A brief tale of an 18th century Irish surgeon's demise

On my recent trip, I had the pleasure of visiting the Royal College of Surgeons in Ireland in Dublin. Its 200-year-old main building is steeped in history. During the 1916 uprising that led to Ireland's independence, the rebels used it as a billet. Pockmarks from British bullets are still visible on its front columns.

Today the RCSI houses a medical school with a diverse international student body. Thanks to my gracious host, vascular surgeon Sean Tierney, I was able to tour the college's modern classrooms. I also saw a well-equipped simulation laboratory and took part in some virtual reality exercises.

In one of the many beautifully appointed rooms is a statue of William Dease, a noted surgeon who was one of the founders of the RCSI in 1784 and its fifth president. He was also a member of the Society of United Irishmen which started the Irish Rebellion of 1798.

Although the circumstances surrounding Dease's death are somewhat unsettled, the most popular version of the story is that in June 1798 he learned he was about to be arrested because of his association with the United Irishmen and committed suicide by slicing open his femoral artery.

In 1886 his grandson donated a statue of Dease to the college. Some years later the statue developed a crack in a most unusual location. The photograph below shows why.

On the shoulders of giants

The following was sent to me by a professor who sits on the admissions committee of a medical school in the United States. Here’s what he asks prospective students during interviews.

Sir Isaac Newton said, “If I have seen further, it is by standing on the shoulders of giants.”

If you want to become an astronaut, I’ll bet you know who Neil Armstrong is. If you want to become a rock-star, you likely know who the Beatles were or who the Rolling Stones are. If you want to become President of the United States, you know who Barack Obama is. But you want to become a doctor, right? That’s why you’re here.

So, who are those giants of medicine? What famous scientists or doctors who have advanced the science of medicine can you name?

The following would not be acceptable:

Mehmet Oz, MD
Sanjay Gupta, MD (Medical reporter)
Phillip McGraw (“Dr. Phil”)

Here are some names that would count: Drs. Watson, Crick, and Franklin

You wouldn't believe the answers I get. For example:

"Stealing" the thyroid gland

Here's a story about a technique of thyroid surgery that is no longer being done

During one summer of my college years in the mid-1960s, I worked as an orderly at a community hospital in my hometown. There are no orderlies anymore. I guess the closest thing would be a "patient care technician." Orderlies used to push patients around on gurneys, help the nurses change beds, clean up poop, run errands, and do whatever no one else wanted to do. It was common for premed students to do at least one summer of orderly work to demonstrate their commitment to becoming a doctor. I suppose it's analogous to today's premed students' doing a summer of research cleaning test tubes.

Anyway, back to the story. A woman was admitted with thyrotoxicosis, a hyperactive thyroid gland resistant to whatever medications were being used to suppress thyroid function at the time.

She was scheduled for a total thyroidectomy, but the stress of anesthesia and surgery was known to induce a potentially fatal condition called a "thyroid storm." A thyroid storm can still occasionally occur in patients with untreated hyperthyroidism. Some symptoms of thyroid storm are fever, rapid heart rate, agitation, delirium, tremor, and low blood pressure, among others.

In the early 1900s, the threat of this problem prompted a famous early thyroid surgeon, George Crile, to devise a plan for "stealing" the gland.

Following Crile's script, what we did with our hyperthyroid lady was to visit her every day dressed in our surgical scrubs. The anesthesiologist would fiddle with her IV and talk to her. The OR nurse and I would chat with her too. All of this was done so that she could become accustomed to our presence. The idea was to one day anesthetize the patient in her bed and take her to the operating room for her thyroidectomy. Since the patient did not know on which day her surgery would occur, she was not so anxious.

A few days went by. One day we were told, "Today's the day." When we went into the room, the anesthesiologist, instead of just fiddling with the IV, injected some sodium pentothal, and the patient fell asleep. Off we went to the OR, and the operation was done.

These days, it's a good thing that hyperthyroidism can be treated with more effective medication. I doubt that insurance companies would pay for a three or four day preoperative hospital stay so that the thyroid gland could be stolen.

What was surgery like in the 1970s?

When I first started my residency in the early 1970s, things were remarkably primitive by today's standards.

There were no ultrasound machines. Believe it or not, we would diagnose acute cholecystitis by history and physical examination alone. The only diagnostic tests we had were oral cholecystogram (OCG) and intravenous cholangiogram (IVC). For OCG, pills were taken the night before the test. If the cystic duct was patent, iodinated contrast would appear in the gallbladder and stones could be seen. Non-visualization of the gallbladder meant either the cystic duct was blocked or the pills were not absorbed (presumably due to inflammation, not necessarily of the GB) or the patient forgot to take the pills. The test was useless in acutely presenting patients. IVC was similar except the contrast was given intravenously. The common bile duct could be seen faintly unless the patient was jaundiced. It rarely showed stones in the GB.

There were no CT scans. We had to make the diagnosis of appendicitis by, you guessed it, history and physical examination alone. And since laparoscopic general surgery did not become common in the US until 1990, all appendectomies and cholecystectomies were done as open procedures.

There were no computers in any clinical departments or nursing units. Everything was on paper. The good news? There was no way to "copy and paste" progress notes. We had different colored paper for different sections of the chart, which made things easy to find. The bad news? Charts often went missing. Handwriting analysis rivaled that of archeologists deciphering hieroglyphics in Egypt. But paper charting was faster to do and easier to "leaf" through.

When submitting a research paper, drafts had to be prepared on a typewriter (an ancient kind of word processor that put the words directly on paper). If you needed to change a paragraph on page 1, the entire manuscript had to be retyped from the beginning. And making slides for presentations involved cameras with 35 mm film, taking the film to be developed and hoping the slides came out OK. Find a typo? Take the picture over and have the film processed again.

Now we use PowerPoint. It's easier, but I'm not totally convinced that it's real progress.

Maybe the biggest change has been the advent of the Internet. In the palm of my hand, I can instantly access huge amounts of information formerly available only in print books and journals. To look up a paper, we had to use Index Medicus, an encyclopedic series of books listing every article by subject in most journals.

There were far fewer journals back then. You had to know the correct heading or keyword to search or you could miss something important. Cross-referencing was not easy because it was in print and there was a different set of volumes for every year. And libraries kept many years' worth of volumes of journals.

Of course, many more changes have occurred. Can any of my older colleagues comment?