“When I was a little boy … I wanted to know about the clouds and the grasses, why the leaves change colour in the autumn. I watched the ants, bees, birds, tadpoles, and the caddis worms. I pestered people with questions about what nobody knew or cared anything about.”1
—John Hunter
“When I heard this Man, I said to myself, ‘This is all day-light.’ I felt that what I had previously been taught was comparatively nothing … and thought I might, like Mr. Hunter, venture to Think for myself.”2
—Henry Cline
The Surgical Intensive Care Unit, or SICU, is a labyrinthine block of three large nursing units, designed for the postoperative care of the sickest or most unstable patients. For the past four weeks I’ve been on thirty-six-hour shifts on alternating days, and even though I’m a surgical intern (in my first year of my surgical residency), I’ve never ventured back to the operating room. Instead, in my role as an SICU intern, I attend to the post-trauma and postsurgical patients who require a higher level of care than can be delivered on a typical “floor” nursing unit. On those units, no one is intubated and their intravenous (IV) medications are relatively simple and not life-sustaining on a minute-to-minute basis, like they are in the Intensive Care Unit.
In my first few days, I was completely overwhelmed and terrified. It was instantly obvious to my fellow interns and myself that we were unqualified and inexpert at keeping the SICU patients alive; in fact, we were all petrified of killing a patient who was clinging to life with one small misstep. The SICU nurses were right in doubting us: despite our newly conferred medical doctor degrees, we held no practical knowledge. Query us about reciprocal translocation of genetic material in chronic myelogenous leukemia and we’ll wax lyrical about switched-on tyrosine kinase; but ask us about a simple ventilator setting and you will be greeted with awkward blank stares. In time, however, we all improved. As the month wore on, the mechanical ventilator (the “vent”), IV drips, lines and tubes, lotions and potions, and bed settings became intelligible and powerfully manageable.
Now in my last week in the SICU rotation, I have spent many hours at the bedside of Travis, a sixteen-year-old Pennsylvania boy whose car full of high school teammates was blindsided by a cement truck after football practice two weeks ago. Three young men were instantly killed, and Travis arrived in the trauma bay in cardiac arrest. My fellow residents resuscitated him right there in the emergency room, making the “trauma zipper” incision from his throat to the pubic bone, clamping his aorta to prevent it from completely rupturing and to barely avert death. In the two weeks since that accident, Travis has undergone multiple operations, coding three different times and facing multisystem organ failure.
There is a stunning level of control over a patient’s body in the SICU. Before residency, I had not fully comprehended how powerful our machines and medicines are in controlling the concentration of gases in the body, the blood pressure, the heart rate, and the degree of wakefulness. The physiology I learned in medical school, the revelations about the organ and cellular functions, is now becoming muscularly effective. But not entirely. Travis was dead on arrival, brought back to life with valiant swiftness by the trauma surgeons, and has endured several operations since then, all while battling failing kidneys, Clostridium difficile (C. diff) bowel infections, alarming edema and bloating of his arms and legs, and little evidence of brain wave activity. He has started to smell like death. I initially doubted the claim of the ICU nurses that they could smell death, but now I get it, the pungent smell of C. diff. mixed with the mildewy essence of pseudomonas pneumonia so common in ventilated patients. During a central line change a couple days ago, one of Travis’s nurses predicted to me that he wasn’t going to make it, and I’m a bit mortified today to admit that he resembles one of those drowning victims that washed up days after going missing.
Yesterday, Travis’s parents asked for permission to bring his loyal Irish setter, Honey, to the SICU. They claim it will be good for Travis. Normally a dog lover, I have serious reservations about bringing a family pet into this hallowed place. Where infections are such a preoccupation, why risk it? Initially rebuffed, the family petitions for the right to bring Honey, and winning their case, have arranged to bring Travis’s best friend to his bedside. I haven’t slept in a couple days, and I’ve come to realize that midday following an all-nighter is the greatest challenge, burdened with a supreme heaviness of fatigue and anhedonia. To be honest: I don’t give a rip if Honey comes here or not; I don’t have the energy to care.
Travis lies in his ICU bed, breathing tube in his mouth, secured with pink electrical tape around the tube and splayed onto his cheeks, IVs connected to electronic pumps that hum with activity while providing him with fluids and medicines, his body supported on an inflatable cushion to help prevent bed sores, and his surgical wounds on his chest, abdomen, arms, and legs covered with gauze dressings. He is bloated and lifeless, and although his chest expands and relaxes, it is the work of the machine that provides this isolated motion. Since the moment he was life-flighted to our trauma hospital he has not moved a muscle, and I don’t think he ever will. I am getting more impatient by the moment.
With some pomp and circumstance, Honey makes his way into the SICU #2, accompanied by Travis’s parents and sister. I wonder if the dog will even recognize Travis. I stand at the sliding glass door entrance to the room, readying myself to keep the dog from accidentally stepping on medical tubing or electrical cords. Honey paces into the room, and with an alert snap of his head, fixes his gaze upon Travis. He deliberately takes another few steps closer to the bed, his head approaching the bed rail. Something very intentional is happening, and with my curiosity piqued, Honey sits down, observing. I glance at his family, and his mother’s hands are to her mouth, his father a study of concentration. Honey rises, and manages to probe his snout through an opening in the bed rail, and touches his nose to Travis’s hand, cajoling a response. There are now about ten residents and nurses jockeying for position, trying to witness this surreal moment between boy and dog, and Honey spontaneously yelps a plaintive bark, and assumes his posture on his haunches. And now, did I detect a wiggle of a finger? Is Travis moving his hand? We are poised, nobody moving, everyone watching that left hand. Except now I see Travis slowly moving his head to the left, eyes still shut and swollen, and although it’s the tiniest of movements it’s obvious that it’s intentional. Honey barks again, and like starting an old car after years out of service, Travis is slowly reigniting. His head lifts almost unperceptively, and murmurs of “yes” and “no” and “oh my god” are whispered out loud. Travis continues to respond, moving every limb as the minutes pass by; this further encourages Honey to bark, nuzzle, paw, and whine as Travis is resurrected by some mysterious force. Eventually, Travis manages to lift an eyelid, and we are so flummoxed there is nothing left to say. Sensing our earlier doubts, Travis’s father locks eyes with mine and says, “I told you there was something about our son and that dog.”
Six months later, I am walking along a public corridor in the clinical towers of the hospital. Internship continues to be a grind, and my preoccupation is to make it through the remaining months until I transition to orthopedic surgery residency. I guess I’m in daydream mode, eyes glazed over until I realize that two people are making a beeline my way. I don’t think I’ve met the younger one, but I recognize the older gentleman, but I can’t recall why. Turning to his son he says, “Travis, this is one of the surgery residents who saved your life.” I am dumbfounded—I don’t recognize Travis at all—and the only mark I see on his body is the tracheotomy scar at the base of his neck. His dad adds, “Dr. Schneider was also there when Honey brought you back to life.” Struggling for words, all I can say is, “It’s nice to meet you Travis.”
Five hundred years ago, Western Europe was still mired in primitive conditions no better than Romans and Greek citizens had enjoyed two millennia before. Muddy roads, animal excrement, plague diseases, and swelling cities subjected mankind to more misery than even our foraging ancestors had endured. While the printing press had revolutionized communication flow, there was precious little new knowledge prior to the groundbreaking advancements ushered in by the astronomers in the mid–16th century. A suffering patient in the late 1500s would have been attended to by a physician with almost no appreciation of how the body functioned and certainly no understanding of individual organ function. At the dawn of the 17th century, there was still not a single human being who grasped what breathing accomplished, how nutrients were taken up from the food we ate, and why our hearts pounded in our chests.
In the year 1600 C.E., a young Englishman abandoned Cambridge medical school in the midst of his studies, determining to venture to Europe’s home of scholasticism and to the Venetian city of Padua. William Harvey (1578–1657) had earned his bachelor’s degree several years earlier at Cambridge’s Gonville & Caius College, but sensing greater prospects in Italy, made his way to Dover to cross the English Channel.
While his companions embarked on a ship bound for Calais without incident, William Harvey was singled out by the governor at the port.
“You must not go, but must be kept prisoner,” the governor told Harvey. The young Cantabrigian was furious, but was forced to watch as his friends sailed away on a packet boat into the evening. During the voyage the boat was caught up in sudden storm, capsizing and leading to the death of all those on board. News reached Dover of the cataclysm, and as the only passenger not allowed to board, Harvey sought out the governor who had detained him. Why had Harvey been the sole isolate, alone on the English shore while his friends drowned?
The governor informed Harvey that “Two nights previously I saw a perfect vision in a dream of Doctor Harvey, who came to pass over to Calais; and I was given a warning to stop you.” Although Harvey was completely unknown to the governor, this premonition had saved his life, and he often told this story as evidence of a special providence and mission for his life.3 The world’s first physiologist had perhaps been identified by the gods, and although it would take years to publish his manifesto about the function of the cardiovascular system, his journey of exploration was officially underway at the onset of the Age of Experimentation.
Like Isaac Newton after him, William Harvey was from the English yeoman class, freeholders who cultivated small estates and the educations of their progeny. The 16th and 17th centuries were auspicious times for upward mobility; William Harvey’s patrilineal sheep-farming predecessors had made provision for his future success, and while his father had little education, the benefits of his financial success surely paid dividends in William’s and his brothers’ futures.
The man who would rise to become physician extraordinary to the King of England originated as a Kentish boy who was endlessly curious about the spiders, horses, dogs, pigs, and hens on the family farmstead. Like William Shakespeare (just fourteen years older), Harvey was educated at grammar school, well versed in Greek, Latin, and Hebrew. When Harvey arrived in Padua, he easily absorbed the information in Latin, the lingua franca of sophisticated scholars. Harvey’s timing as a new medical student in Padua was propitious, with 16th century forefathers Vesalius, Falloppio, and Eustachi having established Padua as the greatest medical center of learning in the world.
Padua also held the greatest advantage for international students, with the establishment of “Nations,” in which the French, English, German, and English expatriates associated with each other within codified structures and leadership. Within months of his arrival, Harvey won election as the “councilor” of the English Nation, which afforded him special privileges, including a front row seat at anatomical dissections in the newly constructed anatomy theater at the Palazzo del Bo, Europe’s first (and still, oldest) anatomy theater.
Standing on the dark granite cobblestones in front of the Palazzo del Bo, the oldest building at the University of Padua, one cannot immediately decipher what distinguishes this edifice among the other medieval and Renaissance structures that surround it. The five-hundred-year-old Palazzo, a rosé-hued, three-story stone building with a center courtyard, has colonnaded arches and stone-framed windows, behind which lie some of the most famous classrooms in the world. In Padua, Copernicus argued for heliocentrism, Galileo lectured about the orbits of the planets, and Vesalius reinvented the scholarship of anatomy. The lecture halls, examination rooms, and anatomic theater are centuries old, and were the staging grounds for some of medicine’s greatest innovators.
Entering the courtyard and following the Italian signs that guide visitors to the entrance of the steward’s office, I am disappointed to find it closed for construction. I check my email on my phone, confirming my appointment for a private tour of this historic venue. The police officer turns me away in broken English, telling me my presence is not permitted. I try to tell him that I have a prearranged engagement, but to no avail—I must go. Frustrated, I walk across the street to the Caffé Pedrocchi, one of the oldest coffee shops in Europe, to plot my next move.
After some deliberation over a scrumptious espresso, I cross the street again, plead my case, and sense my insistence is becoming quite annoying to the Polize. Again, with the wave of his hand, he insists the Palazzo is closed and no one may enter.
Leaving the constabulary obstruction behind, I meander away, examining the locked metal gates at the bottom of a stairway leading up to the Palazzo classrooms above me. Tantalizingly close, I imagine the ancient exam rooms up there somewhere, and heaven only knows where the glorious anatomy dissection theater is.
“Sir—are you the American surgeon who wanted to see our classrooms?” I turn and see a young curator who speaks with a strong Italian accent.
“Yes!” I exclaim, realizing the barriers have come crumbling down at once. And with that, Francesca swings her large ring of skeleton keys up to my face, and with a smile, turns to the venerable gates and skillfully unlocks the aged mechanism with a heavy key, and we march up the steps to the first level of the Palazzo del Bo.
Half a millennium old, the largest classroom is adorned with the family and nation coats of arms of scholars who have been here for centuries. Francesca points out the names I have studied for years, legends of anatomy, medicine, and science. Alone in the grand hall where Galileo instructed, I respectfully approach the lectern and look out across it. Hundreds and hundreds of years later, there is still magic in the air in this place where some of the greatest minds in the history of thought presented their ideas.
In the next room, a timber-ceilinged classroom reserved for final oral examination for the medical degree (to this day), a U-shaped configuration of tables surrounds a small wooden chair. All of the green leathered chairs behind the tables face the simple, lone wooden chair where the candidate faces a barrage of questions testing her worthiness of a degree from Padua. Hanging on the cream-colored plaster walls are the aged paintings of the cognoscenti, no doubt adding to the anxiety of the applicant. I inspect Eustachi’s expression, detecting an aura of supreme shrewdness; I wish he could know what he and his fratelli started.
Francesca solemnly turns my way, and with a warm smile, asks if I’m ready to visit the anatomy theater: I eagerly say yes. Leaving the timeworn room behind (which faces the street below), we walk through an undersized door and enter a low-ceilinged small room with almost no lighting.
Craning my neck and bending forward, dodging heavy, hand-hewn timbers set at an angle, I follow my guide’s voice in the inky blackness. Francesca flips a switch over in the corner, and I become aware of a tiny constellation of lights around me. I still don’t understand the framing around me, but as my eyes become accustomed to the low-light conditions, I realize I am standing in the opening of a great funnel, forty feet high with multiple levels of rising, concentric elliptical circles. I am in the world’s oldest anatomy theater, and I am standing where the body would have laid on a table.
The theater structure was built into the large, empty room, and was made of logs and hand-fitted planks and boards. Rising at a steep angle, the succeeding levels supported a circular ring of boards just deep enough to support the human foot. On the inner side of the ring on each level was a wooden rail at about the level of a man’s knees. This theater was built for standing, and the banisters and balustrades (carved of walnut) kept even a fainting man from falling forward.
The Padua anatomy theater was built in 1594 for Hieronymus Fabricius, the custodian of the anatomical heritage of Vesalius and the man who would train Harvey. As the councilor of the English Nation, Harvey was positioned in the front row of anatomy demonstrations, always held during the colder months of the year where a rotting corpse was less pungent. Much of what Harvey was taught was the old Aristotelian medicine, which he would continue to practice once he returned to England. Steeped in Hippocratic humourism, Harvey was of an age of unscientific analysis and primitive understanding of organ function; in fact, he would remain a Galenic physician till his death.
To understand how revolutionary Harvey’s 1628 book—De Motu Cordis, On the Motion of the Heart—was, one has to contemplate what his professors taught him about the heart and the blood vessels. Galen’s conclusions about the generation of blood, the function of the heart, and blood flow were sacrosanct—and entirely and (by today’s standards) ridiculously wrong. From Greek and Roman times all the way to the early Renaissance, no researcher could reliably and precisely dissect any mammal and ascertain what the purpose of the vessels and the heart was. There was no way of properly sedating an animal while slicing open its chest, so any animal experimentation gruesomely involved strapping down the poor subject for a few seconds and hurriedly carving open the thoracic cavity as it bled to death. This left fleetingly few seconds to ponder about the flow of blood and dynamic function of the heart. It is little wonder that no one understood how it all came together.
Galen and every anatomist after him were confronted with the labyrinth of the large vessels, some as large in diameter as a garden hose, coursing hither and yon about the oddly shaped muscular organ. Anatomy students today are given textbooks with color-coded drawings delineating arteries and veins and the circuitous route of the flow of blood, but in ancient times an open chest with a pounding heart and indiscernible vessels presented an enigma.
For 1,500 years, medical students were taught that there were two distinct and parallel vascular systems based upon the thickness of the vessel walls. Dear Reader, if you and I were in an anatomy lab today I could show you the chief differentiating feature of blood vessels everywhere in the body: on the one hand, a flimsy vessel with thin walls—a vein—on the other, a blood vessel with thick, stout walls—an artery. No matter the location of the vessels (whether they are in the abdomen or in a limb), veins and arteries always fall into these two main categories.
Galen (incorrectly) concluded that arteries had the innate ability to pulsate based upon the thickness of the vessels. Worse, classic Galenic teaching held that the liver was the source of blood. While correct in maintaining that blood was supplied with nutritive properties from the digestion of food, Galen was wrong to teach that blood ebbed and flowed in both directions in every vein in response to the attractive powers of individual organs and muscles. To make it all work, Galen theorized that all organs “attracted” blood to themselves, and “consumed” the blood and its vital spirit.
Unable to understand the function of the lungs, Galen and his apprentices established that the vital spirit, or “pneuma,” entered the lungs with each breath; how else to explain the impulse to breathe? The divine breath, they concluded, is what vivified the pulsating, arterial blood, changing its color from dark purple to scarlet. Additionally, blood was said to have naturally flowed from one side of the heart to the other through large pores in the walls separating the large chambers.
The final, flawed observation about the function of the cardiovascular system was that each organ consumed the blood, imbibing the vital spirit. Any surplus blood merely evaporated. In conclusion, all parts of the body pulled blood toward themselves, drawing in the pneuma and vaporizing away all the superfluous blood. If blood continuously pulsed into dead-end organs via the arteries, how else to explain the function of veins other than claiming that it flowed in both directions in the veins?
Thus was the function of the heart and vessels presented. And it was all breathtakingly wrong.
William Harvey graduated from the medical school in Padua in 1602, and after a brief return to Kent, moved to London, where he would live for the next fifty-five years (with an interrupted stay in Oxford during the English Civil War). He promptly married a well-placed woman who was the daughter of the physician to King James. While not a London native, he steadily climbed the ranks of society, qualifying in 1607 as a fellow of the College of Physicians, the small coterie of the most highly regarded doctors. Even within the college, Harvey rose in stature, becoming the treasurer within a few years of admission.
The “lowly and intensely intellectual country boy”4 adopted the manners of sophisticated life in London, climbing the social ladder and navigating the court of King James. Like his patient Francis Bacon, Harvey attempted to curry favor with the king, eventually being named “physician extraordinary” in 1618, the same year Bacon was named Lord Chancellor. With the death of King James, Charles I became king in 1625, soon naming William Harvey “physician ordinary,” an even more powerful and prosperous title. His newfound rank and affluence garnered something even more important: the time and resources to perform investigations. There can be little doubt that his exposure to Francis Bacon, combined with his best-of-class medical training, prepared Harvey to more scientifically evaluate the cardiovascular system.
As Harvey was advancing in rank and title, his practice thrived. He and his wife were childless, leaving him with greater liberty to perform investigations. By 1615 Harvey was the Lumleian lecturer in anatomy, enjoying the reputation of a skilled dissector and gifted lecturer, stylishly brandishing a sixteen-inch silver-tipped whalebone wand that he used as a pointer during presentations. His elegant attire of “black cloak, full doublet, ribbed stocking of black silk, and long high-heeled boots fringed at the top” set Harvey apart from less important Londoners.
Harvey’s professional success fueled his avocational diversions, and by his mid-thirties, he settled into a routine of daily medical practice and evening home-based private research. His childhood fascination with plants and animals endured, and his London collection of aquatic life, terrestrial specimens, and barnyard animals became the provenance of future discoveries. An important transformation was occurring; Harvey was, in essence, bringing Padua to London, and his home laboratory was becoming a sort of Palazzo del Bo.5 A revolution was brewing, and within a few years of research, Harvey would make one of mankind’s greatest discoveries.
Completely self-motivated and endlessly curious, Harvey dissected almost nightly, even completing a program of the comparative anatomy of the anus of various species of birds. An ornithologist in a 21st-century NIH-funded lab could stomach such a topic if it led to a fount of published articles and tenure, but as a private program of exploration?
Another Paduan anatomist, Realdo Colombo (1515–1559), a pupil of Vesalius, had been a pioneer in describing the flow of blood to and from the lungs, stating, “Blood is carried to the lung by the pulmonary vein, and in the lung it is refined, and then together with the air it is brought through the pulmonary vein to the left ventricle of the heart.”6 Although not completely correct, Colombo’s breakthrough insight was to deny that only air returned in the great vessels from the lungs; it was “refined” blood that returned from the lung in the large pulmonary veins. Colombo was also refuting the Aristotelian and Galenic hope that blood bypasses the lung and travels across pores in the middle of the heart.
With Colombo as his exemplar, Harvey set about to investigate the heart and its machinations. He had witnessed the pulsations of blood in fish and small animals, but a critical breakthrough occurred when he secured the corpse of a hanged criminal through his connections with the College of Physicians. Hauling the body to his private research area in his Ludgate home, Harvey placed the body on his dissection table, and with candlelight, sliced open the chest and cracked open the ribs.
After draining the fresh blood in the great vessels of the chest, Harvey found himself face-to-face with the dead man’s heart and lungs. When an anatomist encounters a heart, the most prominent artery that immediately arises out of the topmost part of the heart is the pulmonary artery, the large diameter vessel that transmits oxygen-poor blood from the right side of the heart to the lungs [see picture in image section]. Harvey took a piece of string, and wrapping it around the pulmonary artery, ligated it tightly, preventing the flow of fluid. Carefully cutting open the right ventricle, Harvey next inserted a metal tube into the heart chamber and tried injecting water into it. With the pulmonary artery tied shut, there was no way for the water to pass through it, and even more important, water did not pass across the thick-walled septum that separates the right and left ventricles. Opening the left ventricle, Harvey observed not a single drop of fluid, and stated, “By my troth, there are no pores.”7 Galen was wrong.
Releasing the ligature from around the pulmonary artery, Harvey again injected water into the right ventricle, and within seconds, water poured into the left ventricle. This blood-tinged fluid had obviously passed from the right side of the heart, through the lung tissue, and then returned to the heart in the pulmonary veins and into the left side of the heart. In an instant, he knew that Colombo had been correct in asserting that the heart pumped blood to the lungs, and that the blood returned back to the heart vivified and scarlet.
William Harvey had convinced himself of the interrelationship of the heart and lungs, but he remained confused about the action of the heart. Should he continue to doubt Galen (true sacrilege among physicians), or believe that the heart, like all organs, swells and draws blood to itself? After dissecting the hanged man, Harvey returned again to his marine fauna, some of which had translucent skin that allowed him to peer at their tiny beating hearts. The germinating skepticism about a heart that flexes open to siphon blood to itself was growing into an ironclad incredulity the more he dissected small living things.
Harvey sliced open the chest cavity of a fish, and observed the minuscule heart rapidly pulsating, even witnessing the flow across the transparent aorta. Placing his finger on the heart, he could feel it contracting, further convincing himself that the heart was more like a muscle and unlike a bellows that opens to suck air (or blood) into itself. Experimenting on an eel, Harvey carved open the fish’s chest and cut out its beating heart. Placing it on his dissection table, the heart continued to throb, and even when he cut it into smaller segments, each piece contracted. Completely convinced that the heart was indeed a muscle whose active phase was contraction, Harvey was well on his way to solving one of life’s great mysteries.
Over the course of many years, William Harvey conducted countless experiments on animals, often turning to dogs. By modern standards, it is cruel and defenseless how hundreds of animals died without any consideration for their sensations or consciousness. In fact, it is daunting and troubling to review Harvey’s vivisection experiments, no matter how important were the discoveries. In the 17th century, bearbaiting, cockfighting, and public animal cruelty were commonplace, and it wasn’t until 1835 that the English Cruelty to Animals Act was passed. Until that point, most Englishmen viewed animals as incapable of feeling pain, and they felt as emotionally conflicted about a dog dying a tortured death as most of us feel about swatting a mosquito today.
Harvey’s many experiments were convincing him about the flow of blood in and around the heart, but he was still confounded over the genesis of blood and where it vanished. In a truly great moment for science, Harvey realized that some sort of calculation was necessary to investigate the function of the heart. With astronomy, physics, mathematics, and biology in their infancy, Harvey pioneered an entirely new branch of science.
Concluding that the active phase of the heart was systole (Greek, “contraction”), Harvey realized he could estimate the amount of blood that was pumping through the heart. In retrospect, his calculations were very conservative, but his results led him to the proper conclusion. Harvey guessed that the heart was not able to fully squeeze all the blood out of its chambers with each contraction, so he calculated that only a fraction of the full diastolic (or relaxed) volume was ejected with each contraction; he estimated that amount to be no less than a dram weight of fluid (one-eighth of an ounce), a vast, but safe, underestimate.
Estimating that the heart beats at least thirty times a minute, and multiplying that times sixty minutes an hour and twenty-four hours a day, a (very conservative) dram in weight of blood ejected with each contraction would mean that a massive 50,000 drams of blood was pulsated into the arteries each day. If that massive amount of blood was continuously manufactured by the liver, as Galen and all ancient physicians had always postulated, it was simply inconceivable to Harvey that the flimsy world of Hippocratic medicine was genuine. The world’s first physiological computation led to the obvious conclusion that Galen was preposterously wrong, even before Lavoisier’s conservation of mass would become law two hundred years later. There simply couldn’t be a fire hydrant of blood gushing from the liver each day. Today, we know that an average 150-pound human has a stroke volume of 70 milliliters, which equates to a daily cardiac output of over 7,000 liters, or almost 2,000 gallons coursing through one’s heart. Harvey would surely pound his fist on a table when realizing that over forty barrels of blood flows through our hearts every day.
If the liver was not continuously producing blood, then where was it coming from? And, perhaps more critically, what happened to the blood once it reached its end destination? Did it indeed evaporate?
Harvey’s final experiment was likely triggered by his mentor in Padua, Fabricius. Shortly after Harvey had left Padua, Fabricius published De venarum ostiolis (The little doors of the veins), in which he investigated the function of the valves. Not comprehending that the flow of blood in the veins is from the extremities back to the heart, Fabricius had trouble determining the function of the “little doors,” or valves of the veins. He wrapped a cloth around a subject’s arm, causing the veins to swell; Fabricius then applied fingertip pressure over a vein near the tourniquet, but found that he was not able to force blood down toward the hand. He concluded that the doors “held up and delayed” the flow of blood, a clear misinterpretation of the venous valves. His blindness to the truth was grounded in his false Aristotelian foundation, but his publication did inspire his pupil to perceive the truth through a repetition of his experiment.
Harvey repeated the experiment of his mentor, affixing a cloth tourniquet around his servant’s arm, and confirming Fabricius’s observation that blood could not be forced back into the hand because the “little doors” prohibited backflow. Unencumbered by a blind belief in Galenism, Harvey was free to interpret the findings of his little experiment. (If you have visible veins in your arm, you can easily reproduce the experiment by tightly wrapping a scarf or rubber band around your limb above the elbow, and attempting to force the blood toward your hand. The blood simply can’t go “backward” in the limb because of the valves inside the vein. Releasing the tourniquet allows the blood to continue its path to the heart.)
Harvey was on the verge of his great synthesis. Contemplating the vast quantity of blood pulsating across the heart, considering the “vivification” of the blood in the lungs and the transmission of the scarlet blood to the body’s tissues via the arteries, combined with this new insight of the one-way passage of blood from the limbs back to heart, Harvey had his eureka moment. He later wrote, “… and when I had a long time considered with my self … I perceived … the blood did pass through the arteries to the veins, and so return into the right ventricle of the heart.”
Harvey finally had it. The blood was forcefully expelled out of the powerful left side of the heart, pulsated through the aorta and arteries into the entire body, and through some mysterious exchange, the same blood itself was conveyed into the venous system to return to the heart, where it would be pushed into the lungs for aeration. It was, therefore, a closed system. His investigations were performed before the development of the compound microscope, and his naked eye could not see the microscopic branching of the ever-smaller arteries that exist in every organ of the body in what is called the “capillary bed.”
Harvey, at the summit, recalled, “And so, I began to bethink my self if the blood might not have a circular motion [emphasis mine]…” Hippocrates, Aristotle, Galen, and all our ancestors were blinded to the truth of the function of our heart. Harvey, the man who knew Galileo in Padua, had declared that our blood orbited in our bodies through a double-circuit, one to the body and the other to the lungs. Instead of blood simply pouring into end-organs, it stayed within vessels as it passed through the organs and muscles, and the new instruments of microscopy would unveil this secret shortly after Harvey’s death. In a word, circulation embodies Harvey’s great revelation.
Marcello Malpighi (1628–1694) was an Italian scientist who first described the microscopic vessels that serve as the connection between tiny arteries and minuscule veins. His first breakthrough came when he was examining still pulsating blood in the lung of a frog, and with the aid of a simple magnifying glass, saw the tangle of tissue that he perceived was the intermediary tissue between arteries and veins. The circulatory pathway had finally been visualized, and Malpighi called them capillaries.
William Harvey endlessly presented his ideas throughout England and Europe on the cardiovascular system, eventually publishing his classic tome, De Motu Cordis, On the Motion of the Heart in 1628. One of the most important books ever published in the scientific domain, Harvey’s magnum opus established him as a key pioneer in understanding the mechanical fabric of our bodies and a fellow coconspirator in René Descartes’s clockwork universe.
Descartes and Harvey altered the intellectual outlook of the 17th century, and together with Francis Bacon’s empirical inductive enquiry, natural philosophy was converted into a scientific program of investigation. Robert Boyle, one of the key figures at the founding of the Royal Society, described the human body as a “hydraulic engine … fram’d and contriv’d by nature.” Harvey’s “mind was incredibly sensitive to the intellectual and cultural spirit of his age, and his ideas were expressive of that spirit.”8 His investigations were the first mathematical and physiological interpretations of the human body, and were foundational works in the burgeoning age of experimentation. His natural heir was not the scientists and natural philosophers who formed the Royal Society within years of his death, but another Brit who was endlessly enamored of nature and who came to London almost as a feral outcast and is today interred at Westminster Abbey.
In England in 1540, the guilds of two unions were united by King Henry VIII to establish the Company of Barber-Surgeons. After years of acrimony, surgeons broke away in 1745 to form their own Company of Surgeons, which would later become the Royal College of Surgeons. Barbers and surgeons struggled for recognition, and in the mid–18th century, both groups could offer little more than a haircut, simple abscess drainage, or a hopeful (or hopeless) letting of the blood. Nonetheless, the emancipation of the surgeons in 1745 did present at least one significant challenge: they did not have their own anatomy theater, and this left them scrambling for a venue and proper proctors.
William Hunter (1718–1783), a Scotsman and renowned physician, obstetrician, and anatomist, grew up near Glasgow before receiving a stellar education in Edinburgh, Leiden, Paris, and London. Shortly after finishing his medical training at St. George’s Hospital in 1744, William Hunter began a course in private anatomy classes, advertising, “Gentlemen may have the opportunity of learning the Art of Dissecting during the whole winter session in the same manner as at Paris.”9
William Hunter’s anatomy school was the first of its kind in London (amazingly, the first chartered medical school in London was founded in 1785, although there had been informal schooling at St. Bartholomew’s Hospital for centuries). Hunter’s anatomy school opened in a rented Covent Garden apartment in 1746 (in 1749, moving nearby to 1 Great Piazza, Covent Garden, now an Apple store!) and was an immediate success. The triumph of the school and Hunter’s growing practice mandated assistance in the procurement and preparation of corpses, and in what seems like desperation, William asked his brother John Hunter, ten years his junior, to move to London and assist him at the school.
William Hunter, “attired in brocade and lace, and sporting a full powdered wig, dined with fellow Scottish intellectuals [and bridged settings such as] coffeehouses and theaters, dissecting rooms and salons … and the contrasting worlds of science and the arts.”10 Younger brother John could have hardly been more different, having dropped out of school as a thirteen-year-old (perhaps suffering from dyslexia), gaining notoriety as an “awkward, uncultured, and largely uneducated country lad … with a shock of red hair.”11 Ten years separated the two brothers, but there had been an abundance of tragedies since they had last seen each other when John was just twelve years of age. John Hunter was the last of ten children, born to a sixty-five-year-old father. Of John’s nine siblings, six had died by the time he traveled to London, leaving William as his only stable guide in a world fraught with instability and disease.
John Hunter had rejected the traditional English grammar school upbringing, choosing instead to roam the countryside, investigating the flora and fauna of South Lanarkshire. If his later life is any indication, it seems that John Hunter was incapable of recoiling in response to putrefaction, essentially immune to all things unsavory or repugnant. Instead of a preparatory education at Eton and an Oxbridge bachelor’s degree, John Hunter came to London with insatiable curiosity, congenital skepticism, and a battle-born durability.
John Hunter arrived in London in 1748 as a twenty-year-old, and despite his lack of formal education, was poised to serve as his brother’s assistant at the anatomy school, now two years old and thriving. They hardly knew each other, and a safe conjecture is that William was searching for a lackey to deal with all the dead bodies. Ideally, John would also perform preparation of the corpses for anatomical lectures, and as the new term was set to begin in September 1748, William and John met at their Covent Garden venue to dissect a dead man’s arm. The autodidact’s practiced hand with the knife had been acquired through years of self-directed morbid curiosity. To William’s great surprise, John was an instinctive dissector, and on the occasion of their first anatomic investigation, William told his unschooled and callow brother that he had the makings of an excellent anatomist and should never want for employment.12
Today, every medical school in the world has fully embalmed cadavers that have been rigorously treated by experts with fixative agents that prevent decay and putrefaction. The corpses’ blood vessels are flushed with embalming chemicals that perfuse all the tissues in a body. A cadaver can be stored at a cooled temperature for years without rotting, and a semester’s anatomy lab can be passed without ever smelling decomposing tissue, and the first-day shock of seeing a dead person fades away in succeeding days as you realize you will never encounter maggots or pools of pus.
The anatomy school at Covent Garden faced one major dilemma: the corpses themselves. By the mid–18th century, many continental countries had relaxed the Roman-era prohibitions regarding human dissection, but England still had rigid proscriptions regarding the procurement of bodies. A minuscule allotment of the bodies of condemned men was granted to the Company of Barber-Surgeons in London in the 1500s, and little had changed in the years that the Hunters’ school had started. The summer months were off-limits for dissection due to the rotting stench of warm bodies, but autumnal changes signaled the start of another dissection season. As many as fifty people were hanged each year in London for even trivial offenses, such as filching a watch.
For centuries, prisoners were kept at Newgate Prison (near St. Paul’s Cathedral and present-day London Stock Exchange) and hanged at Smithfield (near St. Bartholomew’s Hospital, one of the oldest hospitals in the world and the site of the hanging, drawing, and quartering of Scottish independence leader William Wallace), or more commonly in Hunter’s era at the Tyburn Tree. In the northeast corner of Hyde Park, near the Marble Arch, on Bayswater Road, is a small plaque in the middle of a small traffic triangle that commemorates the location of the Tyburn Tree, the three-legged gallows that hosted the capital punishment of thousands of criminals from the 12th century till 1783. Hangings at Tyburn were a spectacle, attended by the masses as a celebration of justice, and the wriggling, hooded victim struggling to breathe (and wishing to die) served as a macabre form of entertainment.
John Hunter’s primary task in the twelve years he partnered with William was the procurement of bodies. John stood only five feet two inches, but his broad shoulders and strong hands from years of hard work made him an able combatant in securing the precious bodies that were freshly dead. The free-for-all and carnival atmosphere called for an indecorous ruffian, and John Hunter—precise dissector and future legendary British surgeon and paragon of scientific intellect—was the ideal down-and-dirty steward of the corpses.
The Murder Act of 1752 was passed by Parliament, codifying the expedient hanging of criminals and disallowing the burial of convicts after hanging. This would serve to increase the numbers of cadavers, but there were still not sufficient bodies available. Where else to get fresh pablum?
Shockingly, John Hunter became one of history’s great grave robbers.
So, hungry for fresh bodies, John Hunter turned himself into a body snatcher par excellence. “So in October 1748, with William clamoring for more bodies for his pupils, John Hunter almost certainly set out himself under cover of darkness from the Covent Garden school, armed with a shovel and crowbar, to scour local burial grounds for freshly dug graves. Most likely, he commandeered parties of students, probably bolstered by several rounds of ale in a tavern beforehand to help in his grisly undercover work.”13
In London and Edinburgh, and later in the Colonies, professional grave robbers ransacked cemeteries and traumatized families. Also known as “resurrectionists,” the midnight burglars would shovel their way down through the freshly turned soil, digging a narrow shaft at the head of the grave until they encountered the wooden coffin. Crowbarring the cheap wooden lid until it snapped, and exposing the upper portion of the body, the body snatchers then used ropes to drag the body from its supposed final resting place.14 The team of miscreants would load the body into a carriage and deliver it overnight at the anatomist’s back-door basement entrance.
John and William Hunter worked together for twelve years, the elder brother gaining notoriety among the well-heeled and royalty, eventually becoming obstetrician to Queen Charlotte (who gave birth to fifteen children, including the future Kings George IV and William IV). John, on the other hand, flourished first as a body man and later as an expert anatomist. A fresh supply of corpses was John’s vocation, and his “youthful liking for a drink, lack of social airs, and colorful language evidently endeared him to his sinister suppliers.”15
Even in their first winter together, a surprising transformation occurred: John’s preternatural skills with the knife were laid bare, and by the spring of 1749, “William declared his protégé sufficiently accomplished to take over all the dissecting work at the school.”16 Thief by night, the resurrectionist was blossoming into an anatomist with authority, and after a year at the school, contemplated the impossible—brandishing his knife on the living. William had followed the typical route of an esteemed physician in London, matriculating from prestigious institutions and proving himself to the intellectual community. The path to becoming a surgeon would be vastly different for John, as there existed no formalized schooling, testing, nor accreditation for aspiring surgeons.
More than 150 years would pass before any semblance of a surgery residency existed either in Europe or America; John Hunter scrambled in 1749 to form a relationship with the most esteemed surgeon in the London area in hopes of transforming himself into a surgeon. William Cheselden (1688–1752), head of the newly formed Company of Surgeons, had himself become a surgeon through the study of anatomy and apprenticeship under practicing surgeons in Leicester and London. (In 1800, a royal charter was granted to the College of Surgeons, and for the first time, a college degree and acceptance into the Royal College of Physicians was required before training to become a surgeon.) For a few short years, before Cheselden’s death, John Hunter was apprenticed to him at his home office and at the Royal Hospital in Chelsea. Instead of viewing Hunter as an unqualified and unsophisticated country boy, Cheselden identified Hunter as an anatomy enthusiast and heir to his surgical governance.
Years later, William Hunter recalled, “Were I to place a man of proper talents, in the most direct road for becoming truly great in his profession, I would chuse [sic] a good practical Anatomist, and put him through into a large hospital to attend the Sick, and dissect the dead.”17 William was surely referencing his own brother as he wrote this, favoring a candidate who came from a proper anatomic training as opposed to an adolescent who had tagged along with an unlearned surgeon in a perpetual line of ignorant and barbaric imposters.
Although John Hunter trained under the finest surgeons, first Cheselden and later Percivall Pott at St. Bartholomew’s, he never lost his bizarre, outlandish, and even savage tendencies. To appreciate how dedicated Hunter was to anatomy and the dissection of the dead, consider that he regarded the sense of taste as a critical component in the physician’s armamentarium. “The gastric juice is a fluid somewhat transparent, and little brackish to the taste.”18 Gloves for dissection would not be available for another century, but one wonders what would compel Mr. Hunter to draw his fetid fingers to his mouth and sample the residue of any exudate or detritus. He was at the precipice of comprehending the organ basis of disease (as pioneered by Giovanni Morgagni), and apparently nothing was off-limits in his quest to understand the body. “The semen would appear, both from the smell and taste, to be a mawkish kind of substance, but when held some time in the mouth, it produces a warmth similar to spices, which lasts some time.”19
Many who attend medical school exhibit a normal aversion for putrid smells, necessarily prohibiting the conquest of surgical and gynecological specialties. Ask any general surgeon or gynecologist who has a standard practice when was the last time they faced a repulsive smell so pungent they were gagging and retching, and they will readily regale you with a tale of woe. A selection process that weeds out applicants with an incapacitating disgust for malodor happens in every medical school. Those who can “stomach” putrescence may continue on; those with “weak constitutions” (read: normal) go into specialties like dermatology and radiology. Even grizzled and gruff veterans of the operating room cannot overcome the deeply programmed “disgust as a disease-avoidance mechanism”20 in severe cases, that in the end serves to protect us from potentially life-threatening infections. Posterity is grateful that John Hunter seems to have had no capacity for revulsion, which, combined with his spirit of inquiry and dogged determination, propelled him to be the preeminent surgical figure of his time.
John and William Hunter worked together for over a decade, and during that time, made gargantuan discoveries regarding the human frame. Their description of the lymphatic system would perhaps only be surpassed by the revelation that the blood vessels between the placenta and the uterine wall did not share blood, as had been assumed, after careful dissection by John Hunter on pregnant women deceased late in term. After years of dissections on mid- and full-term London women, William published in 1774 The Anatomy of the Human Gravid Uterus Exhibited in Figures, displayed in massive “elephant”-folio in one of the greatest works of anatomy ever conceived. The dissections were all the work of John Hunter, the words were William’s, and the magnificent, if not sobering, artwork was by Jan van Rymsdyk.
After several years of training with Cheselden and Pott, and after serving as a surgical pupil at St. George’s Hospital during the summer of 1754, Hunter began to treat his first patients. The coarse country boy was transforming into an objective scientist, and from the beginning, he maintained fastidious notes with observations and outcomes.
Historian Wendy Moore describes an early patient, a young man (a chimney sweep) who had contracted gonorrhea that had resulted in a urethral stricture—a blockage in the urethra—that resulted in painful urination:
Establishing the patient’s medical history, Hunter brought to bear all his natural scientific curiosity—embarking on the experimental approach to surgery that would characterize his whole life—on the sweep lying in pain and frustration … Initially, Hunter attempted the classic approach to unblocking a stricture, presumably learned from Pott, which entailed attempting to push a “bougie”—a cylindrical bung made of wax or sometimes lead into the urethra to force a way through. When this failed, he characteristically decided to experiment and, importantly, record his results. Hunter conjectured that he might shift the blockage by burning a way through, using a caustic salve on the end of a bougie … [Hunter first used mercuric oxide, which caused much inflammation and pain, then attempted] with remarkable forbearance on the part of the sweep, Hunter fastened a piece of “lunar caustic”—silver nitrate—onto the end of [a hollow sliver rod cannula] and probed the urethra … [as Hunter recorded] “three times at two days interval, he came to me and told me that he had made water [urine] much better; and in applying the caustic a fourth time, my cannula went through the stricture; a bougie was afterward passed from some little time till he was perfectly well,” Hunter jubilantly recorded. It was a victory for experimental medicine. His approach—trying a traditional method, analyzing the outcome, forming a hypothesis aimed at improvement, and implementing his results—would become a standard practice throughout his career. Ultimately, it would form the foundation for his scientific revolution of surgery.21
Like William Harvey, born 150 years before, John Hunter was an avid naturalist and keeper of animals. Hunter had a clear advantage over Harvey, as the British Empire held a stranglehold over the seas during Hunter’s lifetime, permitting an exotic collection of animals from around the world, including Asian buffalo, a lion, a jackal, a dingo, and two leopards, which he kept at his country home west of London (in Earl’s Court, Kensington). His outlandish assemblage of animals in close proximity to the tony confines of London has led some scholars to believe that Hunter was the inspiration for the children’s book character Dr. Dolittle.22
Endlessly curious, John Hunter gathered up newly deceased human specimens and live animal oddities. Investigating for his own benefit (he would not publish in the Royal Society’s Proceedings journal until 1767), he made breakthrough discoveries about the cranial nerves in the head, tear ducts, and the descent of the testes in young developing male humans. Writing of the time, Benjamin Franklin said, “This is an age of experiments,”23 and no one characterized the epoch better than Hunter, who performed some of the first embryological research, in characteristic meticulous analysis and note-taking.
Most anatomists of the 18th century believed that every living being began life as a tiny miniature version of itself, steadily increasing in size in the womb or in an egg. John Hunter recognized this as preposterous, and began a project of exploration, wisely using chickens as his source material. Stealthily plucking eggs from underneath hens at frequent intervals, Hunter then cautiously cracked open each egg, using forceps to peel away the outer membrane and examine the minuscule embryo. While still fleetingly alive, he placed the little life in a warm bowl of water and examined it with the naked eye and with his microscope. Eventually placing all his specimens in spirits, he was able to establish a timeline of development over its three weeks of development within the egg. Others would eclipse Hunter in publishing their embryological findings, but his researches on this topic would exemplify his fastidious scientific technique.
Within a few years of Hunter caring for his own patients at St. George’s Hospital, his reputation was sterling enough to attract his own pupils in anatomy and surgery. An early student who was tutored by Hunter was William Shippen Jr. (1736–1808). The elder Shippen, who was a self-educated physician in Philadelphia (and founder of the University of Pennsylvania and Princeton University), recognized the value of a European medical education for his son, and sent him on a seven-week ocean voyage to England in 1758.
Young William Shippen had graduated from the newly founded Princeton University in 1754,24 and then spent four years in apprenticeship with his father. With only a clutch of medical textbooks available to the Shippens, the decision was made to dispatch the progeny to the “… finest Anatomist for Dissections, Injections, etc. in England.”25 “Billie” arrived in 1758, just ten years after John Hunter had himself appeared in London as an unsophisticated and ignorant country bumpkin, and now he was in charge of tutoring one of the Colonies’ most promising offspring.
William Shippen underwent full immersion in anatomical studies, living at the Covent Garden home of John Hunter and spending the winter session of 1758–59 under the spell of the Scotsman. A daily journal entry describes William’s day, “Rose at 6, operated till 8, breakfasted till 9, dissected till 2, dined till 3, dissected till 5. Lecture till 7, operated till 9, sup’d till 10 then bed.” Weeks passed as William was fully indoctrinated in the methodical dissection of the human body, and on many nights, William and John Hunter chatted away, no doubt enjoying a bit of grog. “Shippen spent more and more time at Hunter’s shoulder in the dissecting room, in awe of this charismatic teacher, who seemingly had a knack of inspiring young pupils with a fascination for anatomy.”26
The first medical school in the Western Hemisphere was in Philadelphia, at what was initially called the College of Philadelphia (later “University of Pennsylvania”), and was cofounded by William Shippen and another John Hunter disciple, John Morgan. Philadelphia boasts the oldest hospital in America, the first medical school, and the first “genius society,” the American Philosophical Society. While it is the cradle of modern American surgery, it is John Hunter who may claim paternity over the teaching of anatomy and surgery in the new world.
The remarkable transformation from hinterland simpleton to anatomy sage was largely based upon Hunter’s obsessive and energetic dedication to body snatching, dissection, and inculcation. Generations of medical students trod their way to London to be swept up in the vortex of Hunter’s “companionable” nature in which he “drank his bottle, told his story, and laughed with others.”27 But more than an amiable nature explains his success. His compulsive search for the truth about the structure and function of the body led him to systematically “… question every established practice, develop hypotheses to advance better methods, and test by means of rigorous observation, investigation, and experiment whether these methods worked.”28 To truly achieve advancements in a procedure-based science like surgery, John Hunter needed a volume of cases, and while metropolitan living had provided a concentration of diseases among the growing populace, his future prospects as a reputable surgeon were limited without some other distinguishing experience.
In what historians consider the first world war, Great Britain and France engaged in battles on land and sea in the Seven Years’ War, resulting in Britain’s supremacy and France’s decline after 1763. Five years into the conflict, in 1761, Britain’s war secretary William Pitt decided to focus his attention on the west coast of France and the small French island of Belle Île. Months before, in the fall of 1760, John Hunter was commissioned as an army surgeon, following Hippocrates’s ancient wisdom, that “He who wishes to be a surgeon should go to war.” Boarding the hospital ship Betty, John Hunter surely knew that tragedy awaited, and after the weeklong voyage to the Atlantic coast of France, the first assault commenced disastrously. The flotilla of 130 British ships faced a nearly impregnable island, with almost insurmountable cliffs set along a jagged coastline.
Hundreds of British forces were killed or injured in the opening days, and those clinging to life were ferried to the Betty, where the sailors and soldiers who had suffered bullet and shrapnel wounds were tended to by Hunter and his fellow surgeons. “While the storm tossed and dispersed the wooden ships, Hunter battled to save the wounded, bleeding, and dying men in his primitive surgery.”29 An age-old question has always been, why does the meaning of “casualty” include both those killed in battle and those who are injured? The answer is that prior to World War II, most seriously injured combatants were likely to die in a rather short period of time, so a “casualty of war” was essentially done for. “With no anesthetics to numb the pain, many patients died of shock as the amputation knife cut through their flesh, or bled to death while the surgeons probed around in their wounds to extract debris. Their bodies were given hurried burials at sea. Others would join them days later as sepsis took hold in their wounds while they lay in the hammocks of the foul-smelling sick bay.”30
After a second assault on the island two weeks later, the British were successful in establishing a hospital of sorts among its cottages. Here, John Hunter began a program of investigation on the proper treatment of war wounds. Whereas most of the other surgeons adhered to the ancient practice of exploring traumatic war wounds, Hunter began to realize that less was more. His fellow surgeons were actually inflicting greater pain and hastening death by inserting grimy fingers and filthy tools into wounds. Exercising great restraint, particularly when considering his years of dissection and his renowned dexterity, Hunter opted not to probe and enlarge bullet wounds, instead “being very quiet” in the treatment of wounds.
A chance development occurred in the first week on the island that cemented Hunter’s belief that conservative care was better and the humbling realization that surgeons were violating the central tenet of Hippocratic care, primum non nocere, “above all else, do no harm.” In the midst of battle, five French soldiers had been shot during an exchange of fire, but had avoided capture. Although some of their injuries were serious (including chest- and thigh-penetrating bullet wounds), the men ensconced themselves in a barn and evaded capture until being discovered four days later. Hunter tended to the men, realizing that the French troops who had received no care at all were faring better than the British forces who were unlucky enough to have been “treated.” In the end, in what amounts to a controlled experiment, Hunter concluded that all the secluded soldiers healed without incident, despite not receiving what was considered standard surgical exploration. The folly of aggressive care was revealed by a side-to-side comparison of two treatment arms, made possible by the high volumes of casualties among the belligerents.
There can be little doubt that Hunter’s experience with battlefield medicine was exhausting and exhilarating and, at the same time, very educational. The sheer volume of trauma cases honed his skills and provided further insights in treating wounds and how to think about infection. He stayed on the island for over one year, and then spent time in Portugal before returning home. He arrived back in London in 1763, just as Giovanni Morgagni’s book De Sedibus was gaining notoriety, eventually being translated into English in 1769. An awe-inspiring book, De Sedibus, for the first time, connected symptoms with diseased organs, and was the foundation for modern pathology and medicine. Hunter’s inquisitive nature, scientific programming, and the newly enlightened way of thinking about the human body was a serendipitous amalgamation that made basic surgical treatment, for the first time, a possibility.
Or was it? Hadn’t primitive surgery been attempted in the ancient empires of India, Persia, Egypt, and Assyria? Although scholars in those early empires had misinformed ideas about the function of the human body, how was it that they had the ability to perform painful surgery on primeval peoples? The answer is opium.
Opium is an ancient substance from the poppy, a flowering plant native to the eastern Mediterranean that was cultivated throughout the Middle East and India. Ancient Greek and Egyptian medical texts mention the use of opium, and wherever early surgery was performed, its cultivation is known. The poppy flower’s migration across empires, and its latex product (containing the opiate alkaloids morphine and codeine), has impacted trading and shipping, the modernization of medicine, and the spread of religion. Whereas the incense, spice, and silk trade routes had largely been based on land or sea routes close to the shore, the Age of Discovery led to worldwide ocean voyages and the international trading of tea, tobacco, sugar, cotton, and drugs.
The Dutch East India Company and the British East India Company pioneered intercontinental trade in the 17th century, specializing in the spice and tea trade in their first century of business. The Chinese luxury goods of porcelain, silk, and tea were in high demand from European countries, but there was little reciprocal demand for European goods in China. The solution was the British commercialization of opium production in India and the sale of the highly addictive opium to Chinese markets. With the flourishing opium market in the East, there was an inevitable influx of the elixir back to Mother England and, not surprisingly, a demand for morphine and its cousins—heroine and codeine.
Thomas Sydenham, considered the father of British medicine, prepared a proprietary opium tincture that he termed “laudanum,” a blend of opium, sherry alcohol, cinnamon, saffron, and cloves. Laudanum became a staple of almost every English physician and surgeon, and allowed Hunter to venture into previous prohibited lands in the century before ether and chloroform. In fact, while it may be said that others may claim priority in being the first important surgeon (men like Paré and Pott), Hunter alone is the last great surgeon to operate without comprehensive anesthesia, and whatever success he enjoyed was, in part, owed to opium.
The two years abroad achieved for Hunter what he might have hoped—an acceptance among the well-placed and philosophically interested. He never forfeited his disdain for etiquette nor his love of drink and coarse language, but his “energy, breadth of interest, and ebullient manner”31 won him favor among the members of the Royal Society, who elected him as a fellow in 1767 “as a person well skilled in Natural History and Anatomy.”32 Even within the prestigious society, Hunter ascended into a secret splinter group that engaged in sometimes bellicose confabs in London coffeehouses, with luminaries such as James Watt, James Cook, and Nevil Maskelyne joining in the brouhahas.
John Hunter passed the oral examination at Surgeon’s Hall in 1768, earning the diploma of the Company of Surgeons and finally the right to call himself a surgeon. His pupils William Shippen and John Morgan had already started the medical school in Philadelphia, and were professors of surgery and medicine when Hunter had ultimately achieved the bona fide title of surgeon. Within five months of earning his diploma, a corresponding change was triggered for John Hunter, the appointment as full-time surgeon as St. George’s Hospital (now The Lanesborough Hotel). At age forty, the arc of accomplishment and increased notoriety continued upward, now abruptly.
Hunter continued to build up his menagerie of animals and surgical specimens. His appetite (and forbearance) for the diseased and desperate further propelled his practice, particularly as a St. George’s Hospital surgeon. The hospital’s location in close proximity to Buckingham House and St. James’s Palace strengthened William’s entitlement as Queen Charlotte’s physician and obstetrician, but it seemed impossible that John Hunter could ascend to such a lofty title.
John Hunter’s enthusiasm and masterful teaching skills translated well from the simple anatomy school at Covent Garden to the prestigious confines at St. George’s. The uncouth and uneducated Scotsman had been transformed into the most advanced scientific thinker among surgeons in the English capital, and an amazing five hundred pupils would fall under his spell of skepticism and investigation in the coming decades. His dedication in animal experimentation and the assiduous collecting of surgical specimens slowly convinced him that the ancient notions of disease and humoral imbalances were ill-conceived.
The ancients were gravely mistaken when they intervened in the midst of disease without understanding the disease process. Hunter’s predecessors stumbled in the dark, but he conceived simple experiments to comprehend healing, inflammation, and disease processes. Warmed by a log fire, armed with the most primitive instruments, and scrutinizing by candlelight, Hunter carried out investigations on an assortment of animals and conditions. Nothing was off-limits—not even his own body.
Georgian London was overwhelmed by sexually transmitted diseases (including syphilis and gonorrhea), the result of casual sex in the chief port city of the empire. Still a century from a consensus on germ theory, venereal diseases were the most convincing examples that microscopic terrors were to blame for the transmission of disease from one paramour to the next, but there was still no identification of the culprit. Hunter was determined to investigate one aspect of disease transmission: could the crusty discharge from a syphilitic patient alone be the carrier of disease from lover to lover? Additionally, Hunter was trying to determine if gonorrhea and syphilis were actually two separate diseases, or were they simply different manifestations of the same disease? To investigate this, Hunter conceived a plan to inoculate a symptom-free patient with no history of venereal disease with a sample of the milky-white discharge from a gonorrhea patient. But where to find a volunteer who would knowingly submit to the application of the discharge from the festering wound of a venereal victim … onto the innocent’s penis? How about a body snatching surgeon?
Hunter recorded, in the third person in exacting detail, on the results of his stunning experiment of self-contamination. He never identified the patient, but most scholars agree that Hunter was himself the guinea pig. In May 1767, Hunter recorded, “Two punctures were made on the penis with a lancet dipped in venereal matter from a gonorrhea [milky discharge]; one puncture was on the glans, the other on the prepuce. This was on Friday; on the Sunday following there was a teasing itching in those parts, which lasted till the Tuesday following.”33 Several colleagues and students recorded contemporaneous accounts of Hunter admitting that he had given himself a chancre, sobering evidence that John Hunter would stop at nothing to delve into the mysteries of the human body.
As the days progressed, there was a “teasing itching” in the penis that blossomed into infected scabs that soon generated a discharge and “a little pouting of the lips of the urethra, also a sensation in it making water, so that a discharge was expected from it.”34 Still not sure if he was experiencing gonorrhea or confronting the early stages of syphilis, he realized within ten days that syphilis was now embryonically emerging within his body, with ulcerated chancres growing at the end of his penis and the development of glandular swelling in his groin. Was Hunter mad, or so insatiably curious that his utter lack of self-preservation led him to needlessly condemn himself to a lifelong pestilence? Dear Reader, ponder the verity that gonorrhea is often self-limited and does not recur; syphilis, on the other hand, is a lifelong infestation of a bacteria that visits its victim in waves over the course of years in three primary manifestations, including a brain and spinal cord infection that leads to madness in the final, or tertiary, stages. This is the bacteria that Mr. Hunter was intentionally smearing on self-inflicted lacerations on his male member.
Seven months after infecting himself, John Hunter developed “copper coloured blotches” on his skin and was experiencing ulcerations on his tonsils. For the next three years he was daubing mercury on his sores until a quiescence finally occurred. It is not known if he ever suffered from tertiary syphilis, but his final demise as a sixty-five-year-old was from cardiac disease, a possible connection to syphilis in up to one-third of untreated patients. Hunter’s horrifying tolerance of auto-experimentation demands repudiation and simultaneous recognition of his dedication in the face of ignorance.
While wrestling with Hunter’s recklessness, students of medical history must acknowledge that surgeons have often been immune to revulsion, even to the point of self-sacrifice. A certain resistance to disgust coincides with an odium of disease; these oddly balanced impulses explain many breakthroughs in healthcare. Like firefighters who abhor fire, yet derisively run headlong into a conflagration, healers despise—even dread—microbes while thrusting themselves in the middle of pandemics. John Hunter serves as the bridge between medieval surgical bleeders and the first surgeon-scientists. Explorers and pioneers are prepared to live in the wilderness in primitive habitations; Hunter was willing to dwell in the morass of unenlightened surgery, establishing a foundation of surgical science. “Hunter believed all surgery should be governed by scientific principles, which were based on reasoning, observation, and experimentation.”35
Hunter’s lectures were often iconoclastic, and he was one of the first surgeons to suggest that “bloodletting was not just largely ineffectual but potentially dangerous …”36 The next generation of famous British surgeons, legendary in their own right, are the ones who best capture the impact of Hunter on modern surgery. Henry Cline, the president of the Royal College of Surgeons, first attended Hunter’s lectures out of simple curiosity, and after first hearing him, said, “When I heard this Man, I said to myself, This is all day-light. I felt that what I had previously been taught was comparatively nothing … and thought I might, like Mr. Hunter, venture to Think for myself.”37 John Abernethy, another renowned London surgeon from St. Bartholomew’s, concluded, “I believe him to the author of a great and important revolution in medical science … of this I am certain, that his works produced a complete revolution in my mind.”38
The complex John Hunter would be named surgeon to King George III in 1776, the year of another revolution. The man who some say is the basis of Dr. Jekyll & Mr. Hyde—from his front-of-the-house prestigious medical practice on Leicester Square and nefarious backdoor entrance for middle-of-the-night deliveries of stolen bodies—is undoubtedly the founder of surgical science. His massive collection of surgical specimens and medical curiosities were donated to the Royal College of Surgery from his penniless estate, exhausted from a lifetime of exploration, spending, and consumption, not dissimilar from his American philosophical contemporary in Monticello.
John Hunter died in 1793 while attending a hospital staff meeting at St. George’s Hospital in London. Involved in a debate over house staff, Hunter’s last moments were characterized in fury; he “died, as he had lived, in rebellion, speaking his mind.”39 The primitive surgery he practiced, without anesthesia and with no understanding of sterility, was mostly associated with removal of stones, cysts, and rudimentary treatment of traumatic wounds. A half century after his death would herald the arrival of ether and usher in a new way of placating man before the surgeon’s knife.
The prototype for Langenbeck in Berlin, Billroth in Vienna, and Lister in the United Kingdom, Hunter finished his career without washing his hands, or dreaming of germs. In one of medicine’s great ironies, the giant of surgery with almost no formal education had the greatest impact on the scientific training of surgeons. He theorized that “A hospital … should be not only a charitable institution offering aid to the poor—indeed, even a place where surgeons gained experience before trying their luck on wealthier clients—but also a center for educating the surgeons of the future.”40 “My motive,” Hunter concluded, “was in the first place to serve the Hospital and in the second to diffuse the knowledge of the art that all might be partakers of it.”41
When another young Philadelphian arrived in London shortly before Hunter’s death, the pupil’s father asked Hunter what books his son would need to read, “Hunter simply led the way to his dissecting room, where several open cadavers lay, and declared, ‘These are the books your son will learn under my direction; the others are fit for very little.’”42 Hunter, of course, was correct. Almost nothing in any medical textbook in the 18th century regarding the causes and treatment of disease is accurate or beneficial.
With surgical science in its infancy, Galenic medicine was in its death throes. A century before, at the death of William Harvey, a sobering recollection of Hippocratic faith was exercised. Suffering a stroke in 1657, William Harvey found himself unable to speak, with “dead palsy in his tongue.”43 Summoning his apothecary, Harvey motioned to have his tongue sliced open, completely in line with Galenic humoral conjecture that “letting of the blood” would hasten the return of speech. For the man who unlocked the secrets of circulation, the mysteries of cerebral hemorrhage and stroke were still profound, and the barbaric gashing of his tongue “did little or no good … so he ended his dayes [sic].”44
John Hunter ostensibly died of a heart attack in a hospital, which today would surely result in a “rapid response” by a team of lifesaving physicians, nurses, and technicians in almost any advanced medical center in the world. While no treatment was available to Hunter as he rapidly died, no pointless Galenic treatment was foisted upon his hapless soul. The “Founder of Scientific Surgery,” as is inscribed over his grave at Westminster Abbey, had revolutionized anatomy, education, and surgical science, thus raising surgery from a shameful diversion to a profession with a future.