NOTEBOOKS Esteve Foundation 42 Television fiction viewed from the perspective Medicine in Television Series of medical professionals House and Medical Diagnosis. Lisa Sanders Editor: Toni de la Torre The Knick and Surgical Techniques. Leire Losa The Sopranos and Psychoanalysis. Oriol Estrada Rangil The Big Bang Theory and Asperger’s Syndrome. Ramon Cererols Breaking Bad and Methamphetamine Addiction. Patricia Robledo Mad Men and Tobacco Addiction. Joan R. Villalbí The Walking Dead and Epidemics in the Collective Imagination. Josep M. Comelles and Enrique Perdiguero Gil Angels in America, The Normal Heart and Positius: HIV and AIDS in Television Series. Aina Clotet and Marc Clotet, under the supervision of Bonaventura Clotet Nip/Tuck, Grey’s Anatomy and Plastic Surgery. María del Mar Vaquero Pérez Masters of Sex and Sexology. Helena Boadas CSI and Forensic Medicine. Adriana Farré, Marta Torrens, Josep-Eladi Baños and Magí Farré Homeland and the Emotional Sphere. Liana Vehil and Luis Lalucat Series Medicine in Television Olive Kitteridge and Depression. Oriol Estrada Rangil True Detective and the Attraction of Evil. Luis Lalucat and Liana Vehil Polseres vermelles and Cancer. Pere Gascón i Vilaplana ISBN: 978-84-945061-9-2 9 788494 506192 42 NOTEBOOKS OF THE ESTEVE Foundation Nº 42 The Knick and Surgical Techniques Leire Losa The one thing Steven Soderbergh, winner of an Oscar for Best Director in 2001 for Traffic, had not de- clared when he announced his withdrawal from the film world in 2013 was that he was transferring his unique aesthetic to cable TV, to join a growing list of film directors who are investing their talent in this far less interventionist medium. This is what he has done in this historical drama that takes us back to the beginnings of modern surgery in a highly unconventional way. It is set in a New York hospital in the early twentieth century, and has an even more unusual protagonist: a reputable surgeon who is addicted to co- caine, played by Clive Owen (Closer, Children of Men). Its popularity has raised visibility for HBO’s younger sibling: the action channel aimed at the male Cinemax audience. The Manhattan Dispensary was a hospital found- inition of a surgeon is attributed, along with his ed in Harlem, New York, in 1862, which survived modus operandi: “The things relating to surgery until 1979. Throughout its history it received dif- are: the patient; the operator; the assistants; the ferent names, but was known from 1913 onward instruments; the light, where and how; how many as the Knickerbocker Hospital. This is where the things, and how; where the body, and the instru- series’ action is set, in 1900, taking as its main ments; the time; the manner; the place. The op- narrative referent the early steps of modern sur- erator is either sitting or standing, conveniently gery and efforts to improve it technically. for himself, for the person operated upon, for To understand this period, one needs to briefly the light... The nails should be neither longer nor review the history of surgical evolution from its shorter than the points of the fingers; and the sur- beginnings. Back then, surgeons were consid- geon should practice with the extremities of the ered technicians, and were not always qualified, fingers, the index-finger being usually turned to in contrast to doctors, who were the true healers. the thumb; one should practice all sorts of work However, it could be said that both disciplines with either of them... endeavoring to do them have always been closely related. well, elegantly, quickly, without trouble, neatly, According to archaeological and anthropolog- and promptly.” ical studies, the earliest surgical techniques were Galen of Pergamon was known above all for employed to treat wounds and injuries. They in- being the personal physician of Emperor Mar- cluded rudimentary cauterization, amputations cus Aurelius. Nevertheless, he was considered a and sutures, as well as cranial trepanning, dating fam ous traumatologist, who repaired gladiators’ back before 3000 BCE. Evidence shows that ap- wounds and described new surgical techniques, proximately 50% of individuals undergoing such such as reconstruction of a cleft lip or palate. operations survived. Interest in surgery did not take root among Hindu medicine developed surgical tech- Arabian doctors, except in the case of Al-Zah- niques as diverse as methods for repairing the rawi, the author of a compilation treatise in which auricula of ears, rudimentary reconstructive he included sections that referenced ophthalmol- rhino plasty and even cataract operations. ogical, obstetric and odontological techniques, In ancient Greece, Hippocrates was known as well as hernia repair and hemostasis (aimed at as the paradigm of a doctor, to whom the def- staunching hemorrhages). -19- The Knick and Surgical Techniques The Middle Ages was not an especially kind clamps, which were modifications of the clamps period for surgery, given that its theocentric world that Paré used to extract bullets. Another great view conceived of disease as God’s scourge, contribution was the study of coagulation and the with healing depending on a patient’s repen- discovery of blood groups, which enabled trans- tance. This made surgeons a second-best resort fusions to be made, as can be seen in the final compared to God’s will. The founding of a guild episode of the first season of The Knick, “Crutch- of surgeons in London in 1368 is noteworthy. It field”. In the field of infection, in 1861, Semmel- aimed to separate these practitioners from bar- weiss conceived the antiseptic principle with his bers, who were the surgical precursors of doc- work Etiology, Concept and Prophylaxis of Child- tors truly specialized in surgery as such. Never- bed Fever, which would later be enlarged upon theless, the latter profession would continue their by Lister with his pulverizations of carbolic acid work of extracting teeth, blood-letting and minor (phenol) and by Bregan with the introduction of surgery until the creation of the Royal Academy steam sterilization. In 1887, Mikulicz-Radecki, es- of Surgery in 1731, when that guild was finally tablished the use of a cap, surgical mask and cot- prohibited from carrying out surgery. The second ton gloves during surgical operations, substituted episode of The Knick, “Mr. Paris Shoes”, makes from 1890 onward by rubber gloves. The fight reference to this when Thackery turns to Chris- against pain is highlighted by the arrival of ethe- tiansen and says “You are legitimizing surgery, real anesthesia through inhalation. Later, less toxic taking it out of the barber shops and into the fu- anesthetics would appear, and an important mile- ture”, in a clear allusion to its past. stone was the introduction of tracheal intubation Already in the sixteenth-century Renaissance, by Trendelenburg in 1871. So many profession- Vesalius gained fame as an anatomist, penning als from that period developed significant surgical De humani corporis fabrica. The Spaniard Miguel advances that it would be tedious to list them all. Servet, who discovered pulmonary circulation, And what can be said about the twentieth necessary for the oxygenation of the blood, was century? It is characterized by significant prog- no less well-known. All these anatomical discov- ress in diagnostic methods, such as diagnostic eries were favored by the freedom to conduct aut- sonography, endoscopy, magnetic resonance, opsies, which had been prohibited by the church and so on, that enabled less aggressive surgery, and were punishable with death in the Medieval which, along with minimally invasive laparoscopic Period, should the practitioner be discovered. techniques, made it possible to reduce certain In the Modern Period, a real expansion in complications in conventional surgery while im- surgeons’ numbers occurred, bringing great proving patient recovery times. progress to the specialization. The Frenchman Ambroise Paré is considered to be the father of Characters that become blurred modern surgery. He specialized in bullet wounds, with reality designed prostheses for amputees, and made brilliant studies of Siamese twins. A curiosity from The series’ true protagonist and anti-hero, Dr. John that period was the design of a special vehicle Thackery, or Thack, becomes the head of surgical suitably equipped for the transportation of pa- staff upon Dr. Christiansen’s death. tients (the rudiments of today’s ambulance, iden- While Thackery is a brilliant surgeon, he is also tifiable in The Knick’s first episode, “Method and arrogant and ambitious, and a user of opium and Madness”, as a horse-drawn carriage). cocaíne. He is obsessed with being remembered Not till the nineteenth century did the recogni- in history for some innovative surgical procedure tion and integration of medicine and surgery take that would bear his name, to be remembered by place, with a victory over hemorrhaging, infection, future generations of surgeons for contributing to and pain –the major obstacles this science had medical advances. faced since its birth. Surgeons successfully man- There is no doubt that this character is based aged to control hemorrhaging using hemostatic on the figure of William Stewart Halsted (1852– -20- NOTEBOOKS OF THE ESTEVE Foundation Nº 42 MEDICINE IN TELEVISION SERIES 1922), with whom he shares a great likeness. Another character who is, perhaps, based on This man belonged to the glorious epoch of a real person is Dr. Algernon Edwards. He is a surgery’s development. Thanks to his research black doctor, the top of his year, trained at Harvard on physiology and pathology applied to surgi- and in Europe, who joins Knickerbocker Hospi- cal techniques, he was considered the father tal as assistant chief surgeon, encouraged and of modern surgery, specifically North-American supported by the hospital patrons, the Rob ­­ surgery. Trained in both the United States and ertsons. He must contend with the racism that Europe under the most notable surgeons of that prevails in the hospital, both from his colleagues time, upon returning to the US he joined the staff and from patients.