The Palgrave Handbook of the History of Surgery

The Palgrave Handbook of the History of Surgery. Thomas Schlich (ed). Palgrave Macmillan, London, 2018. 578pp, €200. ISBN 978-1-349-95777-4.

Thomas Schlich is a professor in history of medicine at McGill University in Montreal. In the introduction, he states the aim of the book is to '… provide a point of departure for enquiry and further research into surgery and many historical themes associated with this’. The book is divided into three parts:

I. Periods and topics: Basic themes in history of surgery

II. Link: Subjects outside the history of surgery that are applied to it

III. Technologies: Novel approaches to selected subjects.

The source of much of the information in the book is from a treatise written by surgeons and may thus present a distorted view. The authors have taken pains to collect a large volume of information as is evident from the list of references at the end of each chapter.

Periods and topics: Basic themes in history of surgery The first three chapters of Part I deal with surgery in the antiquity and pre-modern and modern era. The modern era describes the period after the entry of Cheselden and Hunter. The chapters are written by different authors and have overlapping contents.

- The editor and the authors have not included Susruta’s contribution to surgery. Susruta’s existence has been acknowledged by historians.

- There is a void in the history of the periods of renaissance and enlightenment. The surgery in antiquity is well covered and tends to be repeated in the first three chapters. The description of the latest innovations is limited to only a few subjects such as transplant and minimally invasive surgery (MIS) in Part III. Neurosurgery is described as a case study.

- The status of surgery in relation to medicine is described in several contexts. Its transformation into a healing science from a craft and the evolution of training and certification of surgeons make for an absorbing study. This part has been creditably handled. Quoting Wangensteen, the current function of general surgery is defined as ‘spawning surgical disciplines’.

- The text describes upward social movement of a surgeon from being cunning in the pre-modern era to a respectable member of society permitted to exercise his authority. In the 19th and 20th centuries, a surgeon is put on a pedestal with miraculous powers (in a similar vein, the chapter on surgery and emotion in Part II describes the emotional makeup of a surgeon from a brute in the pre-anaesthesia age to a person who has achieved self-mastery of his emotions).

- The chapters are written in the language of historians and a surgeon reading them may appear to be in unfamiliar terrain and strain to get the meaning.

The history of surgery is full of anecdotes, and these are missing in the book. One misses the defining moment when Morton held a demonstration on the effect of ether on pain control. Likewise, the observations of Ignaz Semmelweis on childbirth fever invited the wrath of his peers should have been part of the text. Pasteur’s rhetoric on organisms causing infection is missing.

The chapter gives deserving credit to surgical nurses on the progress of surgery. The chapter records the role of women in surgery as patients and as practitioners and makes interesting observations. As patients they were disregarded for their opinion and as acceptance of surgery increased, it led to greater volumes, but this increase had a gender bias against women with them making the most numbers.

Women were not considered suitable to be surgeons because they ‘lacked humanly qualities’. The introduction of anaesthesia dispensed the need of humanly qualities in a surgeon. During the wars, women easily and effectively slipped into the shoes of men surgeons, men being deployed on the battlefield.

Link: Subjects outside the history of surgery that are applied to it The chapters in this part make interesting reading.

‘Effect of colonialism’ is devoted to British rule over India and its influence on surgery. The experience of war discusses the hypothesis that war surgery has produced no innovations in civilian surgery. It is difficult to believe that statement. However, historians should get evidence whether prisoners of war were used as subjects of untested operations.

‘Images and surgery’ is a chapter that describes the use of images in the 17th century and later. The pictures or drawings were used to market surgeons’ skills and served as teaching aids. The success of the iconic Grey’s anatomy is as much due to skilled drawing as to the text. The author has missed the contribution of Leonardo da Vinci, who was a keen dissector of the human body and had drawn over 700 images.

Two chapters in Part II are outstanding and express the spirit of the book.

In ' Surgery and architecture ', the authors describe an operating room in the 19th century (and call it a Victorian operating room). Light was provided by long windows and skylights and ventilation by exhaust towers. Inside the operating room was a tiered seating arrangement (I witnessed this design surviving in J.J. Hospital, Mumbai, in 1948). In the early 20th century and post-Second World War, the ' Surgical suite’ became much smaller in size and was designed to minimize human error. The surgical suites were located in an area of low hospital traffic and were hyper clean; the gallery of visitors was removed. Artificial light was introduced instead of long windows, marble was replaced by ceramic tiles for the floor and walls and ventilation replaced by air-handling units. This remarkable chapter by linking history of surgery to beyond that of a science of medicine, in this instance to architecture, gives a new dimension to our understanding of the past. The chapter is well illustrated by line drawings and photographs.

The chapter ‘Art and surgery’ is another outstanding chapter contributed by an Associate Professor of History of Arts at McGill University and portrays the surgical hands in three case histories. The third case history is a 5-minute film by Christina Lammar in 2012 titled ‘Hands movies’. Comparing hand movements of a surgeon and a choreographer would be an ultimate compliment to the surgeon.

The film is not part of the book (and I have not seen it) but would be interesting for a surgeon to watch.

Technologies: Novel approaches to selected subjects

Transplant symbolizes the cutting edge of surgery. Moreover, the chapter on transplantation surgery provides all the information on the subject of kidney transplant up to the 7th decade of the 20th century. The text beyond this period is not written and the chapter misses out on other solid organ transplants and developments in immunosuppressive agents.

In the 7th decade of the past century, two young surgeons, David Hume and Roy Calne, tested the immunosuppressive properties of steroids and azathioprine (1967) in dogs in Boston. Finding it the best combination available, its use was successfully introduced by them in human transplants. This was a landmark step by the two young impatient surgeons, and recognition should be accorded to them whose impatience was a virtue in the programme.

The central figures in the development of radical surgery for cancer were George Washington Crile (1864-1943) and William Stewart Halsted (1852-1922). Halsted is recognized as the first surgeon to use available information to design radical mastectomy for breast cancer. Unfortunately, the chapter does not provide the progress made by breast cancer surgery after radical mastectomy described by Halsted. The chapter on radical surgery deals almost exclusively with Halsted mastectomy. There is no description of radical surgery in other cancers.

The relative paucity of randomized controlled trials (RCTs) in surgery is because of difficulty in carrying out such trials, getting an adequate number and size of experiments involving complex procedures. Historical research needs to be directed at the issues related to a clinical trial, especially randomization and addressing the current debate between those who insist on RCTs and those who advocate pragmatic use of other modes of knowledge production, despite their known shortcomings.

The author of the chapter on MIS believes that the superiority of MIS versus conventional surgery has not been established by accepted methods, namely RCTs. The author continues to state that acceptance of MIS has been the result of patient-driven demand accompanied by the support of professionals with vested interests. The opinion of the author of this chapter is out of sync with universal acceptance of MIS and imparting its training to residents in surgery.

Bariatric and cosmetic surgeries are two latest specialties and raise the question that the operations are done on healthy bodies. While surgeons legitimized their contemporary use, historians have paid attention to socioeconomic issues of remodelling body appearance and seen as pursuing no real therapeutic aim. Many social issues remain unexplored, and systematic studies would shed light on the changing role of surgery in society.

The authors use neurosurgery as a case study on the development of specialties. Description of development of other specialties will need to follow a separate pattern for each specialty.

The principal focus of authors of this book is historical research. This is stated in the introduction of the book. The book being the product of many authors, the connection between one chapter and another is little, if any. The book thus would not have a universal appeal and would be of interest to historians of surgery. There are brilliant chapters, and these would appeal to all surgeons.

Personally, among other items, I would like to see the film ‘Hand movies’ and would like to possess ‘Portrait of Pean: A surgeon’. The book has a good get-up with easy-to-read typeface. The illustrations are not in large numbers but are clear.