a type of blood poisoning.
Whereas the ones that were seen by the midwives, most of them, most of the women survived despite complications in childbirth.
The surgeon, Dr Semmelweis, was determined to do something about this problem and he looked at every aspect of this.
He looked at the position of the women when they were in labour.
He decided to do more autopsies and see what had happened to the women.
He even tried to stop the priest who went round the wards ringing his little bell because he thought, well maybe it's the fear, the fear of this disease that was killing the women.
What he eventually realized was that it was because the surgeons were going from the autopsies straight into the wards to examine their women patients, but barely washing their hands in between.
I mean, this is just horrible.
They would even describe that this was somehow attractive, this sweet smell of the cadaver was somehow attractive to the women.
They're going from autopsies straight to the women.
And as soon as Semmelweis stopped this, he made them wash their hands in a sort of bleach solution.
And it wasn't until then that suddenly it was becoming safe to have a child in this hospital.
The trouble was, and the tragedy of this story, is that Semmelweis was quite a difficult man.
And he couldn't get his theory accepted, even though it seemed obvious It was working, that something was going from the dead to the women, even though that Once they started washing their hands, he just couldn't get his theories accepted.
The hospital dismissed him in the end, and he ended up in a mental institution.
And his theory was dismissed.
Someone just called it a crackpot idea.
So it then took at least another 20 years before someone rediscovered the same theory, in which time thousands of patients had died.
How did they rediscover the theory and why the second time around did it work?
I mean, I'm stunned by this.
I knew the Semmelweis story.
It's medical lore.
They had no idea that he was dismissed, died in a mental institution, and that his theory didn't automatically change how we began to clean our hands in surgery.
Well, it wasn't even his theory that was rediscovered.
It was Joseph Lister in Scotland who pretty much did the same thing.
Only the difference was this time that Lister had...
The Pasteur theory, the germ theory, which had recently been published, he had some scientific backing which is really what helped.
So it wasn't until 1865, this is about 20 years after Semmelweis, 1865 that Lister first applied the idea that you keep a wound clean, that you don't introduce any infectious particles.
And then, again, another kind of 10, 15 years before this was widely accepted in surgery.
So it took an awful long time before these ideas were accepted.
And really, Semmelweis wasn't completely recognized until the beginning of the 20th century.
And now he's a hero.
So talk to me a little bit about when surgeons began using masks and gloves and sort of the birth of the modern operating room.
Really, this is about the turn of the 20th century, when they certainly by this time were washing their hands, and washing their hands in a kind of bleach compound, using gloves.
For the most part as well on top of that.
Early operations, this was Joseph Lister pioneered this carbolic spray, which is literally spraying the whole sort of operating table and everyone with it with carbolic acid, this really nasty caustic stuff.
They weren't really lurched from no understanding of infection and dirty operating theatres.
Puss and blood-encrusted aprons and just shocking conditions.
It was completely over the top, totally what they call aseptic surgery with this cloud of this vapor that would wipe out pretty much anything and also really sting your skin.
But then they kind of settled into a We had masks and gloves all around the beginning of the 20th century and just simple things like making sure you had clean sheets on the operating table, make sure people weren't breathing too near the patient.
But even then you look at pictures around the beginning of the 20th century, loads of people, loads of surgeons crowded around the operating table.
You have to remember this is also before antibiotics, so if there was an infection, then that's it.
There is no way of countering it.
So, again, the surgical law is that it was actually the wife or the girlfriend of the head of surgery at one of the major US hospitals who insisted on gloves, which sort of got that started because she said her hands were being ruined by the, I don't know if it was a Clorox-type bleach they were using to clean their hands.
But in any case, that seemed to be created initially for the doctors and nurses more than for the patients.
Yeah, I think, to be fair, a lot of this was, and this is one of the problems that Semmelweis had when trying to introduce this hand washing into surgery, was because he's asking these doctors to wash their hands in this nasty, bleach-like way.
And they didn't like it.
You know, they wanted nice, clean, soft hands.
They didn't want these kind of nasty kind of stinging hands with this horrible bleach.
So yeah, I think it's fair to say surgeons, doctors came first, patients second.
I like to think that's changed.
It's changed in some ways, but I'm not sure as many ways as we'd like.
There's a lot more to come after the break. - Let me if I could turn our attention to what we learned from warfare.
Because you mentioned in the book a little bit about Dwight Harkin.
Who is an icon in America, and his son is a surgeon as well in this country, to teach us a little bit about his insights and how it changed some of the thoughts.
For example, that Theodore Billroth, perhaps one of the most famous surgeons ever to live, had quipped that any surgeon who would attempt to operate on the heart should lose the respect of his colleagues.
That is a quote that is taught to every single doctor learning heart surgery, even today.
There was something about the heart, and I think perhaps there still is about the heart.
There's more to the heart than just a simple pump in many people's minds.
It's tied up with the soul, with the very nature of the body, and of course it's so crucial.
And I think there was a problem getting over that barrier psychologically, that thinking of the heart as just a pump, a way of getting the blood around the body.
But there were also these Quite severe technical limitations for operating on the heart.
You can't just stop the heart.
You can stop the heart for a couple of minutes, but then you've got to get it started again.
You could operate on the heart, but if you cut into the heart, suddenly all the blood's spurting everywhere.
There are so many problems with operating on the heart.
Dwight Harkin, who was...
Really, the pioneer of open heart surgery in 1944, so in the Second World War, he was working in the west of England, and he was seeing patients.
He was a chest surgeon.
He wasn't really such a thing as a cardiac surgeon.
He was a chest surgeon.
He would remove shrapnel, bullets, all sorts of things from wounded soldiers' chests.
And they had this x-ray technique called a fluoroscopy.
So it was like an x-ray, but a moving x-ray.
So you could see what was going on inside the body, like some of the modern scanning techniques.
But this was a sort of early x-ray.
And we were looking at this chest of the soldier.
And normally they could see bits of bullet or shrapnel.
And in this case, they were looking through the lens of this machine over the soldier's chest, and they saw the metal of a piece of shrapnel.
They saw it jumping, jumping up and down.
And it meant that that was embedded in the soldier's heart.
And Dwight Harkin had been doing various experiments on animals, and he reckoned he could successfully remove this piece of shrapnel from a heart.
He got permission to do this operation.
And what also made this possible was that they had blood transfusion at this point and they were able to pump in blood into someone on the operating table at pressure.
So if you lost blood you could hopefully replace at least some of it at the same time.
So he decided to go ahead with this first open heart surgery and he would be operating on a beating heart and you think of the amount of blood that's circulating around a body.
He'd open up the chest and there was the heart beating.
You could see the shrapnel embedded in the wall of the heart and this is the really historical moment.
He cut in to a beating heart which is At the time, even now, it's a brave thing to do.
Cut into a beating heart, and blood gets spurted everywhere.
The blood is still pumping, the heart is still beating, and he was able to remove, or at least get hold, of this bit of shrapnel, and blood going everywhere.
He pulled it, and it wedged in the hole that he'd created.
So I took a bit of a breather, and then it popped out.
So suddenly you've got this spurt of blood, and yet they're putting blood in all the time, but nowhere near as much as this poor man's heart was losing blood.
So he sticks his finger in the hole then, so at least it stops again, and then gradually, slowly stitches the sutures together around it, And then he finds that he's managed to stick his glove into this poor soldier's heart.
So it was incredibly tense.
He eventually cut the glove free.
They actually talked at the time of leaving his finger in there.
It would have been a lot easier.
They cut the glove free.
And the soldier survived.
And he then went on to perform more and more, almost all, successful So, I mean, an amazing man.
I think the history of heart surgery is in itself fascinating.
Well, his offspring have continued his remarkable advances in the field.
If I could fast-forward us for most Americans, it's a moment of pride for the entire world to change.
Our thoughts about the heart when they began doing open heart surgery in the cold town of Minneapolis, Minnesota in the 50s.
Why Minnesota?
Why did it all come together there?
I've always been curious about why they become hotbeds for advancement in places you wouldn't have normally expected it.
It is curious because what they first did with heart surgery, they called it at the time smash and grab heart surgery.
What they wanted to be able to do was cure, if you like, or stitch up, mend holes in the heart.
And a lot of the work on this had actually been done in Canada, so not in Minnesota at all.
And one of the first techniques was to try and gain more time.
So if you're operating on a beating heart and you clamp off everything going in and everything going out, you've got about four minutes before the blood oxygen level drops.
So you're talking about, well, brain damage and death.
So what they want to do is be able to increase this time, so you've got more than four minutes.
The first technique was to call them down, to call the patient down.
And they did this with a...
Predominantly, you're talking about operating on children, very, very sick children who wouldn't probably have had many more years to live.
So the first surgery that was done, yes, in Minneapolis, by calling a child down, gradually, gradually using cold water tanks and these sort of circulating blankets of cold water...
There's a surgeon called John Lewis who did the first of these operations and successfully managed it in six minutes.
And one of his assistants was a chap called Walter Lilleheim.
And he thought, well, we need more than six minutes.
You can do You can do a simple operation.
I mean, simple.
It's really immensely complicated.
And you've got to assume that what you're expecting to find is there.
If it's suddenly more complicated, that's it.
You can't do any more.
He was in the operation.
He came up with, I think, which is one of the most incredible operations in the whole history of surgery, called cross-circulation.
So this was before the invention of a heart-lung machine.
What they would do...
I think, well, actually, we're all heart-lung machines.
So what he figured was he could connect a sick child on an operating table to the blood system of one of their relatives, obviously with the same blood group, also in the operating theatre.
So when he cramped off the child's heart, it was the parent, also in the operating theatre, who was doing the breathing for the child.
Speaking, two circulations together.
And he had a milk pump used to carry milk around dairy to connect these tubes, which were actually the same tubes you'd use for beer.
So in a bar to bring up the beer from the cellar, he used those beer tubes and a milk pump and connected a parent to a child and performed successful operations on children.
I mean there are so many things that could go wrong and it's also I think probably the only surgery in the history of surgery with the potential for a 200% mortality and it did almost kill one of the parents that he used because a bubble of oxygen, a bubble of air got into the system and caused them brain damage.
Oh, that's right.
And I knew Dr. Lilly High, and he would always say that the most difficult task that they faced, and it's almost unimaginable for the audience today to hear this, would be to operate on a child in the morning whose family had trusted you with their kid and had the child die.
And have to go back the afternoon case and meet that family, accept responsibility for that child, knowing that the mourning case had not gone well.
And again, this is a kind of emotional trial and tribulation that accompanied the technical miracles that they were seeking.
I think Walter Lilly High is one of these incredible, like Dwight Harkin and Semmelweis, there are many of them who are these incredible, courageous surgeons.
Surgeons who didn't cross the line, who still pushed the boundaries of surgery and did remarkable things, but got the balance right.
And without them You know, so many people would not be alive, even today.
I think Walter Lillihite, not long before he died, had a reunion of his patients, and he's got to be one of the most loved Surgeons in the world for the amazing advances he made.
And I mean, cross-circulation, it's an amazing thing, but it didn't actually last that long before they came up with, eventually, a workable heart-lung machine.
But let me, if I could, get back to the original question.
Why Minneapolis?
Why did this become the hotbed for advancement and development, really, of cardiac surgery as we know it?
It's a very good question, of which I don't have the answer at all.
I think it's one of these things.
You get one, and then you get several, and you get these hotbeds of surgery.
Because it was extraordinary that that was really the place for open-heart surgery in the entire world.
You know, this relatively small teaching hospital at the top of the United States.
This was the place in the world for open-heart surgery.
And people would come from all over the world For a chance of a cure.
And I think it's true now that you get these sensitive expertise and one expert attracts another expert.
And I suspect that it's because You had not just someone who was prepared to try this with John Lewis, but an assistant there who was also a great innovator who then took these things on.
Mr. Hollingham is talking to us about Blood and Guts, A History of Surgery.
