 Well, it's my pleasure. First of all, I want to thank Mark and Elena because this lecture series would not go without the kind of smile and great AV support and moral innervating that we get from having superb people help us with this. But it's my great pleasure to introduce our today's speaker, Dr. Shelly McKellar. Shelly is the professor and Hannah and Jason Hannah Chair in the History of Medicine at Western University in Canada. Her talk will be entitled Last Resort Sentiments and Implications, Cutting Instruments and Technology in the History of Surgery. Shelly McKellar is the Hannah Chair in the History of Medicine in the Shulik School of Medicine and Dentistry. She's professor of history in the Faculty of Social Sciences, and she also has joint appointment as a professor in the Department of Surgery. Her scholarship focuses on the history of surgery, the history of medical technology, with a special interest in the history of instruments, devices, heart disease, and medical biography. Shelly is the author of several books, including The Artificial Heart, The Allure and Ambivalence of a Controversial Medical Technology, Medicine and Technology in Canada, 1900 to 1950, The Surgical Limits, The Life of Gordon Murray, as well as co-editor of Essays in Honor of Michael Bliss, Figuring the Social with Elzebeth Eman and Allison Lee. She has published numerous articles in various journals such as The New England Journal of Medicine, The Lancet, Technology and Culture, and The Canadian Bullet in the History of Medicine. Shelly is a dynamic speaker and a highly sought out faculty. She is an invited member of the Expert Advisory Panel for Medical Sensations exhibit at the recently opened Canada Science and Technology Museum in Ottawa. An invited member of the History and Heritage Advisory Committee to the Royal College of Physicians and Surgeons of Canada. An invited contributor to Boot Camp Curriculum, the American College of Surgeons, an elected council member of the American Association for the History of Medicine. She has served on numerous research grant review committees, book prizes, academic meeting committees, and manuscript reviewers for academic medicine and journals. In 2019, Shelly was named Western University Faculty Scholar. Her work as a medical historian proved instrumental to the board as she was elected to the Associated Medical Services Board, which is a funder of medical history in Canada and a charitable organization that serves as a catalyst for change for health care in Canada. In addition, she's a dynamic scholar. She's a great lecturer, and she's a terrific colleague both on this side and the other side of the great US Canadian border. And it's my pleasure to have Shelly come and talk to us. And I'm sure it's interesting, Shelly. The University of Chicago is recently named as one of the top heart transplant programs in the nation, which is kind of interesting. So it'll be interesting to have this segue as this is actually part and parcel of our active clinical practice here. So thank you without further ado. Well, thank you, Mindy, for that very, very kind introduction and this invitation to participate in this series. Mindy knows that I'm all about talking outside your silo. And I think different groups of people should talk to each other. So medical historians should be talking to active medical practitioners. They should be talking to bioethicists. Should be talking to the media. And I think that all of us can have a really interesting conversation as we talk a lot about issues that we share concerns and questions and come at some kind of consensus or discussion of what we think are priorities moving forwards. So I was delighted to receive this invitation to participate in this series because I thought this audience would help me frame some of my questions and maybe a little differently than I had a thought about approaching my new book project. So my talk today is a new talk, which I've never given before, but it's a new talk that combines some of my past research work with some new research interests and questions of mine. I'm interested in the history of surgery and I'm interested in decision making. And in particular, I'm interested in this big question. When to cut and when not to cut? When is surgical intervention the appropriate course of action? And when is it not? I mean, who decides when to cut and when not to cut? And does the answer differ if you are the surgeon or if you are the patient or another stakeholder? Now, obviously to cut or not to cut is a big question. So I connect it with another one of my research interests, that being medical technology, devices, and instruments. So how does the equipment play into this decision making of to cut or not to cut? And during my past book projects, when I wrote about the life of surgeon Gordon Murray and certainly when I wrote about the history of the artificial heart, this big question, when and if to cut or not to cut was ever present. There was lots of discussions, always lots of talk about when to cut into the body, which organs to cut into, whether you're going to remove the organs, repair or rebuild damaged organs or do something else. And I would always run across this sentiment or ethos that cutting or intervening surgically was to be a last resort. Surgery was a last resort. So then I started adding that last resort bit to my research questions. How did the devices and instruments play into last resort sentiments and implications in the history of surgery? And that's how I landed on this more focused line of inquiry that would bring together a lot of my research interests and that focused research question of mine is, to what degree do surgical instruments and devices reinforce or disrupt the idea of surgery as a last resort treatment or medical course? So I'll talk to address that today and I'd like to garner your thoughts on this and I've divided my talk for today into four parts. So first I'll address the term or saying of last resort and what that infers. And then we'll situate last resort sentiments and implications within surgical decision-making and we'll drill down on that by exploring the use of artificial hearts as my case study number one and the use of tonsil tomes or tonsil guillotines as my case number two. So note I've chosen two very different organs, hearts and tonsils to discuss cutting or removing or replacing and I've selected two very different time periods when it comes to doing surgery, the 20th century and the 19th century and we'll see what connections we can make. I suggest thinking about three aspects of these case studies and those three aspects being expectations, limitations and uncertainty in the realm of surgery. And that's what I'd like folks to consider as a possible takeaway for my talk, consider expectations, limitations and uncertainty. Okay, I'm interested in cutting. That is the act and the decision to cut into the body within the context of health and medicine. So who decides when and where to cut into the body? Who does the cutting? Why are surgeons cutting and what do they use to cut into the body? Yes, what do surgeons use to cut in the body? I'm interested in surgical instruments. In particular, the instruments that cut in size or dissect such as scalpels, saws, trafines, scarificators, scissors and more. So these are the sharks or sharp instruments. So what can these instruments tell us about cutting? Certainly it's not all about the instruments but I would argue they do play a key role. What is the intention, the mechanism and the action of the instrument? Is that important? Certainly there exist bigger questions that revolve around how and why we trust and do cutting in medicine and certainly that is complicated. In many cases, the decision to cut is shaped by the instruments and the intentions surrounding a specific procedure. Certainly it's situated against the skilled surgeon and certainly the state of surgical knowledge at a particular time and place. And today I'm going to focus more narrowly on cutting as a last resort and the role played by instruments in that framing or construction of some surgical interventions as being a last resort measure. So what do we mean by last resort? Let's try to impact that term a bit. What's a last resort sentiment and what does that imply? So when I say this is a measure of last resort, most people would think this is a final course of action or the final resource to try to solve a problem after we've tried all other attempts and these attempts have been unsuccessful. So something you do when everything else has failed. What does last resort mean in medicine? So a drug of last resort is a pharmaceutical drug which has been tried after all other drug options have failed to provide what we see or would like as the adequate response in the patient. And this may be outside of extent regulatory requirements or medical best practices. So a last resort option I think can be viewed as a final option. Usually when the preferable ones have failed and to thing you decide to do when everything else has failed. So a sense of hope perhaps. On the other side of the specter however, a last resort option may be viewed as a misguided therapeutic innovation. So this is a desperate dreaded kind of Hail Mary attempt to address a medical dilemma. So primarily because there's no other option. So on this slide you see I've got on one side you've got hope, maybe enthusiasm. On the other side, maybe there's dread, maybe aversion. So why is surgery relegated into a last resort category? So surgery as a last resort because unlike most other forms of medical treatment this is about inflicting trauma upon the body. So this may rise eyebrows when you are considering are the benefits of this trauma outweighing the potential harm benefits and harm. So if you think about surgery in the 19th century this surgery is still problematic. In the 19th century surgeons needed to get control of three things to increase their operations success rates. They needed to get control of pain. They needed to control bleeding. They needed to control inflection, infection. So pain, bleeding, infection. And over time they did gain better control over those three things. You might also might ask about this idea of choice. What about a sense of choice? And the bioethicists will certainly weigh in here. Is there really a choice? Is it framed as a last resort when a patient has run out of alternatives? So you see on the slide I'm showing these 21st century images and you see that this is last resort operations such as spine surgery, back pain management, joint replacement surgery, bariatric surgery and you get this sense of last resort is very much intertwined with the sense that the rate of failure is high for these surgical procedures. So the last resort surgeries weighing risk benefit and it might only sort of work or when you've run out of other options. Now the medical historians in the audience will immediately think of Jack Pressman's book and his use of the term last resort which he uses in his book title, last resort psychosurgery in the limits of medicine. Pressman explores the history of lobotomy as a surgical procedure and he examines clinical decision making and he teases out different actor groups that are involved, the psychiatrists, the surgeons, the asylum managers, the patients and others to get their perspectives and Pressman gets at the various cultural attitudes to lobotomy, lobotomy which was dubbed ice pick surgery at the time and he wants to understand how this procedure became popular. I mean lobotomy was once highly valued and thought by many to be efficacious and then it shifted quite dramatically to be viewed in about a decade's time to be seen as this useless surgery, barbaric surgery. So there's a last resort meaning that was attached to surgery and this is a loaded phrase, loaded meaning and in the case of lobotomy, as Pressman kind of teases out, it's loaded with fear yet hope, a bottom procedure for the patient suffering going under the knife for this procedure, there's both fear and hope. And for the most part, surgery fails most people with dread even though it might be in their best interest. So people are nervous about surgery. So in spite of excellent outcomes and low complications, the general public tends to be apprehensive regarding most surgery and this tends to lead them to choose alternative methods of treatment. And I think this is totally understandable because cutting is visceral. So it should be avoided, right? I mean, cutting gets a better wrap when it's deemed to be necessary and when it works. And this puts the definition of success versus failure into the discussion. But in medicine, cutting is physical and symbolic. Surgeons cut into consenting patients to remove and repair damaged body parts. Cutting is a skilled manual action that infers a fix or cure, typically by a scalpel. Cutting also embodies precision and power. It assumes familiarity and wise judgment of the surgeon. And it might also generate new knowledge about disease and the body. So for the patient undergoing surgery or going under the knife, does it come down to technicality and trust to be able to achieve a successful outcome? To what extent does certain death? So if you do nothing, if you take no action, do not take this last resort option of cutting, you will most certainly die. To what extent does certain death sway the decision to cut? So I've presented you with a lot of questions and I thought maybe this context would help you to kind of consider some of the broader questions when we get down to parts and tonsils. And that's the case studies that I wanna present to you today to see if any answers or themes emerge. So let's get into my first case study of hearts. Let's talk about heart failure. So we all know that heart disease is a serious problem in North America. Heart failure is one type of heart disease. Heart failure is a chronic progressive condition in which the heart muscles unable to pump enough blood to meet the body's needs for blood and oxygen. And this results in fatigue, shortness of breath and everyday activities such as walking, climbing stairs or carrying groceries becomes difficult for that person experiencing heart failure. So heart failure is a serious condition and there's no cure. But wait, could an artificial heart be built? One that would work well enough to replace a disease to one heart unless you're eliminating the heart failure problem. Good way? Should we explore such possibility? Researchers and clinicians seriously ask these questions back in the 1950s and 1960s. Now at the time, cardiac replacement as a whole was being debated. And it was not yet evident which was the better replacement course. Place it with a biological heart or place it with a mechanical heart or if either of these options was really a viable options. The whole idea really could you tinker around with the heart and replace it? Remember at the time, 1950s, 1960s, transplantation of the heart. There's lots of issues of rejection and organ supply issues. Whereas mechanical circulatory support systems they had their own set of conundrums and problems. They had technical function issues. They had biocompatible concerns. Would an artificial heart work? The key point, however, that I'm making here is that in the 1950s and 1960s, whether you thought that you should be going for biological heart replacement or mechanical heart replacement, the possibility of cardiac replacement and the specific possibility of artificial hearts was legitimate and their clinical need was compelling. The possibility was legitimate because the new heart lung machine was ushering in this era of open heart surgery in the 1950s. The heart lung machine demonstrated the feasibility of mechanical circulatory support. So if we could do that for the surgeon operating on the heart for limited time in the operating room, why not build a mechanical heart device for use beyond the operating table? The clinical need for artificial hearts was compelling. The rising incidents of heart failure was worrisome and physicians had limited treatment tools. At mid-century, the standard treatment for heart failure was rest, digitalis and diuretic drugs. There was no cure. Medical teams wanted more, society wanted more. Heart disease and the specific problems of heart failure gained widespread attention. There was more research and development attention to prevention, diagnosis and treatment options to address the problem of heart disease. Could an artificial heart be built? Would it work? Could such a device really replace a diseased human heart? Various research teams worked on the development of artificial hearts for decades and its development was contentious. Was it hubris? Teams worked on artificial hearts around the world, although the R&D was predominantly an American enterprise and it would be a tremendous biotechnological feat. We're talking about a device that would be life-saving. We're talking about a device that would alter the usual course events that when a person's heart failed, that person died. And there were research teams and many others who thought it was indeed possible. Building an artificial heart was possible and it would save lives. But the realization of this technology was never certain. At various times, this technology was on the verge of being buried and abandoned for technological, political, economic and bioethical issues. Its development was indeed contentious. Now, the slide I'm showing you now is a very busy slide. Heart specialists in the room will be familiar with this slide. This is a heart failure graphic that shows the stages and possible treatment options if you're presented with a patient with heart failure. The point of this slide is to show you that artificial hearts are in today's medical toolbox for treating heart failure. Yay, terrific, right? But look, look where artificial hearts are. They're positioned as very much a last resort measure. Wouldn't you say? It's right here down in the far right bottom corner. You can see by my red circle here. So at this point, the patient is an end stage, stage D heart failure and cardiac drugs are not working. So all of these options below are no longer working for this patient. Now certainly heart transplantation remains the gold standard treatment for end stage heart failure today. But for many transplant ineligible patients, artificial heart devices are now a real option. So medically, artificial hearts framed as a last resort and the decision making to implant or not certainly seems to be in the hands of cardiologists and cardiac surgeons. So here's the question you're probably asking yourself. Can an artificial heart really replace a diseased human heart? Come on. Technically, yes. And this slide shows several artificial heart devices that are being used clinically today. Perhaps in Chicago, you have a heart transplant program. You're probably using some of these devices either as a bridge to transplant or possibly as destination therapy for transplant ineligible and eligible patients. So on the slide, you see some of the devices that are in play today. It shows that, yes, technically the technology works, but it's not perfect. But maybe that's okay. Perhaps a good enough technology is acceptable when it comes to sustaining someone dying of heart failure. Does a good enough technology enable this treatment to shake off being a last resort treatment? Some patients may think so, especially when patient cases of individuals who are living with these devices start to make the news. There's a media narrative, if you will, of success and improved quality of life, certainly putting off certain death for some of the patients that have gone this route. Consider these past artificial heart patient cases and consider the range of patient experiences and device intentions. So how we got here or at least how patients might perceive this technology as good enough and even improving. And again, keep in mind those three characteristics or aspects of expectations, limitations, and uncertainty that may shape ideas about something being a last resort measure. So I'm gonna show you some cases, some artificial heart cases from the last 20 or 30 years. Now, many of you in the audience may recognize some of the names of these patients. Barney Clark lived 112 days with his artificial heart, but he never left hospital. That was in 1982, 83, but that's pretty impressive given that Haskell Karp was the first patient ever implanted with a total artificial heart, but he was sustained for only 64 hours with his artificial heart and that was back in 1969. Here is a Canadian case. This is Newella Leclerc. She was implanted with an artificial heart in 1986 at the Ottawa Heart Institute. It kept her alive for seven days until her heart transplant surgery. William Schrader lived a remarkable 620 days with his artificial heart. That was in 1984, 85, and he held the record for being the longest living patient with a permanent artificial heart until quite recently. And one person who broke that record was this guy, Turkish patient, Newella Balik. He's a former professional soccer player and he was implanted with his artificial heart in 2012 and he lived for five years plus with his technology. Robert Tuels, probably a name that everyone recognizes, Robert Tuels lived 151 days with his artificial heart in 2001. So in 2001, he was implanted with the Aviapur Heart. The media ops, lots of pictures made in newspapers about him taking day trips out of the hospital including going for lunch to White Castle to eat a hamburger. And during that clinical trial, the Aviapur Heart, James Quinn was one of the patients who received that device. And I wanted to include his case here because at the time in 2001, when he was implanted with the Aviapur Heart, he was one of the youngest implant patients at the age of 51 and he regretted his decision to be implanted with the device. His recovery was plagued with complications. He said that if he had to do it again, he wouldn't do it. He suffered a fatal stroke caused by the device after living 10 months with his artificial heart. Kathleen Shores was dying of heart failure in a hospital ICU in Milwaukee, Wisconsin. An artificial heart saved her life in November of 2012. A year later, she underwent a successful heart transplant. Troy Golden in Oklahoma City would also have died if not for the availability of an artificial heart. The device kept him alive for 15 months. He returned home, even resumed preaching at his church. He was implanted in 2010 and he died in 2011. Now, we don't know how many patients turned down this implant option, but all of these folks on this slide were implanted with total artificial hearts and there were different outcomes as a result of their implant decision. Nevertheless, for all of these patients, their diseased, failing native hearts were removed from their bodies and a mechanical heart, a total artificial heart took its place. And according to Troy Golden surgeon, Dr. James Long, Dr. James Long said it was, quote, almost like performing a resurrection, taking someone who was checking out and giving them life. End quote. And I love that quote and I've talked to Dr. Long about this and it I think very strongly about this resurrectionist capacity of artificial hearts and how that became so appealing to dying patients, their family, society and the media. And it's true, artificial hearts provided extra months to patients to spend more time with family or for the lucky ones to receive a donor heart. Extra months after having exhausted all other options, which led them to this last resort measure of being implanted with an artificial heart. Artificial hearts are seductive devices. We are seduced by the promissory nature of artificial hearts as a curative fix for heart failure. This fits neatly within our society's view of the body as this entity of replaceable parts. We have artificial hips and artificial knees, artificial kidneys and more. Artificial hearts are life-sustaining, but they're also imperfect devices with a controversial history. These devices are not always life-sustaining. Sometimes they make patients worse off, but these devices full the possibility that they just might be the right course to save and improve your health. If I had more time, I would tell you about the 1969 implant case of Haskell-Carp, which was reported by the media as a sensational drama in several ways, this triumph story, but also a rescue-oriented last resort surgery that failed. If I had more time, I would tell you about the 1982-83 implant case of Barney-Clark. And his is important case because he actually woke up after his operation. And by waking up after his operation, he could tell us what it was like to live with an artificial heart pounding, working in your chest. But oh yeah, when he woke up from the implant surgery, he was tethered to a large 218-pound drive unit to operate the device that was now implanted in his chest. His 218-pound drive unit, which was dubbed Big Blue. And Clark never left hospital, and this unnerved a lot of people. If I had more time, I'd tell you about the 2010 implant case of Dick Cheney, who credited the Heartmake 2 LVAD device for saving his life. In 2012, Cheney underwent a successful heart transplant after living 20 months with his artificial heart device. In my book, I argue that artificial hearts are seductive devices, indeed a life-sustaining technology, but with a controversial history. I argue that desirability, more than the feasibility or practicality of artificial hearts drove the invention of the device. I argue that the allure and ambivalence of artificial hearts is what anchors this story of how and why this imperfect technology continued to be developed. I argue that artificial hearts were and are situated as a technological solution to the problem of heart failure, and that an interpretive flexibility of success was key to its momentum and legitimacy. Given our focus today on last resort sentiments and implications, the artificial heart, I think fits easily into a high-risk venture that would make anyone pause. Our artificial hearts are cutting into the heart. Is it a last resort or is it a real lifeline? Anyone with heart failure is probably keen on trying other medical options to manage their condition before signing up for a mechanical heart, right? But there are some medical folks who challenge this last resort position. They argue that device implants should take place earlier in a patient's treatment course before the patients are too sick, before their bodies and quality of life have decompensated too irreparably, before too severe functional deterioration has happened. But then who decides on this timing of when to cut or not to cut, when to implant a device or not? I'm sure folks of the Heart Transplant Program in Chicago there will have some thoughts on that. My point here is that there is this contrasting narrative that mechanical hearts can be a real lifeline for some people as well as a narrative of being a last resort measure. So let's switch gears a bit. What about a tonsil? Quite a different organ than your heart in terms of organ status or value assigned to it perhaps. But let's talk about cutting out tonsils. An inflamed infected tonsil. Now, talking to a medical audience, we all know where our tonsils are located, located in the back of our throat. Please note, not an easy access point for surgeries to get in there and to remove. So what is the best treatment to resolve inflamed tonsils? Surgical removal was one option. Do folks pause when someone suggested removing this organ? Probably not the same way as a discussion about removing one's heart. But there was debate about when and how to remove inflamed tonsils. And I'm gonna talk about one tonsil removing instrument in the context of this decision-making of when to cut and when not to cut. And let me suggest that the instruments used in tonsil removal played a role in that cutting debate. On the one hand, the tonsil removing instruments disrupted perceptions that tonsil surgery was risky and ineffective. While at the same time, or on the other hand, tonsil removing instruments also reinforced risk perception and last resort sentiment. So what instrument am I talking about? I'm talking about the tonsil guillotine instrument. And here are images of several types of tonsil guillotine instruments or tonsil tones. So what is the intention of this instrument? Well, it was devised to remove inflamed tonsils. Your tonsils are oval-shaped, soft tissue masses as part of your lymphatic system. So we have two tonsils located at the rear of our throat. One on each side of our throat, not so easy access location. How does the tonsil guillotine work? Well, as the nation implies, the cutting mechanism and operating action is a guillotine. And I actually have one here in my office. So here we go. I've got this instrument in my hand, if you can see me playing with it. And when I talk about a guillotine action for this device, most people, when we talk about mechanism and the operating action guillotine, guillotine people think French Revolution and Beheading, which was when the guillotine machine was used in executing people. So imagine in your mind that this is a device that has a heavy, sharp blade that slides down vertical guides and removes one's head from your body. And by extension, this guillotine refers to this action of cutting or shearing off with a blade with some force. It's supposed to be quick and clean, right? And the tonsil guillotine instrument, if you see here, has a wide enough base in which to encircle the tonsil and then retractable blade that comes through to shear off the inflamed tonsil. So who designed this instrument? Dr. Philip Singh Physics did, back in the early 19th century. So Dr. Physics was the infamous Philadelphia physician and surgeon. He's been called the father of American surgery and he has given credit for devising the tonsil guillotine, the instrument that I've been playing with back in 1828. Now, let me share with you a tonsil excision case of Dr. Physics with you. And I want you as I'm explaining this case and what's presented in front of Dr. Physics, consider was it a last resort measure when Dr. Physics decided to cut out the inflamed tonsils in one of his patients and consider again those three aspects of expectations, limitations and uncertainty as I tell you about this surgical case. And remember, this is an instrument from the 19th century. So we're in July of 1830 and it's a Tuesday morning and Dr. Physics is examining his newest patient and he's considering how he might use his newest instrument, his tonsil guillotine. His patient was four-year-old Martha Jefferson Trist. She's known as Patty. And she had come with her father, Nicholas Trist, from their home in Washington, DC to Philadelphia for the express purpose of having the famous, the well-known, esteemed Dr. Physics assess Patty's sore throat and her difficulty with swallowing. The suspicion was Patty had inflamed tonsils. The expectation was that the tonsils would be removed, Dr. Physics and Nicholas Trist agreed on this course of action and there was consent to perform the surgery. But there was a problem. The problem was that Dr. Physics' instrument was too large for Patty's small throat. As he was treating Patty, Dr. Physics tried to insert his tonsil tongue several times into Patty's throat but had difficulty positioning the instrument correctly. Several times he inserted, then removed, then reinserted the tonsil tongue in Patty's throat. So he was attempting to fix the instrument around her inflamed tonsil but he couldn't seem to get it. He only succeeded in frightening the four-year-old girl which then prompted him to make the decision, I'm going to postpone proceeding further until the next day. And Dr. Physics later admitted to Mr. Trist that Patty's operation will be, quote, the most delicate operation of the sort he had ever had to perform given her mouth and throat being the smallest he had ever had to examine, end quote. So to him, the answer was obvious. He needed a smaller tonsil tongue. He did not even consider using traditional methods which was using a knife or scissors for the operation, Dr. Physics was clearly invested in his guillotine instrument. So off Dr. Physics went that very same morning, Tuesday morning in July of 1830, he goes off to his instrument makers to inquire about the construction of a smaller tonsil tongue. The instrument makers said, yes, Jess, no problem, a smaller version of the instrument could be made and it wouldn't take long. It would be ready by 10 a.m. the next day, the next day being Wednesday. This is what the instrument maker promised. Who was the instrument maker? It was Henry Shively. Shively was a cutler who repaired knives and other cutting instruments and he was a well-known surgical instrument maker in Philadelphia during the first half of the 1800s. Shively is perhaps most famous as the maker of the Bowie Knife. For Dr. Physics, Patty's operation and the making of that smaller tonsil tongue, quote, occupied his mind all day. He made several trips to his instrument maker shop. On that Tuesday, he's checking in, he's supervising the making of the smaller tonsil tongue. Wednesday morning arrived. Dr. Physics presents himself to his instrument maker to pick up his new instrument, but the smaller instruments not ready yet. So on that Wednesday, Dr. Physics keeps checking in all day long, is it ready yet? Can I pick it up? Can I move on with it? But it's not ready until 4 p.m. that day. And at 4 p.m., Shively hands over the smaller tonsil tongue to Dr. Physics. Now, I'm making a lot of big deal about the timing here. The timing is important. Dr. Physics' plan was to pick up the instrument, then carry on to the upscale boarding house where Mr. Trist and his daughter were staying and where the operation would take place. The timing is important because pain management measures for being discussed for this patient to mitigate her pain during the tonsil operation. But wait, the year is 1830. It's pre-anesthesia. The first surgical procedure using anesthesia was still years away. That's not gonna happen until 1846. So what was the pain management plan in 1830? Dr. Physics hoped to give Patty Waddenham to dull her operation pain. He gave directions to Mr. Trist to give Patty four drops of Waddenham an hour and a half before the operation. The amount and the timing of this is notable. So would four drops of Waddenham be dangerous for a four-year-old? Three or four drops, even less of Waddenham was sufficient enough to kill a baby. An adult medicinal dose might have been up to 30 drops, perhaps as high as 50 to 60 drops a day. The amount of Waddenham planned for Patty is probably acceptable. The timing is trickier. The exact timing of Patty's operation was yet to be fixed. Since it depended on when Dr. Physics actually possessed that new smaller instrument, and in the end, Patty did not receive any Waddenham. In the end, the pre-operation window during which time Mr. Trist would have administered the Waddenham wasn't known in time due to the instrument maker's delay in finishing the instrument. So late on Wednesday afternoon, Dr. Physics picked up the new smaller instrument and then carried on to the lodgings where Mr. Trist and his daughter were staying. Dr. Physics arrived at 5 p.m. with his new instruments and he's ready to excise Patty's inflamed tonsil. Well, you can imagine what's gonna happen. Upon seeing the doctor and the cutting instrument, Patty burst into tears. Patty cried and cried. She's so nervous and upset. She couldn't be consoled or reasoned with. And remember, no pain management strategy in place here. So she's so upset. This meant that her father had to forcibly fold her down during the operation, while Dr. Physics forcibly opened her mouth to insert the instrument into Patty's throat to do the deed of cutting that inflamed tonsil. And this instrument, the tonsil guillotine, promised to remove the offending tonsil in one cut. A quick, painless cut. Was this the case for Patty? Well, I'm happy to report that the procedure went well, according to her father and Dr. Physics. Now remember, her father had a bird's eye view of the procedure because he's holding his daughter down for the operation. Mr. Trist stated that after Dr. Physics, quote, fixed the instrument, he took the thing off beautifully. The tonsil was about the size of the first joint of your thumb. I'm sure Patty did not feel it when it was coming off. End quote. So what about the bleeding? Mr. Trist commented that, quote, she bled about as much as the pulling of a tooth. But in time, not more than five minutes, for Dr. Physics made her ho, utter a sound, and there was not the least sign of blood. End quote. This was good. Now to be clear, only one of Patty's tonsils was removed. There is no record of any discussion surrounding that other tonsil at this time. Dr. Physics was satisfied with this one tonsil removal work and he took his leave shortly after the operation. Later that night, Patty supper, apparently without much difficulty, according to her father. On Thursday morning, Dr. Physics returned to the boarding house to visit his patient. He was pleased enough. Apparently Dr. Physics stated, quote, that Patty's throat was in as good a state as possible. Mr. Trist commented that Patty, quote, looks unusually well and pretty and is chattering like a magpie. End quote. Hmm. Those words were written by Mr. Trist on that very Thursday after the doctor's visit in a letter to his wife, his wife who's back in Washington, worrying of course. Undoubtedly, Mr. Trist is trying to put a positive spin on it. I mean, the subtext of this letter is, quote, all is well. Don't worry about our daughter Patty as well, end quote. So in this letter, Mr. Trist shares his travel plans with his wife and he and Patty shall leave on Saturday, they'll head to Baltimore, and then they'll arrive home. In early August, 1830, Mr. Trist followed up with Dr. Physics with a letter and payment. Sorry, I don't know what Dr. Physics charged for his services. But in this letter, August 1830, Mr. Trist relayed the success of the one-tonsil removal operation, but there still was the issue of a second apparently inflamed tonsil and Patty's throat. Interestingly, Dr. Physics is ambivalent about treatment. Did it warrant a surgical procedure or could a medical treatment do the job? It was suggested that perhaps the use of a lepo goals as an astringent would work to reduce the inflammation and that might be enough to settle down that inflamed tonsil. But at best, this is what Dr. Physics is writing, he says, quote, it's an uncertain remedy, end quote, and it doesn't work for the majority of cases. So if you find that isn't working, Dr. Physics suggested that maybe it's best not to do this. And then you see Dr. Physics sway back to suggesting that tonsil surgery was the right course of action. Tonsil surgery because as he stated, quote, the operation occasions so little suffering. Now, that's all I know about Patty's tonsils. I do not know if she ever had that other tonsil removed. I do know that Patty grew up and she married John Woolfolk Burke. Together they had seven children and Patty lived until she was 89 years old and she died in 1915. So what was the uptake of this method and use of the tonsil tone by physicians other than Dr. Physics? That's the broader question was medical historians to be interested in. It was a fun little case with Patty Triss, but kind of what is the uptake or the acceptance of this new technology or device? And so as medical historians, we'll go back and look at the medical literature of the time, the debate among medical professionals and basically what they're teaching the next generation of physicians coming through the pipe. So we look at contemporary surgical textbooks and you see in this textbook by William Gibson, this is the first edition of the Institutes in Practice of Surgery published in 1825, that in section on the treatment of enlarged tonsils, Gibson describes how to remove tonsils with the knife and ligature. This is 1825. And when Dr. Physics work with the tonsil guillotine comes out three years later in 1828. Lo and behold, the medical world took notice. So this is Gibson's third edition of his textbook published in 1832. And there's quite a lot of space given over to Dr. Physics new procedure and instrument in addition to the knife and ligature texts. So the tonsil guillotine approach did not replace or supplant that earlier information, it was simply added to this section. But Gibson really presents step-by-step instructions and illustrates the new instrument in this edition of his texts. What Gibson has done is more or less cribbed Dr. Physics publication on this matter and Dr. Physics procedure dominates the section on the treatment of enlarged tonsils and the guillotine discussion is much lengthier than the other option of knife and ligature. This is a 19th century American surgical catalog. This is a George Thiemann surgical instrument catalog published in 1879. Note the various tonsil instruments, including guillotines. There's various modified versions of Dr. Physics instrument. During the 1860s, moral Mackenzie's modifications to the tonsil tone greatly added to the popularity of this instrument. More than three decades later, these are pages from the Nyshear company's instrument catalog. Nyshear being another American instrument maker. Note that there are triple the number of pages dedicated to tonsil tones by this time. And you can see the different mechanisms of the instrument. There are forks to pierce into the tonsil. There are different ring sizes. There are finger hooks. If you didn't like the grip of a handle with your fist while you were operating. Here's another page from that same Nyshear catalog. Lots of options for different modified tonsil tones. But here's the thing. How do we know that physicians purchased these tonsil removing instruments? Which instruments do they prefer? Which instruments were the top sellers? And did they use these instruments? So they just carry them around in the doctor's bags. I can tell you that all major instrument catalogs carried tonsil instruments. And that over the decades, the range of different tonsil instruments offered increased and then decreased. So there's this waxing and waning of a number of instruments being promoted out there. And it's following the medical debate that's taking place in the literature surrounding best practices when it comes to tonsil excision. The debate this takes place in the medical literature, the journals first and it makes the way in the textbooks. And I don't have time to go into that debate but I'm happy to answer the questions in the Q&A period about the medical voices out there that are arguing against using this instrument. And to bring it up to date, I found this article which I thought was interesting, just when the tonsil guillotine had fallen out of favor by the late 19th, early 20th century, late 19th, early 20th century, it often has another kind of resurgence in the late 20th century. And this article that the researchers are, you know, quite careful in their wording, but they suggest that in comparing the use of a tonsil guillotine, in this case, a popper's hemostatic guillotine instrument with a traditional dissection by scissors and a blunt tonsil disector procedure, that the results that are produced by the guillotine technique are superior. And they're suggesting that maybe there's a well-trained hands could find a place for this instrument back in the repertoire. So where does this all leave us? By way of conclusion and material for group discussion. I've highlighted two case studies or scenarios around cutting out hearts and tonsils. I'm situating them as arguably last resort options in the 20th and 19th centuries, respectively. Where does this leave us when it comes to my research question about surgical instruments and devices, do they reinforce or do they disrupt the notion of surgery as a last resort treatment? I think it comes down to those three aspects of expectations, limitations, and uncertainty surrounding the specific surgery. The degree to which a particular operation is a last resort measure is linked to expectations of the surgeon and patient around a particular surgery, limitations of the actual procedure as it pertains to the surgical equipment, the instruments, the devices, as well as the surgeon skills, uncertainty surrounding the procedure, that being the surgical risk. The surgical outcomes, so past outcomes as well as anticipated outcomes or how certain a success will be. I would argue that in the history of surgery, technology and instruments are part of this tension associated with an action, an action of both a fix and a harm, that the surgical action is meant as a surgical fix, but it could potentially make us worse off. Thus, cutting is associated with both fix and harm and the technology and instruments exacerbate this tension associated with this action. So perhaps the real takeaway here can be reduced to one word, ambiguity. The case studies and the last resort sentiment and implications are intertwined with this ambiguity of objects, how and why they're used, the outcomes associated with their use and more. The ambiguity of objects, be they 20th century artificial hearts or 19th century tonsil guillotines, both are disruptive technologies in different ways that also reinforce a hesitancy when it comes to that big question, when to cut or not to cut. So thank you for your attention and I look forward to hearing your thoughts on this topic, last resort sentiments and implications. Thank you. Well, thank you, Shelly. I'm gonna take the floor since I, and I'll open it up for questions in a minute, but I did two interesting comments. First of all, I thought that was terrific and it really got the juices flowing, but I love that try out of expectations, limitations and uncertainty and wanna just give you a personal vignette. One of the things we see, I'm a primary care physician, I'm not a surgeon, is that we often are confronted with patients who come in specifically because they need preoperative approval for elective plastic surgery, sometimes by somebody we don't know. And it's just very interesting because it kind of shifts, and you can think about this as you work on your next book about the issue of the difference between expectations, limitations and uncertainty between the doctor, between the patient and by the doctor, I mean the surgeon versus the primary care physician who's often called to say, is this person safe to undergo surgery? So it's an interesting thing. And then the last thing is just the fact that with the whole rise of medical tourism and people advertising for the orthopedic programs, bariatric surgery programs, just another thread to take in as you continue to think about surgery. I was gonna just leave that there and I was gonna let some of the questions come through. What do you think, did that? I agree this medical tourism and the idea of advertising strikes the Canadian so abruptly. And I remember being on a plane back when we were all traveling and opening up an American Airlines and on the back of my seat and seeing an ad for, I think it was University of Texas come here and we can do this for your fixed your heart. And in Canada, we don't, there's no advertising of drugs or procedures and to see it advertised in the way the United States struck a Canadian so strongly. And I think medical tourism is that next level of this narrative out there of a fix of a service with expectations of a successful outcome. Great, I'm gonna let Peggy take over. Yeah, thank you. That was super interesting. I just a question that this is a last resort and that people don't want surgery. I actually think that a lot of people prefer surgery to drugs. And you think, if you think about cancer people want it out and they don't particularly understand why there has to be chemo. Why can't you just take the damn tumor out? So I'm just kind of questioning you say that the reason we don't want or the reason the general public does not want surgery is visceral. And I don't feel that. When I remember when my father had a ruptured appendix and they told me that they were gonna treat it with antibiotics instead of surgery I was not particularly happy. I learned I was wrong and they were right, but okay, I just don't see it as a visceral no. Sorry, I was just curious to hear what you have to say about that. Whereas I think that a lot of people feel very viscerally against certain drugs particularly chemotherapy jokes. True, and I guess that's an historian looking after a longer kind of timeline to what extent is the trauma or cutting into change the sense that it is traumatic or visceral or cutting or something that you choose not to pursue. Is it when we have pain management when we have more successful outcomes when the experience, when other options out there have less successful outcomes? So I guess I'm still teasing out this success, failure, tension and of course in medicine nothing can be guaranteed. So why is there always need to be this discussion, this preamble before going into the OR of looking at the possibility of things that could go wrong? They'll argue because say with the drug kind of the new post 1950s explosion in pharmacological options that you do the same thing it's called side effects. You may experience all these side effects. So every option has its side effects and to what extent does certain groups of people understand those side effects as being acceptable or not? And as then is it a loaded term in terms of depends on the procedure. So like when your father had his procedure that was an immediate reaction just take out the organ that's ruptured because that makes sense to me to remove the offense and it's localized versus something that perhaps isn't localized. It doesn't serve itself well. So maybe I'm being too ambitious and thinking that it's too big a topic that I have to narrow it down to specifics to be able to make any kind of assessment of these terms. I mean, I think there's, I just think there's a common feeling of get the damn thing out. When that's the problem, surgery looks really good. And people feel. Here's a question for you Peggy. Let me throw this back then. Just get the damn thing out. I wanna get it done because next week I wanna be back on the golf course. Is this more comment about culture's immediate reaction? And I only say that because my husband's a physiotherapist. So people want to come in, lay your hands on me, attack me this modality and make me better as opposed to giving me an exercise regiment go away for two weeks and do these exercises and then come back and we'll see where we're at. But there's immediacy. People want an immediate fix. Oh, I mean, I get the idea of physical therapy over surgery, but in the case of severe dysplasia in cells, I mean, why do we want that? We don't want that. Take it out. That makes me super happy. So I just don't, I don't have the visceral thing. I'm also, I'm a scientist so I don't have a gross out factor, but I just don't have that visceral thing that you talked about. So I'm just really curious why you're drawing that line. I don't see the line. And I see it more in general. I see it more in general. It could be an age or a generation thing because we all remember dances of walls, Kevin Costner at the beginning, the amputation of the leg, how visceral and bloody and whatnot. And I mentioned that to my men's students and they go, who's Kevin Costner? And I go, Yellowstone. Okay, that guy, okay, that. So this idea of what surgery looks like that the 19th century or the Nick, right? And kind of looking at shows us show how visceral it is when the first, if you've seen the episode of the Nick where they do the sincere in section, right? And how visceral that is of slicing up the abdomen to grab the baby out, right? Maybe it's more of a 19th, 20th, 21st century. I have to segment it more by times. This visceral action is a cultural phenomenon and even dissected even further, no pun intended, by different cultures in North America and European, African, whatever. Megan, is that okay, Peggy? Megan, you wanna take the floor and keep the conversation going? Well, thank you, Peggy. I'm gonna ask that word visceral and saying rethink that term. Maybe that's not the right point descriptor. Thank you. But I think I do, so I am a surgeon. And I do think the temporal nature has to be considered, right? Like surgery now is very different than it was 20 years ago, 50 years ago. So the concept that it was a last resort I think is different because surgery now is so much safer and what we can do is so much more broad. And I think that goes into part of the conversation, having your appendix out today versus 50 years ago is completely different beast. And so you have to sort of, I think you have to consider that with it. I do agree with Peggy. I think there's a certain notion of, yes, you just want it gone and done and take care of it yesterday. And sometimes I think we as surgeons have to be kind of careful that I was taught and I think this is very true that it's much harder not to operate than it is to operate. And sometimes making the decision to, you say sit on your hands is really difficult, especially if you have a patient who is absolutely convinced that that's what they need. It can be a really difficult position to be in. So that big question to cut or not to cut is that a reflection of your training, as you said, about the better outcome for this patient is not to cut or is this about shared decision making as a patient's choice? Yeah, it's really complicated because yes, the patients do have some choice but they also come at it from a different perspective and a different training, right? Like I have training as a surgeon, they usually don't have training as a surgeon. So at what point does my training as a surgeon get, when should that have more credibility than what they want? I would argue most of the time. If you have two equal things then that's a different story but that's a very rare situation. But I should be able to make the decision and there have been times when I don't know what the right answer is and I just say, we both have to be kind of uncomfortable with this and I don't know what's gonna happen but as long as we talk about it, we talk about what the options are then theoretically no one can really be upset afterwards. No, that's not really true but you just have to be really clear in those situations where you don't know what the best solution is. Can I put you on the spot, Dr. Arnold and ask you that on that slide that I showed you those 21st advertisements was I just took off the internet? They're all about surgery and they all use the words last resort. Yeah, I agree with you. There's so many reasons why I wanna move to Canada but that's one of them. But yeah, I think it's sort of unconscionable how we advertise surgery, drugs, everything medical honestly. And I think it also gives I think a false sense of expectation that you can just go anywhere and ask for what you want based on nothing and drug advertisements are written by the drug companies. There's a reason they're doing it and there's a reason they pay millions of dollars to do this because it works. We all physicians say, oh no, it doesn't influence our prescribing. Well, there's a reason why drug reps aren't allowed in hospitals anymore because it does affect whether you believe it or not. It does affect your decision-making. So no, I think it's a horrible, horrible idea but I'm also a pediatric surgeon. So I'm a little bit protected from a lot of that. You're probably dealing with the issue of fear and just more than a person making a decision on their own bodies, right? It's for my child's body to go forward. Yeah, that can be hard when you have a kid that's screaming at you, don't touch me and you sort of have to hold them down and do things. I describe it to my trainees, it's like an out-of-body experience. You just sort of have to focus on what you have to get done and just get it done quickly and do the best that you can for pain control and distraction and those sorts of things. But yeah, that's certainly a little bit more unique to pediatric surgery. Carol and you're on deck. Thanks so much. Thanks for this talk. I also had a question about shared decision making and it's not a fully formed question so feel free to redirect it if it isn't of interest to you but I was thinking about the implications of your talk for sort of advising patients who may see a surgery as last resort when the physician doesn't see it as last resort. That kind of tension seems to arise fairly commonly. So I was really thinking about like, well, when do you talk about the instruments? Like when would it maybe be useful to talk about the instruments of surgery in order to kind of counsel a patient through this idea of the last resort, the kind of dominating idea of the last resort. And then it made me think that maybe there's a real like distinction that needs to be made between the kind of instrument that you're talking about in the heart case, the mechanical heart case versus the kind of instrument that you're talking about in the tonsil case I mean the sort of actual cutting instrument. And so anyway, there's a lot there but I wondered if you had thought a bit about the sort of implications of your talk on that. This is your great question. You caught me out, you caught me out because you're right, the two instruments there's a lot of disconnect because one's a therapeutic, it's a device to save a life and the other one's a tool to perform the surgery. So it's more than apples and oranges as apples and you know, kumquats or something or squash or something, right? So they are different, but it's interesting because I work with medical objects and we look at kind of the life of objects or how they're used by physicians and surgeons. And for lots of decades or many decades, a lot of the surgeons or physicians the tools were their badge, right? It's like what Dr. Arnold was saying with authority and credentialing and power and I will make decisions. Look at in my bag, I've got all the tricks of the trade and I'm empowered to use them in a successful way and you don't have these instruments. And the instruments themselves within the degree not only do you, you know, I don't have the kind of the low end tonsil tone. I have the best tonsil tone. It's made by French designers, right? You know, there's this whole kind of leveling of showing your authority and power and legitimacy by the tools that you have. And I think with the artificial heart device, I mean, and I show that busy slide just to show you that it's part of this kind of staging of preparing patients for where they're at and what options are out there. And I think the tension is, like you said, when you have these discussions, whether it be palliative care or we're not really there yet or when do we exhaust the drugs and move to devices? And the idea that could we go back and forth? Usually you're pretty committed with an LVAD, right? And kind of the whole shift and everyone understood we're researching the book is each center basically has their favorite device. Not that the, you know, the one LVAD works better than another valve, you know, the heart major or the HVAD. It's what you've been trained on, what you've practiced on and you have your success rate. So again, it's modeled with the device is only one part of the puzzle to contribute to. I still think it's about your successful outcomes. And I think what Dr. Arnold I think alluded to is this doctor-patient relationship shift that's happening and that whereas my grandmother would go and say, be very quiet and say, whatever you think doctor, I will just do. Now it's a discussion, a debate. You go away and you research, you know, we talked with our medical students about Dr. Google. How do you have that conversation where they have lots of information? You kind of co-op them and say, let's share this information, right? And the idea that I think again, it's a service industry in many ways and in your context consumerism in a way that we don't have the same level in Canada. And I think this discussion, this debate is, you know, I think it's so tricky to have and it's relationships that you're building for this trust and moving forward with patient care. But thank you, that was a great question in terms of tools and what they contribute. So, Peggy, do you want to weigh it in there? Yeah, I'm just curious about, you mentioned about, is there a choice when the problem is desperate? And I didn't really get your answer to that. I mean, is there an argument to be made for there being choice? I can easily see the argument that there is no choice there, that it's not a free and open choice, but is there an argument to be made that there is a free choice being offered? Well, and certainly in the artificial hearts case is all idea that a dying person cannot give informed consent, right? That there's somehow that relationship and making clear-headed kind of decisions is suspect, right? And so at what point, and this is a lot of people are arguing to introduce the technology to an earlier point before the idea of options has been eliminated completely. And I think when it comes to terms to doing surgeries and especially when it comes to pediatric cases, Nicholas Trist had decided his daughter was having this tonsil removed by Hell or High Water, right? And whether she had a lot in them or not and holding her down, I mean, you could see how that would happen quite quickly, kind of the idea of choice, who has the choice and who has preconceived ideas is almost at this point, Nicholas Trist has made the decision to travel all the way from Washington to Philadelphia for this service and physics is gonna give it to him. So I'm not even sure the choice is preconceived as a service. I asked my mom whether she gave informed consent before she gets anti-vegetarian into her eye for macular degeneration. And she says, well, I have to call an Uber to go there. So it means nothing to sign a paper. It means something to call the Uber and to get up and make sure somebody is taking care of my dog and so forth. Well, and yeah, it's like my grandparents informed consent. I gave that by the fact of making an appointment with my doctor, full stop. Shelly, later when you have the discussion with the fellows and you talk to some of the surgeons, one of the things I am intrigued by is surgical tools and the competence and that whole area, for instance, here we do things with this Da Vinci robot, you know, huge high tech thing, but I was most struck when I went to the special collections and saw the bone saw and actually held it. And I thought to myself, you were talking about the instrument makers and the cutlers is that the ability to really have an instrument that makes you feel like you can do things. And I brought a couple of orthopedic surgeons and I know they have the experience of seeing some of these older tools and feeling like, oh yeah, that's one of my favorite instruments or I really like this or the fact these things used to be personally made and be decorated, you know, now everything's thrown into like the autoclave, but at one time, you know, they had, you know, either ivory or mother of pearl or these things, they were like just, not just a mark of pride, but customized. So when you have the discussion with the fellows because I think there's a lot to this thing and I think that on one hand, so surgeries continue, right? You know, people think about doing these things, you know, so they think that there are things we do every day all the time, right? You go to a dermatologist, they get biopsy just in the office. I don't even think they ask for consent, they just make a little hole in their arm all the way to, you know, cataract surgery which is done so routinely that people, you know, bad and I, sorry for the pun, so people feel like it's life transforming to, you know, the heart surgery. But I think this concept of expectation, limitations and uncertainty is a great one to think about surgery because there's, you know, the patient, the doctor, and then it may be not just the doctor, but the people who are intermediate between the patient and the surgeon. So I thought that was superb. Yeah, I think that number of stakeholders involved is a much larger number than we give credit for. And again, I'll go back to Dr. Arnold's comment about power and about doesn't necessarily mean if we've got five or six or eight stakeholders of it, they all have equal power. And the surgeon's voice should trump probably the sales rep consumer, you know, that's pushing, right? So, and I think that's one thing to understand about decision-making that doesn't mean everyone has the same slice pie. So I'm gonna just open it up for last questions before we give Shelley a little time to just get a drink, take a rest and then reconnect at 130 with the fellows. But on behalf of the McLean Center, Mark Siegler, Elena and I, I just wanna thank you for an outstanding talk and something that was very provocative and intellectually stimulating, we really appreciate it. Thank you.