Introduction

Life is short, and Art long; the crisis fleeting; experience perilous, and decision difficult. The physician must not only be prepared to do what is right himself, but also to make the patient, the attendants, and externals cooperate.

—Hippocrates, Aphorisms, Section 1

The fact is that he whose purpose is to know anything better than the multitude do must far surpass all others both as regards his nature and his early training.

—Galen, On the Natural Faculties¹

As the junior resident on the hand surgery service, I spend more time tending to the patients on the hospital floor and in the emergency room, and less time in the operating room. This summer has been hectic, with multiple “replants” (the reattachment of fingers after trauma suffered at factories, lumber mills, and backyard fireworks mishaps). Patients get airlifted or ambulanced to our trauma center from all over our region in hopes of saving their hands.

Two days ago, a young Amish boy suffered the loss of three fingers in a barnyard accident. Gabriel is five years old, but speaks no English—typical for a child here in central Pennsylvania, growing up in a cloistered community retaining the simplicity of a bygone era. In fact, almost no one in his family can communicate well with us. I have treated some Amish and Old Order Mennonite patients who speak modern English effortlessly, but some sects of Amish barely break away from their “Low German” dialect.

My job this morning is to change the leeches on Gabriel’s fingers. You read that right. It sounds positively medieval, but there is a role for leeches in modern medicine. Once the hand surgeon has completed the daunting challenge of reattaching fingers, which includes the tasks of realigning and stabilizing the bones, stitching together the tendons, and sewing the nerves and blood vessels with microscopic suture, he must monitor the blood flow within the arteries and veins to see if the finger will thrive. Leeches are used for their bizarre ability to secrete hirudin, a natural anticoagulant from their salivary glands that facilitates hematophagy, the ingestion of blood. Attaching a medicinal leech to a finger decongests the digit, thus increasing the chance of survival. The leech swells with feeding, and once it is fully engorged, it must be replaced with a ravenous collaborator to continue the digit-saving bacchanal.

As I walk into Gabriel’s room, I am greeted with a blast of furnace-hot air laced with the essence of barnyard manure. In an effort to accentuate his fingers’ vasodilation (expansion of the blood vessels), we keep patients’ rooms at 95° F. Inside the room are more than twenty people, all of whom are Amish; the men with characteristic Abe Lincoln beards, black wool trousers, suspenders, and white shirts, and women with bonnets and flowing navy-blue dresses to their ankles. I am reminded that most Amish bathe once a week, and the combination of heavy wool dark clothing, blistering hot and muggy Pennsylvania summers, and farm animal occupations make this room reek, even to me, the son of a large-animal veterinarian.

I have brought a jar of fresh leeches, skinny and dark wormlike creatures. I lean over the stoic Gabriel, his hand in a massive dressing three times the size of a boxing glove. As I undo the layers of white cotton dressing, my community of witnesses leans closer; I seem to be the only one sweating in the oven of room 765. With the removal of the final loose layer of gauze we are all staring at three huge leeches, each attached to a finger. They are crimson and india ink–black, immobile, and drunk with blood. They look ready to explode. I begin to tug on the first parasite, and it won’t budge. A wave of anticipation pulses through the throng, and now twenty faces are within feet of mine, and a mixture of pig, horse, and cow manure wafts pungently toward me with essences of molasses, scrapple (bacon remnant), and chow-chow (pickle relish) mixed in. I could vomit.

With a little more force, I am finally able to pluck the little vampire off a finger and the assembly groans in appreciation, “Yaaaa.” I repeat this two more times, with the fingers oozing at the attachment sites. One by one I then reach into the little jar and pick out a slimy creature and drag it onto a finger. With a little wriggle, the sluglike animal positions itself on the finger and a firm linkage is established. Gabriel has remained motionless the entire time, and he and I make eye contact again. We have no words in common beyond a simple greeting, but we do share at this moment thousands of years of medical tradition—the art of bloodletting. Although bleeding a patient is no longer practiced in America, there are still places in the world where bloodletting occurs in a fashion that goes back 2,500 years to the very beginning of medicine. My medical forefathers couldn’t have dreamed of refabricating fingers to a hand, even one hundred years ago. But they would have been enchanted by the notion of leeches sucking “bad blood.”

On the left bank of the River Seine, in Paris’s labyrinthine Latin Quarter, are situated dozens of buildings associated with the Sorbonne, including the Université Paris 5 René Descartes. Located on the rue de l’École de Médecine, the university’s greatest building is a 17th-century colonnaded structure that houses an enthralling museum of medicine and a library. Inside the building, at the end of the lobby, stands a life-size stone sculpture of a veiled woman who gently lifts a shroud away from her face and upper body, revealing her placid countenance and exposed breasts. The sculpture is titled La Nature se dévoilant à la science, or Nature is revealed through science.

In this place of great learning, this monument captures the very essence of the scientific program of the Renaissance and Scientific Revolution, wherein mankind removed the opaque veil from the distinctive beauty of nature. Centuries had passed since the philosophical and artistic revolutions of ancient Greece, but as medieval darkness gave way to the light of learning, a rekindling of an enlightened curiosity took hold across Europe. The 15th century was a time of exploration, innovation, and reinvention of communication via new technology—much like our current time.² Figures like Leonardo da Vinci, Christopher Columbus, and Johannes Gutenberg upended the status quo, much like Steve Jobs, Elon Musk, Jack Dorsey, and Mark Zuckerberg have done over the last decades—and not without controversy.

The Renaissance is a convenient starting point to trace the origins of modernity in medicine, in part because so little had changed from the time of Hippocrates to the 15th century. Even as the Western world was awakening from a great, thousand-year sleep, it was still mostly pointless to consult with a physician, and likely, more dangerous to be under the care of even the wisest doctor. As is beautifully detailed by David Wootton in Bad Medicine, a patient inflicted with almost any malady, in any era before 1865, would have been better served by suffering alone, away from the “care” of a physician.

Therefore, the two towering figures of Western medicine, Hippocrates and Galen, had actually done very little to improve the lot of men and women under their philosophical care for almost two thousand years. And certainly, they had contributed nothing to the practice of surgery. Nonetheless, it is critical to understand that these fathers of medicine—even though they were merely pulling so many levers behind the curtain like the Great Oz—influenced every Western physician over the last two thousand years, and so their theories matter.

My undertaking in this work is to explore the metamorphosis of the understanding of the way the body works, how disease happens, and the near-miraculous ways 21st-century surgeons can resuscitate, reconstruct, and even reimagine human beings. I will spend little time examining ancient Asian medicine, or the oral traditions of healers in primitive societies. While there may have been surprising perceptions among antiquity’s shamans, dead-end, unlinked intellectual insights are not the focus of this work. The foundational breakthroughs that led to the invention of surgery—from the invention of science itself to the discovery of cells, germs, modern materials, and outcomes research—is the thrust of this book.

Stephen Greenblatt, in his enchanting book The Swerve, relates the story of the near-mythical poem, “On the Nature of Things,” by the Epicurean poet, Lucretius. Lost to antiquity, the poem was remembered for its insights and artistry, but no one in the Middle Ages had ever read it. All that remained were stories about its greatness, similar to the legends of the Colossus of Rhodes or the Hanging Gardens of Babylon. After disappearing for 1,500 years, it was discovered in 1417 by an Italian scribe and book hunter, Poggio Bracciolini, in a southern Germany monastery.

Poggio concealed himself for three weeks in the monastery and copied its 7,400 Latin lines from ancient papyrus, returning to Rome with his treasure. Within a few decades, Gutenberg invented the printing press, and soon copies of Lucretius’s poem would be printed and distributed around the Western world. The discovery of “On the Nature of Things” helped make the world modern, turning away “from a preoccupation with angels and demons and immaterial causes and to focus instead on things in this world; to understand that humans are made of the same stuff as everything else and are part of the natural order; to conduct experiments without fearing that one is infringing on God’s jealously guarded secrets … to legitimate the pursuit of pleasure and the avoidance of pain … to find the mortal world is enough.”³ While it is challenging to pinpoint all the causes of the Renaissance, surely this poem, with its groundbreaking claims, helped the world “swerve” toward modernity.

What made the poem so radical? To start with, Lucretius claims that everything is made of invisible particles. He further postulates that these particles are eternal (which would be a foundational claim of Antoine Lavoisier, one of the fathers of chemistry). Harvard University philosopher George Santayana has called this “the greatest thought that mankind has ever hit upon.”⁴ In addition, our poet tells us that humans are not unique, we are in a primitive battle for survival, there is no afterlife, religions are cruel, and the highest goal of life is the enhancement of pleasure and the reduction of pain. Radical, indeed. When these assertions were resurrected at the end of the Middle Ages, one can see why they were so iconoclastic. As Gustave Flaubert has said, “Just when the gods had ceased to be, and the Christ had not yet come, there was a unique moment in history, between Cicero and Marcus Aurelius, when man stood alone.”⁵ These ponderings would help transform astrology to astronomy, alchemy to chemistry, and, eventually, Aristotelian cosmology to Newtonian Physics.

Hippocrates’s life spans the triad of great philosophers—born ten years after Socrates, most of Plato’s life, and overlapping Aristotle by fourteen years. Not just a physician, Hippocrates was a renowned author, a pillar of the culture, a patriot of Greece, and a moralist. The “Hippocratic corpus,” the sixty pieces of writing that are attributed to him and his followers (though by some estimates, almost half are falsely attributed), contains works that were probably written over a century or two. John Block concluded, “Hippocrates first gave the physician an independent standing, separating him from the cosmological speculator. Hippocrates confined the medical man to medicine.”⁶ All early “healers” were natural philosophers, and Aristotle said that it was the task of these philosophers to look into the principles of health and disease. This started with an obsession with the “correct regimen” and proper diet. “How to find the diet that would maintain the body in health and free it from disease was a problem that invited speculation about the constituents of body and of food, as well as about the structure, the functions and the activities of the body and its parts.”⁷

The ancient truth-seekers mulled over the function of the body without any knowledge of cells, germs, genes, cancer, even bodily organs; is it any wonder that disease was a complete enigma? If primitive man in every corner of the world was transfixed with the starry sky, found meaning in the mutable moon, contemplated the traversing of the sun, and considered the pulsing of the tides and respirations of the winds, how much more significance would be achieved by turning inward to our bodies and examining the motions, ebbs and flows of a pounding heart, of breathing, even urination and defecation?

Siddhartha Mukherjee, in The Emperor of All Maladies, says the ancient Greeks were “preoccupied with fluid mechanics—with waterwheels, pistons, valves, chambers, and sluices—a revolution in hydraulic science originating with irrigation and canal-digging and culminating with Archimedes discovering his eponymous principle of buoyancy in his bathtub. This preoccupation with hydraulics also flowed into Greek medicine and pathology. To explain illness—all illness—Hippocrates fashioned an elaborate doctrine based on fluids and volumes, which he freely applied to pneumonia, boils, dysentery, and hemorrhoids.”⁸

Hippocrates, and later, his disciple Galen, would explain the inner workings and dysfunction of the body with the concept of the Four Humors (liquids). Thinking like a hydraulic engineer, Hippocrates theorized that our bodily vessel is a container of blood, phlegm, black bile, and yellow bile. “In the process of digestion, food and drink are turned into the bodily juices, the humors,” writes Owsei Temkin, “… they are the nourishment of the body, i.e., of its tissues, which consequently owe their existence to the humors. The [Aristotelian] elements of fire, earth, and water do not exist as such in the body; they are represented by yellow bile, black bile, and phlegm, respectively.”⁹ Air, Aristotle’s fourth element, is the pneuma of the Stoics (the vital spirit or creative force of a person), and is the vehicle of vital and psychic functions.

To understand Hippocrates’s 4th-century B.C.E. mindset, remember that English physician William Harvey’s breakthrough experimentation of blood circulation was still almost two thousand years away. The ancients had no concept of circular blood flow, which we trace starting at the heart, coursing through the aorta and subsequent smaller vessels—all the way to the narrowest blood vessels, the capillaries—with a gradual reversal to the thin-walled, low-pressure veins that form tributaries, like ever-widening rivers on their way to the ocean, to the massive vena cava that empties back into the heart. If you are reading this book you probably understand that blood does not simply “dump” into your muscles, like a container of meat being splashed with blood. Instead, your muscles are thoroughly perfused with tiny blood vessels, too small to see with the naked eye. There is no reservoir in our body where all the juices (Hippocrates’s simplified bile, blood, and phlegm) collect together. Why would he conjecture this way?

It seems that Aristotle was the first to scientifically dissect an animal, and perhaps it was his pupil, Diocles who was the first to dissect a human.¹⁰ In the ancient world, human dissection was permitted until being outlawed by the Romans. The Hippocratic physicians would have been allowed to dissect the dead, but this was before embalming and refrigeration, and would have demanded fairly quick action before putrefying flesh made investigation too repulsive. Presented with a recently deceased person or animal, an ancient physician would have likely made cuts into the abdomen, finding smelly bowels filled with half-digested food and large blood vessels containing congealed blood, dark purple in color. In the abdominal cavity, surrounding the bowels, there was abdominal fluid, like warm apple juice. Handling the organs, the kidneys, liver, and spleen would be crimson and full of gelatinous, molten blood. The gallbladder, anchored below the liver, would have been large and pear-shaped. Slicing into it, pea-sized gallstones would have tumbled out with yellowish fluid oozing over the examiner’s hands. In the thoracic cavity, home to the lungs and heart, pulmonic fluid would be discovered surrounding the lungs and filling the lobes with frothy liquid, like watery tea in a sea sponge. The trachea and bronchial airways would almost certainly have had a mucous residue so common in a dying man. In conclusion, we have the four humors: blood, yellow bile, black bile, and phlegm. Without understanding organ function, the early anatomist would deliberate over these fluids, seeking a unifying “theory of everything” to explain the workings of the most interesting system in the universe. There must have been a singular moment (upon a particular corpse), when Hippocrates formulated and simplified his four humors theory; would there ever be a philosophical offering more contemplated and recited than this?

The individual humors, when dominant in a human being, contributed to the personality and behavior. Each one of the four personality types, based upon one of the humors, is familiar to our ears. In Greek, black bile is melancholia, upon which our word for a depressed, “melancholic” person is based. A calm, “cool-headed” person had an overabundance of phlegm, and was therefore “phlegmatic.” An irritable, crotchety, or “bilious” person has too much yellow bile and is “choleric.” If a patient had a predominance of blood, and was spirited or intemperate, he would have been called “sanguine,” from the Latin word for “blood.”

And here is the very important observation about the dominance of Hippocratic theory all the way to the Scientific Revolution. Even the savants of the Renaissance, who were forced to contemplate the function of the body in a world without science, were powerless to resist the allure of Hippocratic musings. Because the philosophical foundation was a fraud, medicine was ineffectual, even lethal. The Hippocratics provided much explanation for why the therapies worked: it never occurred to them they did not.¹¹ If Hippocrates is the Father of Medicine, it is a dubious paternity; we can’t identify any success associated with his (or his followers’) theories.

The most logical intervention for a sanguine person would have been to decrease the volume of blood. If the patient was “hot-headed,” or if a disease was causing redness and heat (we would describe them as having a “fever”), the Hippocratic physician would bleed the patient. This was classically performed by cutting a vein (venesection), but later by cupping (suctioning the skin with a cup) or applying leeches. “Bloodletting” was therefore the ancient art of trying to achieve a balance in humors, and explains why so many patients were bled (often, to death). Consider all the times you have been sick with a fever. That fever, a bodily increase in temperature, is a systemic reaction to a bacterial or viral attack that is now easy to explain in scientific terms. Had you lived a mere five generations ago, you likely would have been bled bedside by your community physician.

The Roman Empire began in 31 B.C.E., with the consolidation of Greece and Hellenistic Egypt under one ruler, Augustus Caesar. Augustus ruled until 14 B.C.E., and Rome was the center of a powerful, peaceful kingdom for two hundred years. Greek city-states assimilated under Roman rule, and in turn, the Early Empire embraced classical Greek culture.

Into this period of relative peace and order was born the other great physician of antiquity, Galen (130–200 C.E.). Like Hippocrates, Galen was from east of the Aegean Sea, and was born in Pergamum in Asia Minor (present day Bergama, Turkey). Like Hippocrates’s island of birth (Kos), Pergamum was home to a sanctuary of the healing god Asclepius. Galen’s training started at home, extended to Smyrna and Corinth, and ended at Alexandria. Owsei Temkin has written: “The founding of Alexandria was an important event in the history of ancient scholarship, science, and medicine. From the 3rd century B.C.E. until its conquest by the Arabs in 642 C.E., Alexandria was the foremost center of medical study and especially of anatomy.” As will become plain in this book, there has always been a “center of scientific and medical learning” in the world. “For a time, it seems, anatomy could be studied on human bodies, until Roman law put an end to such study and confined anatomy to animal dissection.”¹²

Galen returned to Pergamum, flush with his Alexandrian education, where he became physician to the gladiators. An early “sports medicine physician,” it has become clear that Galen probably performed no human dissection during his career, but he was exposed to deep anatomy during his surgical treatment of gladiatorial injuries. Galen was later summoned to Rome by the emperor Marcus Aurelius, and it seems that he spent his last forty years there, writing, teaching, and attending to the emperor.

Galen was not just an influential physician. He was a philosopher, a dazzling and highly industrious author who wrote in a cultivated Greek style, a scientist and skilled dissector (albeit, of monkeys and pigs). Highly prolific, “his preserved works alone would fill about a dozen volumes of approximately one thousand pages each.”¹³ If Aristotle was the first to perform animal dissection, and the first to postulate that the organs of the body had individual function, it was Galen who raised animal dissection and vivisection (dissecting on live animals) to another level. The major revolution in anatomical learning had occurred in Alexandria, led by Herophilus and Erasistratus, who were both contemporaries of Epicurus, in the 3rd century B.C.E. Alexander the Great had just founded his city at the time of their birth; it was a frontier city on the Mediterranean near the mouth of the Nile, surrounded by barbarians. It is possible that dissection (and even, shockingly, vivisection) was performed on convicted criminals in that city. Steven Johnson has described the “hummingbird effect, an innovation, or cluster of innovations, in one field [that] ends up triggering changes that seem to belong to a different domain altogether … sometimes change comes about through the actions of political leaders or inventors …”¹⁴ The young city of Alexandria, as a Hellenistic outpost, was the ideal laboratory for the Greek natural philosophers, with a tradition (handed down from Alexander) of assimilating local customs and leaders and inculcating international students. For almost one thousand years it was the greatest city of learning in the world and had the largest library (of papyrus scrolls). The marriage of ancient Egyptian scholarship, Greek philosophical insight and empiricism, and contributions of conquered Persian and Indian peoples made Alexandria the ideal city for Galen to complete his studies.

Galen’s great work On Anatomical Procedures is a wonder. It was his last major work, and was based on a lifetime of anatomical investigation. It has been said that Galen, though not the founder of the science of anatomy, was its first important witness, and this work is his pièce de résistance. Like most anatomy books, there is an abundance of information on bones, muscles, blood vessels, and organs. However, much of the writing is imbued with Hippocratic humoral physiology; it is laughably wrong when examined today, but it was the authoritative work until Vesalius’s De humani corporis fabrica (On the Fabric of the Human Body) was published in 1543. So highly regarded was Galen that Vesalius, as we shall see, had to tiptoe around criticizing the master and gently sow the first seeds of doubts about his authority.

Galen became a true pioneer when he performed anatomic experimentation. Tragically, it involved vivisection, but instead of conjecture about the imbalance of humors, Galen became the first to uncover organ function. “By tying and untying the ureters Galen proves the flow of urine from the kidneys to the bladder; he severs the spinal cord at different levels and describes the ensuing loss of motion and sensibility; he ligates the recurrent nerves [that lead from the brain to the vocal cords] and he has discovered and notes the subsequent loss of voice.”¹⁵ This 2nd century natural philosopher upended centuries of Aristotelian theory about the heart being the “command center” of the body, and instead demonstrated that the nerves carried the impulses to the muscles from the brain.

Why do we breathe? The Greco-Roman philosophers had no concept of oxygen, and were left pondering the role of respiration and conjectured that there was a pneuma, a vital spirit, that must be drawn in to infuse the body. The psychic pneuma, Galen concluded, must well up from the net-like plexus of arteries at the base of the brain, what he termed the rete mirabile, and travel to the ventricles, the fluid-filled caverns in the middle of the brain. As Galen had established that impulses must originate in the brain, the empty space of the ventricles must be the domicile of the psychic pneuma. Galen’s rete mirabile, the fount of the psychic pneuma, would become a major issue 1,300 years later, but for now, Galen had led a critical revolution in deciding that cognition originated in the brain.

Near the end of Galen’s life, at the end of the 2nd century, “peace and stability collapsed, and for about a hundred years political conditions close to anarchy disrupted cultural and economic life.”¹⁶ Eventually, barbarian incursion on Roman soil destabilized the empire. In one of the most impactful developments in Western civilization, the emperor Constantine made Byzantium (which he renamed Constantinople, modern day Istanbul) his capital in 330 C.E. Rome and Constantinople were dual capitals for decades, but in 395 C.E., after the death of the emperor Theodosius, the empire was divided permanently between the Latin West and East. By the late 400s, Rome was in full collapse, and the Latin Middle Ages would last for one thousand years.

One cannot comprehend Western civilization without understanding the (temporary) survival of the Roman Empire in Constantinople for hundreds of years. “While the West was on its way to the Latin Middle Ages, the Greek East preserved its ancient heritage. Justinian even succeeded in reconquering Italy, Africa, and part of Spain, and reuniting the Roman Empire. But the reunification did not long outlast him. Culturally, Antiquity faded away slowly, but politically the East, even before the onset of the Arab conquests in 634, had become the Byzantine Empire.”¹⁷ During the final breakup of the Roman Empire, Greek culture (and medicine) continued to spread throughout the Middle East, first to Syria, then to Persia, and finally to the Mohammedan world. “Several of the Prophet’s successors (Mohammed died in C.E. 632) … were great patrons of Greek learning, and especially of medicine. The Arabian scholars imbibed Aristotle and Galen with avidity.”¹⁸ As we shall see, Arab scholars kept the faith, so to speak, of Hippocrates and Galen, and their writings were translated from Greek and Latin into Arabic. These Arab language books, serving as repositories of ancient wisdom, awaited translation back into Latin at an appropriate time—a time of awakening—the Renaissance.

Homo sapiens have been on earth for some 250,000 years, but modern man has existed 8,000 years, which equates to 300 generations. On a single sheet of paper, you could write the word “great” 300 times; each “great” would represent a particular ancestor of yours, ending with our common biological “Adam,” the first modern man.

So we are left contemplating 295 generations of vulnerability, completely at the mercy of nature; five generations blessed to exist under the auspices of “good medicine”; and two generations thriving in an era of modern medicine and what I will call the implant revolution. The Greco-Roman domination of medicine persisted into the 16th century, finally undermined by an elegantly simple innovation that revolutionized humanity’s ability to communicate, allowing incremental advances in the understanding of the way our bodies work, and then, later, dynamic leaps forward with the invention of surgery.