Back in time in medicine

Being a Doctor Who fan and all, I’ve often wondered what it would be like to be able to travel through time and visit times and places in history that I’m most interested in. For instance, being a World War II buff, I’d certainly want to be able to check out what every day life was like here in the U.S. during World War II. Given my affinity for psychedelic music and that I was only four years old during most of the Summer of Love, I’d think it cool to check out Haight-Ashbury, although I suspect my reaction to the reality of it would be similar to that of George Harrison when he checked it out for the first time. I guess, if pushed, I’d have to admit that if I had been a high school or college student in 1967, I probably would have been one of those straight-laced, short-haired types destined either to go to college to become a doctor or an engineer or to go to Vietnam to fight. Despite loving the music, I never had any interest in experimenting with the drugs. Heck, I never even tried to smoke tobacco; I can’t stand the stuff.

In any case, what provoked this bit of musing was a post a couple of weeks ago by Martin Rundkvist, who wrote about Fear of Time Travel, where he imagines what it would be like for a modern person to be transported back in time:

First, imagine that you’re dropped into a foreign city with only the clothes you wear. No wallet, no hand bag, no money, no cell phone, no identification. Pretty scary, huh? But still, most of us would get out of the situation fairly easily. We would find the embassy of our country of origin, or if it were in another city, contact the local police and ask to use their phone. A few days later we would be home.

That’s not the scary scenario I rehearse. Imagine that you’re dropped into the city you live in with only the clothes you wear. No wallet, no hand bag, no money, no cell phone, no identification. And it’s 500 years ago. (Or for you colonial types, 300 years ago in one of your country’s first cities.)

It’s a fun thought experiment, with Martin pointing out that you would speak the language with what to the natives living at that time would seem a very strange and nearly incomprehensible accent. Think of how hard it is to understand the English spoken in Shakespeare’s plays, which is full of idioms, turns of phrase, and vocabulary peculiar to the time, and then just think about the number of words that we use that would be incomprehensible to, say, an American living in the Midwest, which at the time for where I live would have been ruled by the French as part of New France but mostly populated by indigenous tribes. So for purposes of the thought experiment, I’ll pick New York or Boston. Here’s the part of Martin’s thought experiment that caught my eye:

Some might think that a well educated modern Westerner would soon become one of the sages of the age thanks to their superior technological and scientific knowledge. For one thing, it wouldn’t be hard for most of us to become the best doctor in the world of AD 1509 if knowledge was all it took. But I have a feeling that such knowledge would not be easily applied in a society that is completely unprepared for it, and not easily implemented in an environment where none of today’s infrastructure exists. And say that you’re actually a doctor or an engineer – how much could you achieve without access to any materials or tools invented in the past 500 years? I mean, I know the principles of nuclear fusion, aviation, antibiotics, vaccination and basic biochemistry, but don’t ask me to put them into practice starting from scratch!

Well, I am a physician and surgeon, and I don’t know if I could elevate myself to a sage of the age with my knowledge. The reason is that so much of what I do and have done in medicine relies on the technology and science of the time. Let’s start with something very, very basic. I’m a surgeon. I try to cure or treat diseases by operating. Operating on a patient, however, is very difficult without reliable anesthesia, and inhalational anesthesia using ethyl ether wasn’t discovered until the 1840s. Before that, there were various herbal anesthetics and hypnotics, natural drugs like opium extracts and later morphine, and alcohol. While these may have sufficed for minor operations (barely), they were not at all sufficient for doing anything major, such as entering a major body cavity.

That’s why, before anesthesia, surgeons had to be fast, and surgery was very bloody. Think of Abigail “Nabby” Adams Smith, the first born of our second President, John Adams. She was diagnosed with a malignant tumor of the breast and underwent a mastectomy without anesthesia, the gruesome details of which were described in Jim Olson’s Essay on Nabby Adams:

Nabby entered into the room as if dressed for a Sunday service. She was a proper woman and acted the part. The doctors were professionally attired in frock coats, with shirts and ties. Modesty demanded that Nabby unbutton only the top of her dress and slip it off her left shoulder, exposing the diseased breast but little else. She remained fully clothed. Since they knew nothing of bacteria in the early 1800s, there were no gloves or surgical masks, no need for Warren to scrub his hands or disinfect Nabby’s chest before the operation or cover his own hair. Warren had her sit down and lean back in a reclining chair. He belted her waist, legs, feet, and right arm to the chair and had her raise her left arm above her head so that the pectoralis major muscle would push the breast up. A physician took Nabby’s raised arm by the elbow and held it, while another stood behind her, pressing her shoulders and neck to the chair.

Warren then straddled Nabby’s knees, leaned over her semi-reclined body, and went to work. He took the two-pronged fork and thrust it deep into the breast. With his left hand, he held onto the fork and raised up on it, lifting the breast from the chest wall. He reached over for the large razor and started slicing into the base of the breast, moving from the middle of her chest toward her left side. When the breast was completely severed, Warren lifted it away from Nabby’s chest with the fork. But the tumor was larger and more widespread then he had anticipated. Hard knots of tumor could be felt in the lymph nodes under her left arm. He razored in there as well and pulled out nodes and tumor. Nabby grimaced and groaned, flinching and twisting in the chair, with blood staining her dress and Warren’s shirt and pants. Her hair matted in sweat. Abigail, William, and Caroline turned away from the gruesome struggle. To stop the bleeding, Warren pulled a red-hot spatula from the oven and applied it several times to the wound, cauterizing the worst bleeding points. With each touch, steamy wisps of smoke hissed into the air and filled the room with the distinct smell of burning flesh. Warren then sutured the wounds, bandaged them, stepped back from Nabby, and mercifully told her that it was over. The whole procedure had taken less than twenty-five minutes, but it took more than an hour to dress the wounds. Abigail and Caroline then went to the surgical chair and helped Nabby pull her dress back over her left shoulder as modesty demanded. The four surgeons remained astonished that she had endured pain so stoically.

Without effective anesthesia, I could do no better than these surgeons from 200 years ago. In fact, I would probably do much worse, because I’m used to operating in a deliberate fashion, cauterizing individual blood vessels as I go. The reason surgery before inhalational agents became available was “cut and slash” was because it had to be. To do otherwise was to prolong the torture of the patient. I’m not used to operating that way, and there was no such thing as a Bovie electrocautery machine back then. It would all be scalpels and scissors–or, as in Nabby Adams’ case, razor blades and, in essence, a set of tongs to elevate the breast. It’s another reason why surgeons were frequently so fast in doing amputations that their assistants had to be careful not to let their fingers get in the way. As for more extensive operations, even with the anesthesia available in the latter half of the 1800s, a full 150 years after the time period Martin’s thought experiment envisions, there was no way to control respiration. Anesthesia was a delicate balance between not putting the patient so deep that he stopped breathing but putting him deep enough so that he wasn’t reacting overmuch to the surgical stimuli. Mechanical ventilators were an invention of the 20th century.

That’s just one example. There are numerous other tools, disciplines and examples of knowledge that a modern surgeon depends upon in order to do his or her job, such as antibiotics and germ theory, pathology to identify what a patient has based on tissue samples, transfusions, and a wide variety of medications, to name a few. Then there’s diagnostic radiology. There would be no CTs or MRIs; there wouldn’t even be X-rays. Indeed, even something as simple as suture would be a problem. The needles used 300 years ago were huge by today’s standards because of the difficulty making small needles. Throughout history, needles were made of bone or metals such as silver, copper, or bronze, while sutures were made of either cotton, flax, hemp, silk, or even tendons and nerves. There was a reason they called “catgut” suture catgut. Although cat gut suture was not made from the actual gut of cats, it was made from actual gut–connective tissue from intestines. Actually cat gut was pretty good suture and was still occasionally used 20 years ago, when I first started my residency, mainly by the older surgeons.

In any case, I think Martin’s right in that, without the infrastructure and scientific background being there, it would be very, very difficult for a surgeon of 2010 like me to recreate much of anything that I do now in the year 1710, even if I were dropped into Boston among the most learned physicians of the age. No one there would have any idea of germ theory (and thus sterile technique, both of which were 150 years away), anesthesia, or much of basic physiology. Indeed, at that time, diseases were thought to be caused by imbalances in the four humors or miasmas, for the most part. If I were to try to explain these concepts to the learned men of the time, assuming I could master the dialect of 300 years ago, they’d assume I was either mad or a witch. It would be a good thing for me that the wave of witch hunts and executions was pretty much over by the early 18th century.

There is one area that I can think of where a surgeon of 2010 might be able to translate some of his knowledge into 1710 and hope to have some influence. The first, of course, is sterile technique. It would not be that huge of an undertaking to sterilize instruments (although sterilizing sutures would be very problematic), either in flame or in alcohol. It would probably not be that huge a challenge to use alcohol, carbolic acid, or some other compound to clean the operative field, the patient’s skin, and one’s hands. (Given the lack of latex or rubber gloves, I’m not sure if it would be possible not to operate with my bare hands, as surgeons of the time did–and in fact continued to do until the late 1800s and beyond). In other words, I could be Joseph Lister well over 150 years before Lister showed the benefits of antisepsis. Come to think of it, I could potentially be Louis Pasteur, again 150 years before Pasteur did much of his work. At the very least, I could figure out how to replicate his experiments disproving abiogenesis and to develop Pasteurization. Of course, convincing the world of 1710 of the validity of these ideas would be even harder than the time Pasteur had convincing his contemporaries of germ theory.

In fact, it brings up an issue that should demonstrate just how hard it would be to convince the physicians and surgeons of 1710 of our knowledge. Consider something as simple as blood pressure. Although, as I have described before, ancient Egyptians knew enough to palpate pulses, the very first measurements of blood pressure (more accurately, pulse pressure) were not made until 1733 by Stephen Hales, who measured the blood pressure of a horse. It was not until 1855 when the first sphygmomanometer was devised by Vierordt of Tubingen, an instrument called at the time the sphygmograph, which was considerably improved upon by Etienne Jules Marey in 1860. Before this, it was not possible to measure arterial blood pressure other than under surgical conditions using a canula inserted directly into an artery. Finally, the modern version of the sphygmomanometer was invented by Samuel Siegfried Karl Ritter von Basch in 1881, but Italian physician Scipione Riva-Rocci improved upon it by producing a more easily used version in 1896. After that, Harvey Cushing discovered the device during a visit to Italy in 1901 and popularized its use in the U.S. after he returned home. What all this means is that the routine measuring of blood pressure as a “vital sign” in virtually all patients did not become truly routine until around 100 years ago. Even more amazing, it was still 20 years before Russian physician Nikolai Korotkov popularized the use of the device to measure diastolic blood pressure as well, meaning that the systolic/diastolic blood pressure ratio that we’re all familiar with didn’t become routine practice until the 1920s.

Hmmm. Maybe I could be Harvey Cushing 200 years before Harvey Cushing was in his prime.

Finally, it occurs to me that the way medicine was practiced 300 years ago here in the colonies bears a lot of resemblance to many “alternative” therapies. Medicines back then were virtually all derived from herbs or animal products, often the herbs or animal products themselves, unpurified. Germ theory was meaningless, and disease was thought to be due to things that very much resemble alt-med’s concepts of disturbances in the flow of qi. While I might be very much a fish out of water in 1710 as far as trying to practice medicine and surgery, I suspect many “alternative” medicine practitioners would not be.

In any case, if there’s one thing this little thought experiment has done for me, it’s to make me realize how much of what I do depends on hundreds of years of history and science and any achievements I may have in my career rest squarely on the shoulders of giants. This leads me to wonder if similar thought experiments could be done with other branches of science. What would be possible in your field of science if you were to find yourself plopped into your city 300 or 500 years ago?