The Martlet; a newsletter where Surgery, Culture, Innovation, Finance and Informatics cohabitate
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A title, a profession, a licensure? |
This question is more complicated that it may seem at first. The word originated as a designation by the Vatican to identify those individuals authorized to teach scripture. With this as its root it was extrapolated by universities in Europe to signify those individuals of sufficient learning to be authorized to teach a particular subject. This is where the notion of Doctor of Philosophy comes from, in this case from the classic Latin definition of Philosophia, “lover of wisdom”. How it applies to physicians in highly variable amongst regions. In some cases, such as the US, it is both an academic title “Doctor of Medicine” and a professional title. In many part of Europe, a physician might be referred to as “Doctor” but they aren’t considered a true “Doctor” until they get their PhD, often encompassing research, after their medical degree.
Interestingly, Surgeons in the UK drop the title "Doctor" and go by Mr. or Mrs. once they become a Fellow of the Royal College. This is a form of reverse snobbery since surgeons were originally not considered “Doctors” and therefore were prohibited from using that title since their training was on the same apprentice tract as barbers.
In the Italian Comedia Dell’Arte tradition, Doctors ( il Dottore) are not physicians, but usually portrayed as decadent erudites that are involved in all kinds of shenanigans and wear academic robes. One only needs to think of Dr. Bartolo in Barber of Seville as a prominent example. |
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The Surgeon and the Sword Swallower
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The name Kussmaul is embedded in the memory of every medical student because of Kussmaul’s Breathing and Kussmaul’s Sign. But Adolf Kussmaul was also the visionary that developed the rigid endoscope in the 1870s. Seeing a sword swallower at the circus, he theorized that he could pass hollow “sword” through the relaxed cricopharyngeus and look into the stomach without making an incision. He therefore collaborated with a professional sword swallower to developed the first gastroscope. The biggest challenge was lighting. Recall that electric lighting was still 25 years away. He experimented with gasoline flames and mirrors. An extension of this work was the balloon dilatation of gastric outlet obstructions, a procedure that had require surgery previously.
Someone gifted hits a target few can hit, but a genius hit a target no one else can even see.
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Dr. Samuel-Jean Pozzi: Society Surgeon, Pioneer and Anthropologist
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Dr. Pozzi was an abdominal surgeon in Paris who rose to prominence in the 1880 and had a famously complicated life. He had studied with the greats of Europe such as Lister and Broca and was an early advocate of antiseptic technique, formal inpatient rounds and hysterectomy for symptomatic fibroids. In addition to being a founder of abdominal surgery in France he helped translate some of Darwin’s books into French. He was a prominent socialite having had affairs with George Bizet’s widow (the composer of the Opera Carmen) and the actress Sarah Bernhardt. Coincidentally it was Bernhardt’s performance of the play Tosca that inspired Puccini to write the opera version, and she had a pet lion named Scarpia after the villain from that play.
Such scandals made him well known in his day, but what really solidified his legacy was his portrait by John Singer Sargent entitled Dr. Pozzi at Home (1881). In it you can see his provocative pose, red coat and the emphasis on his hands, which conveys the duality of his skill as a surgeon and his reputation as a “ladies man”. Some have colloquially referred to this painting as “Dr. Love or Dr. God”. The painting is on display at the Met in New York.
Dr. Pozzi went on to volunteer as a surgeon in Franco-Prussian War, but his life was cut short in 1918 when a disgruntled patient walked into his clinic and shot him three times, before turning the gun on himself.
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Subclavian Artery Injuries: The subclavian, and proximal axillary artery are a trauma surgeon's nightmare. The exposure is tough because of the clavicle, the dissection full of vital structures, such as as the phrenic nerve and the cords of the brachial plexus, and the patient is either arresting, or just about to arrest. There's just no easy way to get to it.
If you think you are dealing with one of these, and the patient is unstable, it's probably worth intubating immediately, putting in a chest tube (if there's not time for a CXR) and getting to theatre as quickly as possible. Passing a foley into the bullet tract and inflating it can help you get out of the Trauma Bay at least. Decide early on where you're going to get proximal control and don't be shy about going straight to a median sternotomy to get control in the superior mediastinum. You'll probably need to divide the thymus and innominate vein, so have a white stapler ready to go.
Proximal Axillary Artery injuries are also tricky. Often you don't know if you're going to get control above or below the clavicle. In these cases the "incision of indecision" is right on to the clavicle. You can then retract superiorly to divide the anterior scalene (watch the phrenic) and get a bulldog on the subclavian, or retract inferiorly and get control medial to pectoralis minor. No matter what, be glad these injuries are rare and most trauma surgeons only see a handful in their entire career.
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