The Invention of Surgery

The Invention of Surgery

Author: David Schneider

Background

This book is about the implant revolution – what the author characterised as the contemporary technologically-enabled surgical practice that has empowered ‘21st-century surgeons to ‘resuscitate, reconstruct, and even reimagine human beings’. Attributing this movement to the medicine’s better understanding of the human body, and of disease, the book explores the scientific developments that transformed surgery from its obsolete beginnings into its modern iteration – the culmination of ‘the marriage of science, art, hubris, imagination, madness, bravery, and patience‘. Interspersing historical narrative with personal anecdotes, the author charts the progress of medicine as a whole from a profession dominated by such ineffectual therapies as leeches and bloodletting, to the sophisticated interventions that typify all surgical sub-specialties today. With exhilarating and passionate prose, the author provides not just a comprehensive account of surgical implants, but he also explores such diverse subjects as sports medicine, the politics of health insurance, and the regulation of medical technologies (page x, xiii and 52).

Medical implants. ANBerlin [Ondré] on Flickr. https://www.flickr.com/photos/anberlin/29643349430

Synopsis

In his detailed account of the earliest consequential contributions to the emergence of modern medicine, the accomplishments of Andreas Vesalius stood out for marking a major turning point. In his biographical portrait of Vesalius, the author painted a picture of a man whose character was symbolic of all those those who later contributed the most to inventing surgery – ‘tinkerers, oddballs, lonely geniuses, inspiring mentors, and stubborn misfits‘. Crediting Vesalius with being ‘the man who knew more about the human body than anyone who had ever lived’, he referred to his groundbreaking book, De Humanis Corporis Fabrica, as ‘the world’s first printed medical textbook’ that ‘would change medicine, and the world, forever‘. The author particularly lauded the book for challenging and dismantling ‘1,500 years of authority’ based on the misguided teachings of Hippocrates and Galen. Another pioneer whose contribution had a similar impact to that of Vesalius was William Harvey, a man the author portrayed as ‘completely self-motivated and endlessly curious‘. The author recounted how Harvey unravelled the mystery of blood circulation in his book De Motu Cordis, the radical text which upended Galen’s ‘sacrosanct’ but ‘entirely and…ridiculously wrong‘ ideas of how the heart functions and how blood flows in the human body. The author argued that Harvey established the principles of blood circulation by disproving such erroneous ideas as the presence of pores between the ventricles of the heart, and this ‘great revelation‘ constituted his ‘eureka moment (pages 22-37, 56-65).

Andreas Vesalius, De Humani corporis (1555). University of Liverpool Faculty of Health & Life Sciences on Flickr. https://www.flickr.com/photos/liverpoolhls/10818477975

In ascertaining the foundational concepts that underpin the emergence of modern surgery, the book took a thrilling adventure into the history of an astonishing range of concepts. Perhaps the most momentous of these was germ theory – the idea that ‘paved the way for antiseptic surgery‘. The book highlighted the lives and works of those who contributed the most to proving this notion, visionaries such as Ignac Semmelweis, Joseph Lister, Louis Pasteur, and Robert Koch – ‘the father of bacteriology‘. The book also memorialised the pioneers of antimicrobial treatment such as Paul Ehrlich whose work led to the introduction of Salvarsan – ‘the world’s first synthetic chemotherapeutic agent‘, and Alexander Fleming, Howard Florey, and Ernst Chan who respectively discovered and promoted the therapeutic use of Penicillin. In a similar approach, the book recalled the breakthroughs in anaesthesia which advanced surgical practice. In this narrative, the author noted the contributions of physicists such as Joseph Priestley, Joseph Black, Henry Cavendish, Daniel Rutherford, Humphrey Davy, and John Dalton on gases; of Crawford Long, Horace Wells, and William Morton on ether; and of James Simpson and John Snow – ‘the world’s first full-time anesthesiologist‘ – on chloroform (pages 113-121, 125-127 and 130-137 and 145-150-159).

Penicillin Mould, 1952, Recto. CRC, University of Edinburgh on Flickr. https://www.flickr.com/photos/crcedinburgh/10154342636

A major theme of the book is its depiction of the surgeons who made the most impact on modern surgical practice. Of these, William Halsted was conspicuous for his legacy of establishing ‘the school of scientific, safe, and anatomically correct surgery’, and for implementing ‘a working environment that shaped the education of generations of surgeons‘. The author related how Halsted ‘initiated a series of innovative changes that resonate in every hospital and academic institution to this day’. Amongst his legion of contributions, the author cited the innovation of sterile surgical gloves; the introduction of regional anaesthesia after he self-experimented and became addicted to cocaine; the perfection of the technique of intestinal anastomosis; and the performance of the first appendectomy and gallstone removal. It was however his approach to the treatment of breast cancer that the author claimed would stain Halsted’s reputation, arguing that the great surgeon did not take into account that ‘cancer cells spread through the bloodstream and not just through contiguous, centrifugal growth‘. The author maintained that Halsted believed in ‘cutting wider, deeper, and more aggressively‘ as ‘the answer to freeing the patient from the invader‘, and that he ‘perceived his heroic task was to lacerate, harrow, and extirpate‘. In this way, the author remarked, Halsted ‘would enlarge the zone of excision, eventually removing the entire pectoralis, and occasionally ribs, the collarbone, and all the lymph nodes‘ (pages 169-182).

Breast cancer awareness. ~Pawsitive~Candie_N on Flickr. https://www.flickr.com/photos/scjn/6196228320

Besides Halsted, the book profiled other accomplished surgeons who established surgery as a scientific discipline, and prominent amongst them was John Hunter, ‘an instinctive dissector‘ to whom ‘nothing was off-limits in his quest to understand the body’. Describing Hunter’s scientific method as ‘the bridge between medieval surgical bleeders and the first surgeon-scientists‘, the book catalogued his staggering contributions such as describing the placental circulation. Another prominent figure in the book was Giovanni Morgagni – ‘the father of anatomic pathology‘ – whose book, De Sedibus, dealt ‘a final blow to humoral medicine’ and changed ‘the way that physicians looked at patients and thought about the essential nature of disease‘.  Another equally prolific scientific surgeon was Rudolph Virchow, a polyglot who was ‘incredibly intelligent and monstrously energetic‘, and whose breakthroughs made ‘several quantum leaps in the understanding of cellular function and behavior’. Also in the book’s annals of the most eminent surgeons were Emile KocherFriedrich Trendelenburg, Bernhard von Langennech, Astley Cooper, Benjamin Brodie, Carl von Rokitansky – ‘the man who literally built the house of pathology‘, and Theodor Billroth – ‘the most influential surgeon in the world for a quarter of a century‘ (pages 66-79, 85-87, 94-97 and 164-168).

Theodor Billroth CC BY-SA 4.0, Link

Most symbolic of the innovations that have transformed surgical practice are its state-of-the-art implants. The author reviewed the different classes of implants – plastic, metal, organic, biologic, and electronic, and he discussed their staggering range of applications as coronary artery stents, bypass grafts, pacemakers, heart valves, ventriculo-peritoneal shunts, neuromodulation, spinal cord stimulators, cochlear implants, organ transplantation, invitro fertilisation, penile implants, lens replacement, prosthetic mesh devices, silicon gel-filled implants, and dental implants. The book also provided a helpful background to the early breakthroughs in implant surgery, and this was particularly so through the perspectives of two of its major pioneers. The first was John Charnley whose landmark contribution was the introduction of polyethylene to total hip replacement‘, an achievement that followed heartbreaking disappointments with Teflon. The second personality was Charles Neer – ‘the most important shoulder surgeon who ever lived’ – whose research opened the door for shoulder joint implants (pages 3-11, 211, 259, 260-276, xiii, 229 and 289-305).

Prosthetic hip. DanR on Flickr. https://www.flickr.com/photos/dansdata/2909406987

Opinion

This book’s unique approach to the history of surgical advances is both fascinating and enlightening. The author puts the history of surgery in the context of the scientific developments of the times, from printing and physics, to astronomy and the philosophy of science. The snippets of the author’s own clinical experience, and of the visits he undertook to the historical sites he commemorated in his narrative, greatly enhanced the appeal of the book. Whilst there was a strong hint of contempt in the book’s denigration of older medical practices, this was perhaps justifiable as the author’s aim was to establish how far surgery has advanced since then. The book suffers slightly from hyperbolic adjectives and distracting commentaries, and from a disjointed approach to some of its biographical accounts. The prose is however superb and unhurried, and the contents appropriate to the remit of the subject.

Overall assessment

This book is a sweeping history of the foundations of surgery, from pathology to  infection control, with one of its greatest strengths being the way it links these threads into a cohesive whole. The author provides helpful contexts in which to view the advances that have moved surgery out of its historical limitations, and into its implant-dominated practice. Whilst this carried the risk of entrenching surgery as a technologically-obsessed specialty, it conveys the reality of the developments that have made the field as safe and as efficient as it is today. The contents of the book are extremely relevant to medicine and I recommend it to all doctors.

Book details

Publisher, Place, Year: Coronet, London, 2020
Number of chapters: 21
Number of pages: 380
ISBN: 978-1-529-36226-8
Star rating: 5
Price: £17.99

2 thoughts on “The Invention of Surgery

  1. Indeed, we stand on the shoulders of formidable giants! Happy to know the excellent contributions of Halsted as I was only familiar with his ‘radical’ approach to breast cancer before. Happy New Year Doc.

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    1. We do indeed. I have a review of Halstead coming up in the future as he was one of the big 4 at Johns Hopkins (together with Osler, Welch, and Kelly); I think he did more good than harm

      Like

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