Blood and Guts
Author: Richard Hollingham

Background

With an enlightening and exhilarating narrative, this book brings to life the landmark breakthroughs and setbacks of an important medical field, and the bold pioneers who made them. It is an exhaustive historical account of the remarkable feats that brought surgery away from its mid-nineteenth century practice which was ‘firmly rooted in superstition‘ – when ‘at best, all doctors could hope to do was to assist the natural process of healing‘. The book paints a vivid picture of surgery’s early ineffectual practices such as of cupping and bloodletting, and its latter unorthodox activities such as bodysnatching and lobotomy. The book’s strengths lie in its simple chronological approach that explores the lives of personalities from Galen to Christiaan Barnard, and that recounts paradigm-shifting revolutions from antisepsis to brain surgery (pages 49-50, 65-68, 164-168 and 272-289).

Synopsis

Galen was the dominant figure of the book’s account of early surgical practice, undoubtedly because of his profound and enduring influence on all aspects of medicine. As physician to the Royal gladiators in second century Rome, the author noted that Galen took on the role of setting the broken bones, and amputating the injured limbs, of survivors of the hostile contests that characterised the age. This, the author argued, turned him into ‘one of the first trauma surgeons‘ because it made him ‘perfectly placed to study the inner workings of the human body’. The author noted that the opportunity enabled him to understand human anatomy at its most gruesome as illustrated by his study of the digestive system of defeated gladiators whose guts were ‘spilling out‘ from their stomach wounds. Whilst the book acknowledged that Galen’s deductions were often correct, it argued that he was wrong regarding key anatomical features such as his teaching that ‘blood was produced in the liver‘, and that the heart was ‘some sort of furnace‘ with tiny holes between the chambers. The author therefore concluded that the ‘boastful Roman surgeon‘ was ‘wrong about so much’, and ‘it took more than one thousand years before doctors and surgeons began to question his teachings’ (pages 44-47).

At the heart of the book are the transformative developments which made surgery a modern and evidence-based endeavour. One of such seminal breakthroughs was the  better understanding of the anatomy of the human body – a revolutionary feat the author credited primarily to Andreas Vesalius. Describing the Belgian anatomist as a man who had ‘set himself the task of reaching a fuller understanding of human anatomy‘, the book depicted how he was able to ‘map every single organ, muscle and ligament in the human body’, and in the process correcting ‘more than two hundred of Galen’s mistakes‘. The introduction of anaesthesia was another groundbreaking achievement that determined the direction of surgical practice. In narrating this story, the author referred to ether, the first anaesthetic agent which was introduced by dentist William Morton, pointing out that it turned out to be too toxic and flammable, and it had several unpredictable effects, especially in pregnant women. The narrative also explored the introduction of chloroform to circumvent the adverse effects of ether, an innovation the author attributed to obstetrician James Simpson who had first self-experimented with the anaesthetic. The reputation of chloroform was however tainted by cases of unexpected deaths – a mystery that was only resolved when John Snow discovered that the deaths were caused by excessively high doses of chloroform (pages 52-53 and 69-79).

Antisepsis was the major innovation that launched the era of safe surgery, and the book explored this topic on the background of the post-operative wound infections and puerperal sepsis that bedevilled the profession from its inception. The author attributed the initial insights into antisepsis to physician Ignaz Semmelweis who was mystified about why the mortality in an obstetric clinic run by midwives at Vienna General Hospital was far lower than that in the clinic run by doctors. The author recounted how Semmelweis examined countless hypotheses – including ridiculous ones as the temperament of mothers and the positions they adopted for childbirth – before he concluded that doctors were responsible for transporting the disease from the autopsy room. The book explained how he developed his ideas after observing that a pathologist who accidentally pricked his finger during an autopsy had died of a similar illness to puerperal fever. The book also described the futile attempts of Semmelweis to convince his institution and the wider surgical fraternity of his theory; his idea  rebuffed, the book depicted his consequent psychiatric break down and how he spent his final days in a mental asylum. The author went on to document the confirmation of germ theory based on the works of Louis Pasteur, and the introduction of surgical antisepsis by Joseph Lister – although ‘it took more than ten years’ for the idea to take root (pages 80-101).

A seminal figure in the early history of surgery, one who featured prominently in the book, is Robert Liston – ‘Britain’s finest surgeon’ and ‘the foremost surgeon of the day’. Whilst the book characterised Liston as ‘domineering and self-assured‘, it also portrayed him as an empathetic surgeon who ‘made every effort to instil in his students some sense of the feelings and fears of the patient’. This concern for the patient, the author argued, was a contributing factor to his famed surgical speed – a skill he developed to limit his patients’ distress. The book illustrated Lister’s surgical speed with a graphic scene of him performing a leg amputation – as a demonstration of his ‘remarkable dexterity‘ and ‘brilliant showmanship‘, the whole operation lasted only 30 seconds ‘from first cut to final stitch‘. The book however also described some of Liston’s personal deficiencies such as his arrogance which ‘would get the better of him’ and lead to operative errors; an example of this was when he accidentally amputated a patient’s penis along with his assistant’s fingers. Amongst the other earlier surgeons the book explored was Ambroise Pare, the French battlefield surgeon who abandoned the conventional treatments of the day, such as boiling water and cauterization, and in their place he introduced ‘better and more humanitarian ways of treating battle wounds’ (pages 34-42 and 54-59).

A theme that ran throughout the book is the courage of the surgeons who devised and implemented new surgical techniques, as well as of those who advanced older interventions. This was most evident in the book’s narrative on the heart, an organ that was held in awe by leading surgeons of the nineteenth century such as Theodore Billroth who vehemently discouraged any attempts to operate on it. The author recounted the first attempt to break the taboo on operating on the heart by army surgeon Dwight Harken during the second World War; Harken successfully removed a bullet from the living heart – a feat which the author said made the heart ‘no longer untouchable‘, and made Harken ‘the first true cardiac surgeon‘. The book traced subsequent innovations in cardiac surgery, from the introduction of hypothermia and cross circulation, to the introduction of the groundbreaking heart bypass machine by John Gibbon – the device that enabled such dramatic operations as the first successful cardiac transplantation by Christiaan Barnard in South Africa. The book highlighted many other innovative developments that advanced surgery including the vascular experiments of controversial Nobel Prize winner Alexis Carrel; the first kidney transplantation by James Murray between the identical Herrick twins; the introduction of cyclosporine to prevent transplant rejection by Roy Calne; the plastic surgery innovations of Harold Gillies and Archibald McIndoe; and the first brain tumour surgery by Rickman Godlee (pages 110-119, 148-155, 169-183, 191-197, 203-205, 225-242 and 262-265).

Opinion

This enlightening journey into the exciting history of surgery is very detailed and narrated with a dramatic flair. By highlighting the major breakthroughs and the exceptional personalities who made them possible, the author succeeded on projecting the passion and adventure that symbolise the specialty. Some stories, such as the cosmetic surgical odyssey of the socialite Gladys Deacon, took more space than they deserved as they did not reflect any developments in the field. The long forward was also probably unnecessary as it did not add much to understanding the book’s content. Apart from these minor faults, the book is a refreshing look at the history of a major field of medicine.

Overall assessment

This book is an interesting and exhaustive review of the history of surgery. It highlights its glorious achievements, just as it documents its less worthy moments. In portraying the gradual progression of innovation, the book also puts the current state of surgery in its historical context. The book also brilliantly shines a light on the way different specialties collaborate together to make medical advances possible. It is an inspirational and enlightening work, and I recommend it to all doctors.

Book details

Publisher, Place, Year:  BBC Books, London, 2008
Number of chapters: 5
Number of pages: 320
ISBN: 978-1-84-607503-2
Star rating: 4
Price: £14.89