THE WALL STREET JOURNAL. **** Saturday/Sunday, March 7 - 8, 2020 |C9
BYJOHNJ.ROSS
I
N 1536,during one of the perpetual
wars between France and Spain, French
troops invested the Italian city of Turin.
After one bloody skirmish, the surgeon
Ambroise Paré had to dress the wounds
of the soldiers who had been shot by the
hackbuts of the besieged. The conventional
wisdom of the time held that bullet wounds
should be cauterized with boiling oil. To Paré’s
dismay, he ran out of oil, and had to treat the
remaining casualties with a tamer concoction of
egg yolk, oil of roses and turpentine. Like many
a surgeon before and since, Paré spent a rest-
less night, and went out at first light to round
on his charges. He was astonished to find that
the men who received scalding-hot oil were in
agony, “with great pain and swelling around
their wounds,” while those treated with bland
dressings were resting comfortably.
In David Schneider’s bold and compelling
“The Invention of Surgery,” modern surgery
began with a great unlearning of venerable
balderdash, some of it dating back as far as
classical Greece. Twothousand years of Western
medicine was based on the teachings of
Hippocrates, whose theory of the four humors
added words to our vocabulary such as bilious
and sanguine but also killed off untold numbers
of patients. Critically ill and dehydrated patients
were given noxious drugs to provoke vomiting
and diarrhea, or bled to death with leeches and
lancets. “If Hippocrates is the Father of Medi-
cine, it is a dubious paternity,” Dr. Schneider
writes. “We can’t identify any success associ-
ated with his (or his followers’) theories.”
Dr. Schneider’s work is not a comprehensive
history of modern surgery, but a lively personal
account, informed by his fascination with the
field’s “tinkerers, oddballs [and] lonely geniuses.”
First of these was the Renaissance anatomist
Andreas Vesalius. Before Vesalius, the pre-
eminent authority in anatomy was Galen, who
had been the personal physician to the Roman
emperor Marcus Aurelius. Galen’s anatomy was
a pastiche of personal experience, gleaned from
dissecting pigs and apes and patching up
mangled gladiators, joined to a host of Hippo-
cratic misconceptions. Vesalius, an obsessive
Belgian transplanted to northern Italy, worked
under conditions that are unimaginable today,
furtively dissecting decomposing remains in a
time before preservatives or refrigeration.
The end product of these ghastly researches
was the first great text of scientific anatomy,
“On the Fabric of the Human Body,” which
pointed out more than 200 of Galen’s errors.
Dr. Schneider rounds up the usual suspects
in his survey of the birth of modern surgery.
There is John Hunter, the combustible Scot who
invented scientific surgery but is remembered
today for his “bizarre, outlandish, and even
savage tendencies,” including a misbegotten
experiment in which he infected himself with
syphilis. Joseph Lister, the father of antiseptic
surgery, is here, as well as the various claimants
to the invention of anesthesia. There are some
surprising faces too, such as William Henry
Perkin, an 18-year-old chemist who accidentally
discovered that coal tar could be used to make
brilliant purple dyes. Perkin’s synthetic dyes
were adopted by the textile industry and made
him a rich man. But they also made possible the
discipline of pathology. Before Perkin, tissues
seen under the microscope were grainy, indis-
tinct blobs. His dyes transformed them into a
world of Technicolor brilliance and clarity.
Prior to the modern era, Dr. Schneider
writes, surgeons were “mercenaries called upon
in the face of catastrophe,” only operating on
patients faced with death. Operations were
commando raids in which surgeons got in and
got out with maximum haste, while cutting off
as few of their assistants’ fingers as possible.
Armed with the new techniques of anesthesia
and Listerian antisepsis, surgery underwent a
remarkable metamorphosis. As it became less
lethal and more controlled, it expanded to the
treatment of “conditions that are inconvenient,
annoying, or even just aesthetically unpleasing.”
Dr. Schneider is especially good on his
specialty, orthopedics, and the history of joint
prostheses in particular. Hip replacement has
become so routine, a geriatric rite of passage,
that it is hard to imagine that its evolution was
gradual, with many painful misfires along the way.
In 1890, a German surgeon with the
formidable moniker of Themistocles Gluck
performed the first joint replacements,
implanting beautiful ivory prostheses in joints
destroyed by tuberculosis. The artificial joints
worked like a dream, until they failed due to
infection. After World War II, the new wonder
drug penicillin fueled further attempts at joint
replacement, using prostheses that looked like
a golf ball sitting atop a tee. Unfortunately,
their short stems tended to work loose from
the bone. An Oklahoma surgeon named Earl
McBride solved this problem by returning to
the long stems used by Gluck, which extendeddeep into the femur. But implant durability
would continue to be a problem.
Puzzled as to why hip replacements failed,
the English surgeon John Charnley studied the
workings of normal joints. He found that joint
cartilage was almost frictionless, and concluded
that this was the secret to reducing wear andtear. In 1956, Charnley performed the first total
hip arthroplasty, using Teflon to line the hip
socket. He shrunk the replacement femoral head
from the size of a Ping-Pong ball to the size of a
marble, an odd but scientifically sound decision.
But within a few years, the Teflon in the cup
was eroding, and seemed to be provoking
further damage. Charnley confirmed his hunch
about the Teflon by injecting it into his thigh,
where it led to the formation of inflammatory
globules. After a lucky encounter with a travel-
ing salesman, Charnley substituted polyethylene
for Teflon, leading to a long-lived and highly
functional design that is still the standard.
Fueled by private insurance and Medicare
reimbursement, the medical-device industry
has grown exponentially. Dr. Schneider notes
that outcomes with implants and devices are
not tracked in the U.S.: “Patients are, in effect,
part of a large, uncontrolled experiment.” “To
this surgeon,” he writes, “it is unconscionable
that there is no national joint registry in theUnited States of America. One can be a free-
market capitalist and simultaneously recognize
that every stakeholder in American medicine
must do better.”
Dr. Schneider concludes by making a leap
forward into a not-so-distant future, when
those who can afford it may become barely
human assemblages of prostheses, like the
titular character of Thomas Pynchon’s “V.”
Citing the startling recent advances in nano-
technology, Dr. Schneider foresees that brain-
machine interfaces may soon become common-
place. He attempts to see this as a positive, but
admits that “Homo electrusmostly freaks me out.”
He does commit one notable blunder,
stating that “among the worst FDA failures
ever was the inappropriate clearance given to
the makers of Thalidomide,” the drug that
caused fetuses to develop phocomelia, or
shortened and malformed limbs. The FDA
never approved thalidomide, thanks to the
heroic skepticism of the lead reviewer, Dr.
Frances Kelsey. However, cases of phocomelia
did occur in the U.S., as the manufacturer of
Thalidomide dispensed samples to physicians
for investigational purposes.
Dr. Schneider prefaces his chapters with
short autobiographical essays. These are
uniformly excellent, sometimes moving and
often wryly amusing, as when he writes of
“gunners,” those ambitious medical students
“who must pretend to be stellar team players
while simultaneously outperforming the
competition.” Hopefully, in addition to the
usual complement of gunners, surgical-training
programs still have room for the occasional
tinkerer, oddball or lonely genius.Dr. Ross, an internist, is the author of
“Shakespeare’s Tremor and Orwell’s Cough.”The Invention of Surgery
By David Schneider, M.D.
Pegasus, 380 pages, $28.95
Honing Their Craft
IN GOOD HANDSNeurosurgeons operating on a child at the UCLA hospital, 2010.
ANN JOHANSSON/CORBIS/GETTY IMAGESOperations were once like
commando raids. Surgeons got
in and out with maximum haste,
while cutting off as few of their
assistants’ fingers as possible.BOOKS
‘Let us hope there may spring...aline and race of inventions that may in some degree subdue...thenecessities and miseries of humanity.’—FRANCIS BACON
Cured
By Jeffrey Rediger, M.D.
Flatiron, 386 pages, $28
BYDANIELJ.LEVITIN
A
S A POPULARad for
state lotteries goes,
someone has to win. And
that is true. But the
chances of that someone
being you are so very slim that it
makes no sense to bother buying a
lottery ticket. People die of disease
everyday.Andyeteveryonceina
while, a patient told an incurable ill-
ness will kill her spontaneously re-
covers. Long after she’s supposed to be
dead, she finds herself cured. It doesn’t
happen often, but it does happen.
Are the chances of that someone being
you so slim you should ignore them?
Or can you do something to increase
your odds of surviving?
In “Cured: The Life-Changing
Science of Spontaneous Healing,”
psychiatrist Jeffrey Rediger tries to
find commonalities across people who
experienced “spontaneous remissions”
of deadly diseases: All were given a
death sentence, but lived. These
“miraculous” cures occur more often
than we think, he says, and studying
them may help us to discover new
treatments. It’s a lofty goal. In search-
ing for similarities among patients
who experienced spontaneous remis-
sions, Dr. Rediger considers changes in
diet, exercise, social relations, stress
reduction and meditation, eventually
summarizing his approach as “chang-
ing your relationship with yourself,”
a concept he admits is “nebulous.”
Dr. Rediger is at his best when
he voices the reasons we should be
skeptical about outrageous scientific
claims, and when he reviews some of
the fascinating history of medical
advances. He recounts, for example,
how the surgeon William Coley discov-
ered, in the 1890s, that a high fever
sometimes corresponded with the dis-
appearance of cancerous tumors, by
kicking the immune system into high
gear. Recent evidence supports this,
attributing the effect to adaptive im-
mune function and T-cell lymphocytes.
Dr. Rediger posits that our efforts to
reduce a fever could be making us
more vulnerable to cancer.
He typically starts out each section
of the book laying out the reasons
to be skeptical and how one would
appropriately evaluate evidence. His
mission is to investigate reports of
“genuinely incurable illness with docu-
mented evidence of both accurate
diagnosis and clear remission with
no complicating factors that could
explain their recovery.” He is truly
gifted with analogies. Describing a
patient with a devastating, progressive
form of arthritis, he explains why an
anti-inflammatory medication, such as
Naproxen, wouldn’t help. “No-anti-
inflammatory medication that’s been
developed so far can make a sig-
nificant dent on chronic, systemic
inflammation in the body and brain.
Naproxen attempts to reduce one
pathway of inflammation in a body
that has multiple pathways. It’s like
putting a Road Closed sign up when
there are five other roads that run to
the same location.”
Part of prophylactic medicine is
“treating the whole person,” with doc-tors helping patients to manage their
stress. The news is that stress is not
just what the doctor or other people
think might be stressful to you, but
what you find stressful in your own
life, two very different things; people
respond to the same life events very
differently.
Dr. Rediger gradually abandons his
skepticism and he seems to change his
relationship with the scientific ap-
proach, as when he writes, of a stay at
a healing center in Brazil, “I particu-
larly enjoyed the açai bowls, which are
considered by many to be a super-
food.” There are no “superfoods.” We
don’t even know if dietary sources of
antioxidants actually change antioxi-
dant levels in the body.
He embraces the New Age view that
refined flours and sugar cause accumu-
lation of toxins in the body requiring
detoxification. Although flour and
sugar are not healthy, “detoxification”
is not a thing. He touts Rolfing, a
pseudo-scientific form of soft tissue
manipulation. Any pretense of logic or
skepticism completely vanishes when
he lauds praise on Dr. Issam Nemeh,
a faith healer, who has been taken
to task by Jerome Groopman and Paul
Offit, two writer-M.D.s who suffer
neither fools nor such quackery.
And Dr. Rediger never grapples
with the statistics of medical prog-
noses. The book recounts stories of
patients who were told things like
“you have six months or less to live.”
Hidden in the pithy and presumed
certainty of such a statement is the
fact that this is merely an average
across a lot of people who are not you,
who have their own distinct biology,
complications and mediating factors.
Some will die within a day, some will
live 20 years. That’s just basic, fresh-
man probability: Averages are what
happen in the aggregate (and in manyDr. Rediger reports that she turned
things around after she reassessed
“her fundamental understanding of
who she was and what her purpose
was in this life.” She named her tumor
“Mel” and wished it away. She had a
recurring dream in which “a set of
hands appeared in front of her, big and
gentle. She knew them...theyjust
radiated a sense of home.” She
“changed the way she ate and thought
about nutrition.” Oh, and she had a
round of chemotherapy. Incredibly,
Dr. Rediger asks us: “Was Mirae simply
a ‘high responder’ to the chemotherapy
drug?”Um...yes.Yes,shewas.
Dr. Rediger quotes the 19th-century
physician William Osler: “The person
who takes medicine must recover
twice. Once from the disease and once
from the medicine.” Well, the person
who refuses to take established treat-
ments is playing the lottery with their
recovery. When Osler said this, it was
common to treat coughs and diarrhea
with opium, toothaches with cocaine,
not to mention all of the other nos-
trums offered at traveling medicine
shows. The FDA and medical micro-
biology were in their infancies at the
end of Osler’s life. He was not referring
to modern medicines that have been
scientifically developed and clinically
tested—drugs that, for the most part,
effectively and safely do what they are
supposed to do.
For the sake of giving Dr. Rediger
the benefit of the doubt, I suspended
disbelief and allowed myself to drink
the medicine of his woo-woo thinking
for the first 280 pages of the book.
But now, thankfully, I am cured.Mr. Levitin is a neuroscientist
and the author, most recently, of
“Successful Aging: A Neuroscientist
Explores the Power and Potential
of Our Lives.”Miracles
Versus
Medicine
cases happen to no one). In anything
we describe with the Gaussian—
or “normal”—distribution, the tails
theoretically trail off to infinity. That
means that if we say that something is
“incurable” we mean that, statistically,
a very small number of cases “out
in the tails” will be cured. As statis-
tician Jim Ramsay has said, “the
fundamental problem with tails is that
we don’t have much data on them.”
And this is because, by definition,
there are so few cases in the tails.
Misapplying these statistics leads theuncareful to draw all kinds of un-
warranted conclusions.
Equally worrying, he utterly ignores
half of the statistical question that
could shed some light on all of this.
Sure, some people rid themselves of
cancer while following the “keto diet.”
But the information we really need to
know is: How many people followed
the keto diet and were not cured? If
9 out of 10 are cured, you’ve got my
attention. But if it is 9 out of 10,000,
that just falls in the category of fluke.
In other words, counting only the “yes”
votes while ignoring the “no” votes
leads you to faulty conclusions. By that
logic, I could conclude that every car
in Pasadena is green (because I only
counted the ones that were).
The book’s ultimate story of a
“spontaneous remission” is a woman
named Mirae who had metastatic
melanoma that was deemed incurable.Searching for
commonalities among
people who experienced
‘spontaneous remissions’
of deadly diseases.