I’ve been a big Star Trek fan ever since I first discovered reruns of the original Star Trek episodes in the 1970s, having been too young (but not by much!) to have caught the show during its original 1966-1969 run. True, my interest waxed and waned through the years—for instance, I loved Star Trek: The Next Generation, while Star Trek: Enterprise and Star Trek: Voyager pretty much left me cold—but even now I still find myself liking the rebooted movie series. In the original series, my favorite characters tended to alternate between Spock, the Vulcan first officer and science officer on the Enterprise, and Dr. Leonard “Bones” McCoy, the ship’s chief medical officer. I sometimes wonder if my love of these two characters had anything to do with my becoming a doctor and researcher myself. It probably did.
One aspect of all the Trek shows that always interested me was its portrayal of medicine in the 23rd and 24th centuries. After all, what doctor wouldn’t like to have a device like the tricorder that he could wave over the patient and come up with an instant diagnosis and course of treatment? Who knew, of course, that nearly 50 years after the first Trek episode first aired, we would have technology that makes the communicators on the original series (TOS, for those Trek non-fans) look primitive and large by comparison and that we’d be well on the way to developing devices that can do some of what tricorders did on the show. Throughout all the shows and movies, the medical technology of a few hundred years in the future is portrayed as vastly superior to what we have now, with 20th century medicine at times denigrated by “Bones” McCoy and other Star Fleet medical personnel as barbaric quackery.
A confluence of events and media led me to want to explore a couple of questions. First, which procedures that we consider state-of-the-art science-based medicine will be considered “barbaric” 50 or 100 years from now? Second, is the contempt expressed for the medicine of the past (e.g., by “Bones” McCoy) justified? These are questions that I’ll explore a bit with the help of the Star Trek universe, a recent new cable television drama series, and a couple of articles that appeared on medical sites as a result of the premier of that series.
Star Trek: 23rd century medicine vs. 20th century medicine
Perhaps the most amusing example of McCoy’s contempt for the “primitive” medicine of the 20th century occurs in the 1986 movie Star Trek IV: The Voyage Home. (I found it particularly amusing because I was a third year medical student when the movie came out.) For the purposes of this post, you don’t need to know the plot, other than that it involves the crew of the Enterprise time traveling to San Francisco in the year 1986 to obtain something from the past that would save the Earth of the year 2286. During their mission one of the crew, Chekov, is seriously injured fleeing from the military, captured, and as a result taken to Mercy Hospital for emergency surgery. When Dr. McCoy learns of this, he begs Captain Kirk not to leave Chekov in the hands of 20th century medicine. So Kirk and McCoy disguise themselves as doctors and infiltrate the 20th century hospital where Chekov is about to undergo emergency surgery in order to rescue him. It is during this part of the movie that this hilarious exchange occurs:
For those of you who can’t play the YouTube video, here’s a transcript that shows you what I mean. First, “Bones” encounters an old woman on a gurney in the hallway and asks her a question:
McCoy: What’s the matter with you?
Patient: Kidney… dialysis.
McCoy: Dialysis?! What is this? The Dark Ages? Here! You swallow that and if you have any more problems, just call me!
Later, as the crew is escaping, McCoy encounters the woman again, who’s telling everybody that McCoy had given her some pills and she grew a new kidney.
In another scene, Kirk and crew are in an elevator with some interns, and McCoy overhears the following conversation, not being able to stop himself from butting in:
1st Intern: So, Weintraub says radical chemotherapy or she’s gonna croak. Just like that…
2nd Intern: And Gottlieb?
1st Intern: Well, what’d you expect? All he talked about was image therapy. I thought they were going to punch each other.
McCoy [Muttering and shaking his head]: Unbelievable…
1st Intern [Turning to McCoy, having heard his muttering]: You…have a different view, Doctor?
McCoy: Sounds more like the goddamned Spanish Inquisition!
Kirk [Turning to the interns and shrugging shoulders]: Bad day…
Later, Kirk and McCoy kick a neurosurgeon about to operate on Chekov to drain what sounds like an epidural hematoma out of his operating room at phaser-point, and McCoy proceeds to save Chekov’s life with his 23rd century technology.
You get the idea: In the fictional Star Trek universe, to a physician of the 23rd century what physicians of the 20th century do appears as barbaric as the practices of 18th century physicians appear to us physicians of the 21st century. What really got me thinking about this question again was the premier of a new historical medical drama on Cinemax entitled The Knick, which tells the story of Dr. John Thackery, fictional chief surgeon at the Knickerbocker Hospital in 1900. As a surgeon, I can’t help but apply the same sort of eye to surgery as practiced 114 years ago as Dr. McCoy did to medicine practiced in 1986. Unlike McCoy, however, I can’t lather up the same level of contempt for the fictional surgeons of the Knick that McCoy can for the hapless doctors of Mercy Hospital.
The Knick: What a difference 114 years makes!
Although I subscribe to HBO, I don’t subscribe to Cinemax. Consequently, I was only able to view the first episode of The Knick using On Demand, and have since only seen the first three episodes because HBO happened to show them all in a block about a week after the third episode aired. I haven’t seen episodes four or five yet, although I’m seriously tempted to subscribe to Cinemax for the remainder of the season just to see the show and then to drop it after the show’s run ends. However, the episodes I’ve seen are enough to pique the interest of any surgeon interested in the history of surgery. Producer Steven Soderbergh likes to brag about the measures his team has taken to assure historical accuracy with respect to the medicine practiced and the surgical procedures portrayed, particularly how extensively his show has used the Burns Archive, a trove of more than a million historic photographs (a few of which are digitized and displayed here, unfortunately without much in the way of text or captions to tell the viewer what they are), to recreate the look of medicine in the early 20th century.
Of course, it being a fictional show, there are things that The Knick takes some creative license with, such that I wondered about them immediately. For instance, body snatching to supply hospitals with medical cadavers and fights between ambulance drivers over who gets to pick up patients were apparently not as prevalent as The Knick portrays, given that New York was one of the first states to pass “anatomical acts” in the mid-19th century to discourage trade in bodies and body snatching. By 1900, such activities would be a risky, at best, crime not likely to be particularly profitable. On the other hand, given the level of endemic corruption in New York in 1900, characters like corrupt Health Inspector Jacob Speight who takes kickbacks to refer patients he finds with reportable infectious diseases for which the city mandates treatment to the Knick and the equally corrupt hospital administrator who works with him are not implausible.
One thing I noticed in the very first operating room scene (and in all the operating room scenes in the episodes I’ve seen thus far), surgeons are depicted operating bare-handed. Instead of scrubbing up and using rubber gloves, as surgeons have done for many decades now, they dipped their hands into antiseptic solution right before the start of surgery. It turns out that the great surgical pioneer upon whom Dr. Thackery is loosely modeled, Dr. William Stewart Halsted had pioneered the use of rubber gloves in 1889 or 1890 because his scrub nurse (with whom he later fell in love and who ultimately became his wife) had begun to develop severe contact dermatitis as a result of the nasty chemicals (mercuric chloride and phenol) used to disinfect the hands of the operating staff at the time. Rather than have her reassigned, Halsted requested the Goodyear Rubber Company, as an experiment, to make “two pair of thin rubber gloves with gauntlets.” At first, only assistants used them, but within a couple of years, the surgeons at Johns Hopkins, where Halsted practiced, were using them. So it seems a bit of creative license that the surgeons at the Knick would still be operating bare handed. On the other hand, it’s not too beyond the pale that some surgeons might still be operating bare handed in 1900, given that it wasn’t until 1899 when Halsted’s protégé Dr. Joseph Bloodgood (what an awesome name for a surgeon!) published a report of 450 hernia operations using gloves, observing that the infection rate fell by nearly 100%. Bloodgood’s report led Halsted to take himself to task, asking “Why was I so blind not to have perceived the necessity for wearing them [rubber gloves] all the time?”
Think of it: A man with one of the most brilliant minds in the entire history of surgery responsible for so many surgical innovations, from emergency blood transfusions, to cancer surgery, to something as mundane as a bedside chart to track a patient’s vital signs and the use of surgical gloves operating room, a man who first laid down surgical principles still taught to all surgeons today, such as a completely sterile surgical field, hemostasis, gentle handling of tissue, careful anatomic dissection, and exact approximation of tissues, and Halsted couldn’t immediately figure out that wearing sterile rubber gloves instead of dipping one’s hand in caustic chemicals to disinfect them was a superior means of preventing surgical infection!
Other examples, although perhaps anachronistic, are found in the fictional world of The Knick. For example, the very first OR scene in the very first episode portrays the attempt by Dr. J.M. Christiansen and Dr. Thackery to perform a Caesarian section on a woman with placenta previa, after having failed at this procedure eleven times before. They fail again, with the mother and baby both dying. As a surgeon, I found this scene particularly disturbing and effective. As I watched the impressively realistic pools of blood form, overwhelming the ability of the pedal-driven suction to clear them, the surgeons frantically working, and the nurse reporting a faster and faster pulse (and ultimately no pulse), all as dozens of doctors and trainees observe the procedure, I couldn’t help but wonder how surgeons could actually save anyone in such an environment.
The same question came up later in the same episode, when a man with a bowel perforation had his injury repaired primarily. The surgeon who did the repair was taken to task by Thackery on rounds for not resecting. Later, the patient develops intra-abdominal sepsis, requiring Thackery to operate on him using an instrument he had constructed himself to resect the nonviable bowel and sew it back together. While I admit that this part made me wonder (bowel anastomoses were pretty standard procedures by 1900; so I’m not sure why this would have been so revolutionary), I still had to marvel how any surgeon could expect any patient with a bowel resection to survive intra-abdominal sepsis after a bowel perforation with no antibiotics as adjunctive care for the drainage and resection.
More examples included a man with an aortic aneurysm, for whom the treatment would be a galvanic procedure (using electricity to induce thrombosis of the aneurysm), an attempt to reconstruct a woman’s nose lost to syphilis using a tissue flap from the arm that necessitated the arm to be attached to the nose for several weeks to provide a blood supply (a technique still in use today for some reconstructive procedures), and the portrayal of Dr. Thackery anesthetizing a patient using a cocaine epidural. A lot of these weren’t exactly 1900 medicine, although they were generally from within a few decades. Dramatic license again. The point, however, is that medicine always operates within the context of the existing scientific and clinical knowledge of the time. Of course, The Knick is a vision of what medicine was like in 1900 imagined by a man of 2014. However, it’s also informative to look at medicine as portrayed in the media contemporaneously, as we will see. To do that, I leap from the world of The Knick to 50 years in its future.
Dr. Kildare, or I’d rather have a bottle in front of me than a frontal lobotomy
Over the last few years I’ve become a bit of a fan of old time radio, having discovered Radio Classics on Sirius XM Radio. In particular, I discovered The Story of Dr. Kildare. This particular radio show stared Lew Ayres as Dr. Kildare and Lionel Barrymore as the irascible Dr. Leonard Gillespie (the latter of whom was actually hilarious, by the way). It’s an episode of this show that demonstrates perhaps the clearest example of a standard of care that turned out to be disastrously wrong.
I sometimes listen to Dr. Kildare not so much for the stories themselves, but because of what a time capsule the show represents when it comes to how medicine is practiced. Most of the radio episodes I listen to tend to be from the early 1950s. One episode remains stuck in my mind, an episode that originally aired February 1, 1950 entitled “Angela and Steven Kester“. The episode begins with Dr. Kildare showing up in his office on a typical morning to cover a long shift on duty. He’s greeted with a phone call from an old friend named Angela Kester. Kester used to be a famous concert pianist, but in this phone call she frantically begs Dr. Kildare to come right away to her apartment because she’s convinced that her husband is planning to kill her. Dr. Kildare protests that he’s on duty and can’t easily leave the hospital, but she’s so upset that he tells her he’ll be right over. On his way out the door Dr. Kildare runs into Mrs. Kester’s husband Steven, who has come to visit him. Kester tells him that he’s very worried about his wife, who, according to him, appears to be exhibiting obsessive behaviors, playing the same piece over and over again, sometimes practicing 16 hours a day. Apparently, five years prior at a concert at Carnegie Hall, she suffered a breakdown and couldn’t perform in front of an audience after that. Kildare informs Kester that his wife had just told him that she thought Kester was trying to kill her. Kester, not surprisingly, is horrified, and the two of them rush over to the Kesters’ apartment, where they encounter Mrs. Kester feverishly playing and yelling that her hands are being controlled by the music.
Later, we learn that Mrs. Kester’s father had been a “second rate” pianist who had wanted his daughter to succeed where he failed. Recognizing Angela’s talent at a young age, he spent lots of money on lessons for her and pushed her harder than any father should push his child, taking pains to make sure that Angela was constantly reminded of just how much he had sacrificed for her. We also learn that she had undergone insulin shock therapy, a treatment in which large doses of insulin were administered to induce a hypoglycemic coma, a treatment that fell out of favor a few years after this particular episode aired because not only did it not work but it was very dangerous given that hypoglycemia can easily kill. We then learn that Angela Kester had undergone many cycles of electroconvulsive therapy, with little or no improvement. Much discussion occurs about how Angela couldn’t tolerate another course of ECT or insulin shock therapy.
Around this point, Angela tries to commit suicide by shooting herself in the chest, but fortunately for her all she did was to give herself a pneumothorax. Dr. Kildare operates and easily saves her life. Angela’s suicide attempt, however, leads Dr. Gillespie and Dr. Kildare each independently to delve into the medical literature looking for answers (one of the better aspects of this particular episode, as disturbing as the solution they both ultimately found was). The solution they come up with? They both decide that a prefrontal lobotomy is Angela’s only chance to be “cured” of her condition.
So, even though Dr. Kildare was a fictional surgeon, in this episode we see him diagnosing Angela with paranoid schizophrenia (which in all fairness was probably an accurate diagnosis), obsessive-compulsive disorder, and neuroses. In any case, not surprisingly, given the framing of the choice in such terms, the decision is made to go ahead with the operation, even though Dr. Kildare is not a neurosurgeon and appears not even to have performed this particular operation before. None of this stops Steven Kester from agreeing to the operation on behalf of his wife, and the operation proceeds. Dr. Kildare whips out the leucotome (a special instrument designed to use in performing prefrontal lobotomies) and does the operation, drilling a hole in Mrs. Kester’s skull and using the leucotome to cut the connections between the prefrontal cortex and the underlying structures. Naturally, Dr. Kildare’s surgical skill is copiously praised when he finishes the operation. After a few days of suspense, during which everyone wondered whether the lobotomy had been successful, Mr. Kester demands to see his wife, who is initially afraid of him, but then, after she recognizes him, declares that her “hands are free,” meaning that she didn’t feel the compulsion to play anymore. She is declared “cured.”
From the perspective of 2014, this episode is disturbing in any number of ways. First, there is the demonization of mental illness that shows through even a seemingly sympathetic script. Words like “lunatic” and “lunacy” were thrown about not by lay people but by Drs. Gillespie and Kildare themselves to describe Mrs. Kester’s mental illness. In some ways, the desperation is understandable. 64 years ago, there was little that could be done in such cases, and it is not entirely surprising that a sense of desperation led to the conclusion that desperate conditions call for desperate measures, such as insulin shock therapy (a dangerous therapy that didn’t work), ECT (which could work and is still occasionally used in the case of severe depression refractory to medication but was hugely overused then), and, of course, prefrontal lobotomy.
Interestingly, this particular episode of Dr. Kildare aired right at the height of the lobotomy craze (and, quite honestly, that’s what it is best described as, as is evident from Mo Costandi‘s description of the rise and fall of the lobotomy). It’s therefore no coincidence that this episode aired in 1950. No doubt the writers were doing what writers of medical series frequently do now: Feature a new medical or surgical treatment as the focus of drama.
Discovering this episode a few months ago simultaneously fascinated and appalled me. Like most TV and radio shows, Dr. Kildare is a time capsule both of the popular perception of how medicine was practiced during its time and of how medicine actually was practiced at the time. We had the young gun surgeon, highly skilled and compassionate, willing to take risks and push the boundaries paired with the old curmudgeon of a doctor who serves as his mentor and, despite his crankiness, is often revealed to have a heart of mushy gold. The show featured portrayals of medicine as practiced then, and, much like medical TV shows today, had medical advisors to guide the writers. In 1950, the prefrontal lobotomy, although admittedly controversial even then, was an accepted standard of care that we now view with horror. But how many others are there?
Is today’s standard of care tomorrow’s horror?
All of this brings us back to the central question of this post, which was mirrored when The Knick first premiered over six weeks ago, by Dr. Sanjay Gupta at MedPage Today, who asked the question Is Today’s Standard Care Tomorrow’s Horror? To supply fodder for the article, six physicians were polled by e-mail with this question. The answers were rather interesting, although some of them were more about politics than actual science-based medicine. For instance, Cherie Binns, RN, answered the question this way:
Talk of limiting care for geriatric patients or the multiply handicapped child (especially at birth) and limiting access to resources for those with chronic health conditions that utilize a majority of services and healthcare dollars available are certainly, if they become standards of care, something that will be mocked, misunderstood, maligned in another generation.
She also laments how the Affordable Care Act allegedly prevents patients from seeing skilled health care providers. Whether that’s true or not, it’s not really an answer to the question, at least not as far as I’m concerned. Even though few people would be unsympathetic to this point of view, her response is really is more a matter of value judgments and resource allocation than it is a matter of the scientific standard of care.
Disappointingly, a lot of the responses were like that. Only one respondent, Dr. Murali Doraiswamy, was bluntly honest:
Ninety-nine percent of treatments today will be viewed as harmful or unethical in the future; for example, most psychiatric treatments given to children or most back surgeries.
Personally, I think Dr. Doraiswamy vastly overestimates what percentage of treatments will be considered harmful or unethical in the future, given the high percentage of treatments currently used that are evidence-based. For instance, there are many surgical conditions that can’t be fixed unless the anatomy is fixed. The operations aren’t going to go away; they’ll simply evolve to become less invasive, as they are doing now with the introduction of laparoscopic and robotic surgery and as the treatment of breast cancer has evolved from radical mastectomy to much less invasive procedures. Conditions like hypertension are still likely to require medication, as lifestyle changes, although they alleviate a lot of hypertension, won’t be enough for many people.
A more common example that came up was the use of “shotgun-style” or “one-size-fits-all” treatments, or, as one doctor put it, a “carpet bomb” approach to medicine. Of course, one doctor, Dr. John P. Higgins, has the opposite problem to go along with demonizing the past, namely a Pollyanna view of the future, in which he proclaims that “targeted and individualized therapy for a patient’s unique physiology will be used, with precision efficacy and near zero side effects.” There is little doubt that we will be able to target our treatments more and more effectively, but “near zero side effects”? Whatever Dr. Higgins is smoking, I’d want some if I could stand to inhale.
Let’s take an example that our good Dr. McCoy aimed his contempt at. It’s a treatment that’s commonly demonized not just by those who are—shall we say?—not completely down with the whole science-based medicine thing but even some physicians, chemotherapy. If you do a quick Google search, it doesn’t take long to find posts decrying chemotherapy for cancer as setting the standard for barbarism in the field and even as “criminal.” Of course, there’s no doubt that chemotherapy is toxic and can be brutal (although it’s getting less so, thanks to better supportive care and more targeted therapies). However, as I’ve pointed out before, death from cancer can be far more toxic and brutal. When an ugly death is the consequence, chemotherapy’s risk-benefit ratio becomes more acceptable. Moreover, contrary to the claims of those who like to label chemotherapy as ineffective, chemotherapy, used appropriately, works. It’s also important to remember that most people who call modern treatments “barbaric” have an agenda that is not necessarily science-based.
Of course, there’s no doubt that chemotherapy has way more toxicity than we’d like, but to proclaim this issue a “crisis” is exaggerating. It’s more like a longstanding problem that will require research to overcome. Crisis or not, efforts are in full swing to find more targeted and less toxic therapies. It’s also true that individualized therapy, now more commonly referred to as “precision medicine”, will come to the fore. However, the process will not be as easy or fast as the hype promises. For every success, we will see failures. Moreover, we still don’t know what, exactly, “individualized” treatment will mean, even as quacks try to define it for themselves. Advancement in science-based medicine always occurs by fits and starts.
A rebuke to Dr. McCoy
As much as I love Dr. McCoy as a character, in that famous Star Trek IV hospital scene, he is dead wrong in his sneering contempt for medicine 300 years before his fictional time, just as I would be wrong to express the same sort of contempt for physicians from 1714 for believing diseases were a result of imbalances in the four humors, surgeons in 1900 who practiced without the benefit of antibiotics, or physicians in 1950 who were believing the case reports about frontal lobotomy. Physicians all practice according to the standard of the time, and that standard is based on the science as understood at the time. It is ridiculous to criticize physicians for not knowing something that hasn’t been discovered yet. In 2014 I hold in the palm of my hand a computer (my iPhone 5s) that is hundreds of times faster, drives nearly 2.5x more pixels, and holds thousands of times more data than the first computer I ever bought for myself, my clunky Mac LCII. Should I heap scorn on the computer engineers of a mere 22 years ago because computers then were so much less powerful than what we have now? Those engineers did the best they could with the technology they had.
I would also point out that science advances incrementally, building on what is known before, although there have been moments of rapid advance. It turns out that 1900 was a time of such advances in the field of surgery and medicine. Indeed, Dr. Thackery gives a remarkable eulogy in the very first episode for his friend who committed suicide, the very same Dr. J.M. Christiansen, who calmly walked into his office after his attempt at a C-section failed and the patient died, placed a sheet over the couch in his office, picked up a gun, laid himself on the couch, and shot himself in the head. This eulogy is particularly remarkable for its view of medical progress:
In particular, Thackery notes:
We now live in a time of endless possibility. More has been learned about the treatment of the human body in the last five years than was learned in the previous 500.
Many have said the similar things during the last few years, given the revolution in genomic medicine in which we currently find ourselves, and it’s true. We do live in a time of endless possibility, with amazing technology and science almost unimaginable by even the generation that preceded us. So, yes, I’d be shocked if some, or even a lot, of what we do right now as the standard of care is overturned even in the remainder of my career. I’ve already seen it just since I first entered medical school in the 1980s. It will continue, and that’s a good thing.
We are all products of the time in which we live, and we all have a tendency to view history through the lens of what is known now. To have a true understanding of the history of science, however, it’s important to try to put yourself in the shoes of physicians and scientists of long ago and take into account what they knew then and what tools they possessed. For example, the Halsted radical mastectomy is often decried as a “brutal” and “barbaric” operation. And so it seems to a surgeon of 2014. But remember: In the 1880s, when Halsted first conceived the operation, there was no chemotherapy, no radiation therapy, no adjuvant therapy of any kind. Breast cancers tended to present at an advanced stage. If a woman with breast cancer was to be saved, surgery alone was what would have to do it, without the highly effective help we surgeons now receive from our colleagues in medical and radiation oncology. In context, based on the understanding of cancer of the times, the operation made sense, and Halsted’s results were better than those of other surgeons. Similarly, today chemotherapy seems “brutal,” but it works. It’s the best that we have.
Going back to the fictional past of the Knick (and the real past), physicians in 1900 were just as clever, just as dedicated, and just as desirous of curing their patients as physicians are now. What they lacked then is the knowledge and technology that we have now that allow us to do what we do now. Medicine stagnated for hundreds of years, until the latter half of the 19th century, when it began to embrace science, and its failures tend to occur when it forgets science. Yet medicine advances nonetheless, thanks to science. It might do so in fits and starts. It might go down blind alleys. It might fall for fads based on less than rigorous science. But eventually, it advances, and we obtain the knowledge and develop the technology necessary to improve. Even in the fictional universe of Star Trek, I’d bet that the physicians of 1986 were no less clever and dedicated than Dr. McCoy. The difference is that Dr. McCoy had tricorders and other products of the science and technology of 2286. Science is what got us from the world of the Knick to where we are now, and science is what will get us to the world of Dr. McCoy.