Sure, Speedy, and Shoutless

There is something about late nights in a bookstore that encourages earnestness. As I browsed among the stacks one evening, I overhead a clerk intently discussing his recent dental treatment with a colleague. "I had eight teeth extracted," he said. "It was like..." He paused as he searched for the right word. "—surgery! Yeah, that’s exactly what it was. Surgery."

Although about thirty percent of American dental schools offer degrees in dental medicine (as the legendary ADA secretary Harold Hillenbrand argued all dental degrees more appropriately should be), dentistry is widely regarded as comprising a set of mostly surgical skills. In England, dentists are dental surgeons, and operate out of surgeries instead of operatories. French practitioners, likewise, are known as surgeon dentists.

Traditionally medicine and surgery occupied two separate realms. Until the 19th century, surgeons were generally expected to deal with the exterior of the body—most surgery was superficial—while physicians dealt with the interior. But the real difference was not one of domain but culture. The word surgery is descended from the Greek cheirurgia, "hand-work." While the Greeks expected their physicians to perform hand work (and had no particular name, nor independent job description, for "surgeon"), by the middle ages doctors considered themselves thinkers who as gentlemen should not stoop to such messy manual labor as surgery demanded. Even now, surgeon Sherwin Nuland, writing in his history of medicine, Doctors, pauses to protest surgery’s millennium-long devaluation: "Even surgery’s most dramatic component, the operation, is no more a feat of manual dexterity than is the painting of a beautiful landscape. The operation is the moment during which the mind of the healer makes his or her hands carry out a bidding based on a sensitive wisdom about the ways in which the human body is supposed to work and the ways in which it has failed."

It wasn’t until the 1830s in America that surgeons began thinking of themselves as doctors. Not coincidentally, the same decade also witnessed dentistry declare itself a doctoral discipline. Even when they merged, medicine and surgery remained distinctly dichotomized. Surgeon-writer Richard Selzer recalls that his doctor father hung out a sign in 1924 inscribed, "J.L. Selzer, MD, CM," the CM standing for Master of Chirurgie. The dental school I attended, University of the Pacific, was called, until the 1960s, The College of Physicians and Surgeons of San Francisco.

Dentistry is separate from medicine precisely because it encompasses a narrow branch of surgery. In the 1300s, the French physician Guy de Chauliac proposed the development of a specialist surgeon to treat teeth which he called, coining a term from Latin, a "dentista." Ambroise Pare, the seventeenth-century surgeon thought of as the father of modern surgery, included in his writings extensive descriptions of dental instruments and procedures. In 1619, the French king passed an ordinance granting equal rank to three surgical specialists: dentists, bone setters and lithotomists. On passing examinations before a commission of three Masters in Surgery, each specialist would be considered "expert" in his branch of surgery.

A century later, naval surgeon Pierre Fauchard settled in Paris and devoted himself to dental surgery. He envisioned dentistry as a profession instead of the craft medieval monks, blacksmiths, and itinerant performers had made of it, and in so doing created the modern concept of dentistry. Over forty years of practice, Fauchard catalogued existing techniques, procedures and ideas, then published them to the world in an age when secrecy among practitioners was deemed essential for business. His landmark work, The Surgeon Dentist, published in 1728, signaled the beginning of shared information among dentists. Fauchard presented dentistry for the first time as a coherent, cohesive discipline—and clearly a surgical one.

Dentistry even gave medicine two surgical specialties. One is anesthesia. Every dental student learns the story of Hartford dentist Horace Wells, who during a raucous nitrous oxide party noticed that he had gashed his leg under the influence and didn’t care. Wells began experimenting with nitrous in his office, and discovered he could extract teeth without anxiety. He went to Boston in 1845 to try out his discovery at the great Massachusetts General Hospital. The surgeons and students gathered around, but the patient cried out, and the audience booed. Wells never got over the humiliation. His friend and associate, William Morton, however, experimented with ether. Went back to the same hospital, and with steely nerves persuaded the same famous surgeon to attempt a surgery with anesthesia again. And it worked.

The other medical specialty pioneered by a dentist is plastic surgery. Dr. Varaztad Kazanjian was head of Harvard Dental School’s prosthetic laboratory when World War I broke out. He was named chief dental officer to a Harvard medical unit organized in 1915 to care for casualties of the British Expeditionary Forces. Kazanjian arrived in France to discover that battle-inflicted facial wounds were routinely left untreated. Kazanjian began experimenting on face wound patients, combining his interest in dental and maxillofacial prosthetics with reconstructive surgery. He ended up treating three thousand cases of facial wounds, was knighted, and dubbed the father of modern plastic surgery.

The Greek medical diety Asclepius’s ancient motto describing the ideal surgeon was "sure, speedy and shoutless." The early nineteenth century surgeon Astley Cooper described his profession’s necessary attributes as the "eye of an eagle, heart of a lion, hand of a woman." Anesthesia and antisepsis allowed surgery to become less heroic and more routine; these days Hollywood has identified a new slogan: "This is the 90s," says the Goldie Hawn character Elise in the movie First Wives’ Club. "Plastic surgery is like good grooming. It’s like brushing your teeth!"

In fact, it’s dentistry that offers the most routine of surgeries. For example, in 1998, the American Automobile Association compared shopping for a new car to having a root canal. Could AAA ever have substituted, say, a tonsillectomy? In the past, when the likes of silversmith Paul Revere and painter Wilson Peale also dabbled in dentistry, dentists might have been considered artisans. In the future, as DNA engineering promises the repair and regrowth of tooth structure, dentists may become geneticists. At the turn of the twenty-first century, however, the dental doctor is still a surgeon.