Interview: Dr. Stanley Burns, The Knick's Medical Advisor

Dr. Stanley Burns is the medical advisor for The Knick, a medical drama starring Clive Owen and directed by Steven Soderbergh. He's also curator of an encyclopedic archive of historical medical photography; this comes in handy because the show is set in 1900, and is all about period details. mental_floss interviewed Burns about his role on the show and some quirks of medical history. First up, here's a brief preview to give you a taste of what the show is like (note, some surgical gore and mild early-episode spoilers are here):

Where to watch The Knick: Fridays at 10pm on Cinemax. You can catch up on clips on The Knick's website.

On Historic Medical Photography

Chris Higgins: Can you talk to me a little bit about what The Burns Archive is and what led you to start it?

Dr. Stanley Burns: Well, I was always a historian and when I discovered the value of the photographic and historic documents in 1975, I aggressively collected photographs. My original photography is The Burns Collection and The Burns Archive are the copy prints and the other paraphernalia related to my collections. And I've used that over the last almost 40 years, to write and work with the media, and create documents. It's basically a collection of medical photography, memorial photography, and historic documentary photography. As I tell everyone, there is no art, music, or sports in there, because all the other institutions have that.

Higgins: You were—and are, I suppose—an ophthalmologist, is that right?

Dr. Burns: Yes, I am. I still practice. I have a big day tomorrow in the office. I don't do major surgery anymore, I just don't have the time for that.

His Role in The Knick

Higgins: Right. So, let's get into The Knick. As a medical advisor to the show you have an unusual job. How does that job work? I mean, what do you do? Are you there on set during shooting, are you reading scripts and giving notes?

Dr. Burns: Yes, I'm on set. I was on set from three to five days a week. Certainly for all of the medical episodes when medical things of interest, all the surgeries . Michael and Jack and Steven Soderbergh came to me with their pilot and they spent some time here and realized the treasure trove, the Tutankhamun Tomb of early medical photography that's here—and the stories. Remember, I had written 44 photographic historic textbooks. At least 40 of them are on medical photo history and I've written over 1,100 articles in medical photographic history. So, this is the work I've been doing and continue to do. My next book comes out in November, it's called Stiffs, Skulls & Skeletons: Medical Photography and Symbolism. [...]

Higgins: I've seen the video that shows you giving a tour of the collection and putting it in context. It is massive.

Dr. Burns: Well, I have about a million photographs and probably somewhere in the neighborhood of 80,000 good medical photographs, but it's also supplemented, which is what makes the writing and the research easy, by the major textbooks of the time period and the journals of the time period. So for instance, I have all the issues from 1880 to about 1930 of the Annals of Surgery, the Archives of Surgery, the International Journal of Surgery, and the Synopsis of Surgery. So, I have the original articles that these great doctors wrote on their great cases and also a lot of the great articles they wrote on their foibles, the things that went wrong. And so, you'll see both aspects in the show.

Organizing a Million Photos

Higgins: How do you keep all this stuff organized? Is there a database or some sort of taxonomic system?

Dr. Burns: Well, no, it's in my head. But see, every time we do a book, then that subject gets organized, it gets scanned, it gets numbered, labeled. So that as far as Stiffs, Skulls & Skeletons are concerned, the book will have 450 photographs, but in order to produce that we've scanned about somewhere between 2,500 and 3,000 images from which we edit it down.

Higgins: Right on.

Dr. Burns: So, each time I do a book the subject matter gets scanned and localized. Put in a box and put up on a shelf until it's called for.

Recreating Period Props

Props (before surgery) / Mary Cybulski/Cinemax

Higgins: So, when you talk about folks coming through to do a production like this, are there set designers, costumers, looking at things to find period details and such?

Dr. Burns: Yeah. Well, we work with all of them. And I tell you it was a thrill, because everyone was so professional. For instance, if we had a rusty instrument, but it was important you can't have instrument made in 1900 that's rusty, they'd make a new one. [...] Probably the most amazing thing created were Lister's antiseptic vaporizers. This is an essential part of surgery of the era and they're very expensive machines, if you can find an original one, which they did and then they accurately reproduced it, because they needed four or six of them in the operating rooms. And so, that went on throughout the entire show.

[... For one episode], they had to cool someone's head and I had in my photograph collection one of the early 1900 devices or 1890 devices that consisted of a cap with a rubber tube running around it for which they'd put cold water in with multiple layers of rubber tube. It looked like a little coil, and I would show them the picture and I worked with them and out came a hat from 1895.

Higgins: That's awesome.

Dr. Burns: But that's really a good example. And another example: [...] I said, "You know, you really need this certain neurological condition that this baby has. You really should show that, because that's really a dramatic exposé of what it meant to have this condition." And they produced it. I gave them the pictures, they sent it away to...I think it was done in California where they have the latex labs, because I think there's only one here , so most of the latex and the models came from California, and so, they made it. And that to me was the most amazing aspect of this show, other than the Lister atomizers, because they made an animatronic person, but that exhibited the medical maladies that I wanted it to. So, it was kind of strange to see that, but as a medical historian it was kind of wonderful to see that it was produced so accurately.

Reorganizing the Operating Theater

The Knick's Operating Theater / Mary Cybulski/Cinemax

Higgins: Are there any memorable moments where you had to step in, either in the writing phase or in the room, and suggest that something be changed to make it more accurate?

Dr. Burns: Oh, yeah. That happened on the very first day. [...] I walked into the operating room and I looked at the audience, they had already seated about a hundred distinguished doctors and they were about to operate and I said, "Steven, this is wrong." was something like the fact that if Martin Scorsese and Steven Spielberg invited you to direct a movie he wouldn't put you in the back row. And so, likewise in medicine. In the front row would be the old distinguished doctors and the next row would be the associate professors and assistant professors, et cetera. So, what they did is they had to spend the time to reorder the entire audience [...]. They were shifting beards, hairs, and lookalikes, depending on how the film was going to be shot.

But of course I only had to do that once, because they knew afterwards what to do and they just shuffled the older doctors in the first row and the young doctors were all the way on top.

The Knickerbocker Hospital Medical School

Higgins: I gather from reading other interviews that you had to train the actors in the basics of suturing and some surgical procedures. What was that like?

Dr. Burns: Well, for me it was a lot fun. First of all we created the Knickerbocker Hospital Medical School, where I my medical students, which consisted of all the actors, including Clive . He had a couple of extra lessons, because he really wanted to learn. I showed them the procedures, I had books that showed step-by-step the operative techniques, and most importantly I taught them how to place sutures in operative wounds. We did that because the prop department provided us with latex arms that were very realistic and I had the needle holders and needles. And so, I taught the actors how to do a mattress suture, continuous running sutures, and subcuticular sutures. I taught them how to tie with their hands very quickly as you will see onscreen as a surgeon does till this day.

I taught them how to use hemostats, which are these little clamp-like devices that we closed off blood vessels. And I showed them pictures of one procedure where there were over a hundred hemostats in this relatively small wound.

Just as a sidebar, that was one of the great accomplishments of William Halsted, whom Thackery's character is modeled after. Halsted taught people how to be delicate with tissue and how, if you want to have a great result to your surgery it had to be a bloodless surgery, that if you left pools of blood inside it would usually attract bacteria. And so, the hemostat was really an important advent of the time. [...] I taught my students how to hold a hemostat on the second finger of the hand and how to be able to tie or hold a scalpel to make a cut, while holding the hemostat in that second finger and then swing it around, open it to clamp the blood vessel and then go back to doing their stuff, and they loved it.

And one comment was, [...] of all the things they learned during the show, this would probably hold in the greatest stead throughout their entire lives, because they felt confident. They'd say, "Well, if I came across an accident or if I had to suture someone up now, I know how to do it." And this was a general comment right across the board and it is something great to learn, how to be able to put stitches in and take stitches and do all that.

Dr. Burns and Clive Owen on set / Mary Cybulski/Cinemax

Higgins: That is excellent.

Dr. Burns: Oh, the one other thing I should tell you. They were so attentive and so serious, more than medical students! [...] If you learn it and you don't do it right if you're a medical student, you'll do it again the next time or you'll learn next week. But when you're filming you get this one chance and you better look good. And so they all strove, not to look good, but to look great, and they did. And I'd let Clive suture me up. I mean, these guys know how to do it. This was their expertise, this one little aspect in medicine.

Scrubbing In

Higgins: So, a couple of specific questions that came up while watching. I've seen the first seven episodes. So, by 1900 the germ theory is well established and we see things like surgeons scrubbing in. One thing that jumped out at me in the first minutes of the first episode is seeing doctors dipping their hands and beards into a series of bowls of liquid—

Dr. Burns: Right.

Higgins: I'm curious—what is that liquid and why are there three tubs of it?

Dr. Burns: Well, there are three liquids used. One was an acidic solution to sterilize the hand, carbolic acid was another weak solution. Then there was a potassium permanganate solution, which colored the hands, which all sterilized. And then there was a washing solution. And the point was to get rid of germs and this was a good technique at the time.

How Doctors Became Addicts

Higgins: Now, we also see several doctors addicted to cocaine and other substances. I'm wondering if you have a sense...how common was this for doctors in 1900 to be hooked on cocaine and opiates?

Dr. Burns: Well, it was common, but not for the reasons that you think. It was common because this was an era when doctors experimented on themselves. [...] I always talk about the great neurologist Henry Head, who cut his own nerves—and of course he would have a permanent defect afterwards—to find out what innervation was and what it was like.

And Halsted again, who the character is modeled after, was one who developed infiltrative anesthesia, that is injecting cocaine locally, to be able to operate without giving general anesthesia. They practiced on themselves and they didn't know the side effects of all these drugs. One of Halsted's , a close associate when he was practicing in New York before he went to Hopkins, died. Halsted's effect was the fact that he became a cocaine addict. And I know during his tenure at Johns Hopkins when William Henry Welch was the head of the institution would try to take on his boat during the summer to somehow make him break the habit. But I think was an addict until he died and I think ultimately he became a morphine addict.

Cadavers vs. 3D

Clive Owen (Thack) contemplates a pig / Mary Cybulski/Cinemax

Higgins: Can you talk a little about the problems obtaining cadavers in 1900? We see this a lot in the show—the use of pigs and other sort of substitutes.

Dr. Burns: Well, doctors did need to get cadavers and there was a short supply of cadavers. They used to get them from Potter's Field—unclaimed bodies. And this had always been a problem because as medical institutions proliferated you needed more cadavers. It became almost an auction and who you knew. Stiffs, Skulls & Skeletons actually addresses this [...].

What's happening today is they're actually using, in some medical schools, three-dimensional models and stereography and interactive models to do dissections. It's not the same as going into an old-fashioned room and smelling the body, but the way medicine's going today for a lot of people this may work. used to be one of the obstacles to becoming a physician to try to get through your first year anatomy course. But that was a problem, grave robbing was a problem, but most of that in New York State was really done with at that time, it was just a matter of where you could steal the unidentified bodies from.

Higgins: Also in an early episode we see some interesting photos of medical oddities, we see those briefly during a burglary. Are those from your collection?

Dr. Burns: Yes. All the photographs used are from my collection. They have 80,000 real great ones, it was just a matter of choice about which ones they would use for that particular scene, and I think they used some of my favorites. Living with this stuff every day, writing and doing work so we picked some great ones, and I think they chose some great ones what they wanted to show.

Early X-Rays

Clive Owen (Thack) with an x-ray / Mary Cybulski/Cinemax

Higgins: At one point we see an early X-ray machine. Can you talk about how useful this would be and how dangerous it might have been?

Dr. Burns: How dangerous? Okay. The X-ray was discovered in November...I think, November 8, 1895 by Rӧntgen, a physicist in Germany. It was one of the few inventions that was instantly accepted medically, it went around the world. By March of 1896 people were publishing papers on the medical use of the X-ray and it was not very powerful. And again, let's talk about the cocaine, this is really the worst example of doctors not knowing the effect. Edison, who of course was a great electrical scientist of the era—because you need electricity to run the machine—recognized that his hands were getting red, so he had his assistant Dally doing all the X-rays and the fluoroscopies, and Dally was dead by 1904. I think he had only been working on it for about seven or eight years and what happens is the doctor's fingers were falling off, they were getting squamous cell carcinoma, and a whole bunch of other carcinomas from exposure to the X-ray. An X-ray of the abdomen for instance in 1900 was over 45 minutes.

In the Spanish-American War there was this great woman radiologist in San Francisco who took photographs of the soldiers, of the bullets, it was really the major exposé of war injuries that was published, this Spanish-American War book, with these early X-rays. And she died also about 1904. So it was extraordinarily dangerous both for the doctor and for the patient.

But the X-ray opened up dramatic fields. For instance, by 1901 it was routine to treat skin cancers with X-rays, as well as the dreaded condition Lupus Vulgaris, which is tuberculosis of the face. And as I said, this time period was when these inventions...all the great inventions of medicine were put into practical use. It was a time, as I always explain, that the chest, the head, and the abdomen became the playground of the surgeon. They were able to operate within those organs for the first time and heal patients successfully, operate on the brain and the heart. The first heart suturing was being done at that time.

The Burns Archive

Higgins: So getting back to The Burns Archive. Is the Archive something that people can visit?

Dr. Burns: Not really, we're working. We can't have people coming through here when I'm talking and Elizabeth's writing. We work in there all the time. [...] The public gets to see our materials via our books and our website [...] But we do have researchers come all the time.

About 20 years ago we were open to the public and we were listed among the unusual museums of New York City, but we're just dancing as fast as we can. There are only four of us here and lots of stuff to do and we produce more than most museums with the number of exhibits, books, and other things that we do.

Historical Perspective in Medicine

Dr. Burns: One of the statements I say to everyone I meet, just so you get the correct idea about these doctors, is that these doctors from 1900 and the doctors from 1700 and 1800 are just as smart as you and I, just as innovative, just as genius. The problem is they labored under inferior knowledge in technology and all they tried to do was help and heal. They did the best they could, but the advance of medicine and technology is so great that a hundred years later a lot of the stuff looks foolish and you're wondering why a patient would put up with it. And what we're doing today will be looked at, I'm sure, a hundred years from now the same way.

Where to watch The Knick: Fridays at 10pm on Cinemax. You can catch up on clips on The Knick's website.