Lessons from computerless surgery

An aerial photo of historic Fort Snelling. (Courtesy of Minnesota Historical Society)

by Reuben R Shamir

A few years ago, we have traveled with the kids to Fort Snelling, Minnesota on the 4th of July. Fort Snelling is a historical military fortification that comes to life on Independence Day in the United States. Nineteenth-century soldiers march along the fort’s paths, cannons fire and villagers welcome guests into their houses, workshops and public buildings. One building caught my special interest: the hospital. In practice, it was a three-room house. One of the rooms was occupied by the patients. One room was packed with bottles and shelves for medicine and herbs. The antibiotics were in their infantry in the 18th and 19th centuries and unavailable in practice. In the American Revolutionary War, most of the soldiers died from infections and secondary complications from their wounds, rather than in combat. For this reason, the surgical instruments exhibited in the third room included saws of various shapes and size. To avoid the spread of a limb infection, the best practice was to cut the limb. Clamps, leather straps and other tools designed to immobilize the patients were also common. Anesthesia was not well established at the time either. A surgery at these times was painful and dangerous. Being at the hospital after visiting the (actors) villagers earlier and being with the soldiers all day it struck me: the poor unlucky soldier that was shot in his hand, had to be immobilized to the table while the doctor removed his arm! How terrible!

Beside feeling grateful for living in better times, it also triggered another interesting thought. What would we have been doing if we were born in these times? Take a moment to reflect. I imagine that some of us would be working on a better saw. Maybe a more durable version or one that would be less painful, resulting in shorter recovery time and with less risk for infection. Then I imagine that it would have been a great success and thousands of surgeons would prefer the ISCAS saw. The commander of Fort Snelling is shaking the inventor’s hands and the society is awarded a prestigious medal. Then, I think, it is still just a saw and it would not be so useful for any surgeon in the latter half of the 20th century. This strange chain of thoughts makes me feel that many of us work today on improving today’s ‘saw’. It is important and may touch the lives of thousands of people, but it will also probably disappear and will be irrelevant next century.

I like it. It makes me feel humbled and relaxed. On the one hand, we can find a meaningful purpose for life since the technology we develop may help many people. On the other hand, it cannot harm people if we got something wrong, or no one will use the device in the next century. How can we mistakenly consider a technology to improve patient’s quality of life, while it is actually doing the opposite? Is not the scientific method and the regulatory rules we have today are supposed to protect us from these cases? Yes, they are, and I believe that the methods we have today filter out many cases of unsafe or ineffective treatments. Yet, sometimes the answer is not so clear. One infamous example is lobotomy. A surgical procedure that was aimed at reducing the symptoms of mental disorders by severing connections in specific brain areas. This surgical procedure was considered the best practice in the 1940s and 1950s and the inventors received the Noble Prize for medicine in 1949. In practice, the surgery did reduce the mental disorder symptoms, however, with severe adverse effects on the patient’s personality and intellect, in addition to a 5% mortality rate and an increased risk for committing suicide. Criticism grew with over time as evidence was collected, and after about 80,000 patients and ~20 years, the method was abandoned. Today, lobotomy is often used to describe medical barbarism. I agree that it is probably an extreme example and that evidence justifying its termination was there early on. Yet, I do believe that the doctors performed this surgery believed at the time that they were doing the best for their patients. Recently, I encountered a criticism regarding a technology that I was intimately involved with and that is today the standard of care. I do not think it is going to be a second lobotomy story, but I do think that we should put the patients first and listen very carefully to the criticism.

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