Book Review

Medical Theory, Surgical Practice: Studies in the History of Surgery

N Engl J Med 1993; 329:1208-1209October 14, 1993

Article

Medical Theory, Surgical Practice: Studies in the History of Surgery
(Wellcome Institute Series in the History of Medicine.) Edited by Christopher Lawrence. 331 pp. New York, Routledge, 1992. $92.50. ISBN: 0-415-00046-7

The aim of Medical Theory, Surgical Practice is to relate a number of pivotal advances in surgical practice to theories current in medicine and in society in the era in which the advance was made. Thus, the book deals, to no small extent, with the age-old question of whether an advance in practice is to be credited to the individual doctor or, rather, to earlier persons on whose shoulders he or she stood. More important, it poses the question of whether social trends, attitudes, and expectations led to the discovery or strongly influenced its adoption. In the first chapter Christopher Lawrence writes,

An exemplary corrective to the view that surgery is, by definition, concerned with timeless, life-threatening events is to be found in Margaret Pelling's illuminating study of the barber-surgeons of sixteenth-century London. By paying close attention to the local context Pelling argues that the Tudor identification of ugliness, deformity as mirrors of morals and metaphors of social order shaped the goals and techniques of surgical practice.

The book's 10 chapters provide many interesting insights into the state of surgical practice and, indeed, medical practice during recorded history but particularly in the past four centuries. The bibliographies suggest the depth of the research that has gone into its preparation.

Lucinda McCray Beier describes a very interesting source of information about 17th-century English surgery, the casebook of Joseph Binns, a London surgeon who died in 1664. She states:

In Binns's treatment of hernia, as in his therapeutic approach generally, one can see both his dependence upon medical theory, his empiricism. On the one hand, he prescribed purges, clysters, issues and phlebotomy in order to keep or produce a humoral balance in the body. On the other, he altered the treatments he applied according to his perception of their efficacy.

Likewise, the chapter on scrofula by Roger French is illuminating, and the ensuing chapter on Giovanni Battista Morgagni's development of the physical examination is a revelation. Apparently, before Morgagni's time most physicians and surgeons were reluctant to examine parts of the body that were normally covered by clothing and relied largely on the history and what the patient chose to show them for their evaluations and diagnosis. The chapter on John Hunter points out that although he practiced experimentation and direct observation and taught these techniques to his students, he was not uninfluenced by the medical theories of the time.

The chapter on Joseph Lister emphasizes how slowly his teachings were adopted in some quarters. All the ensuing chapters, on the trend from conservative to radical surgery in the late 19th century, the growing emphasis on anatomy, and the introduction of anesthesia, are formidable studies. The final chapter by Ghislaine Lawrence, “The Ambiguous Artifact: Surgical Instruments and the Surgical Past,” adds additional insights.

Christopher Lawrence quotes Henry Sigerist as saying, “Surgery became great, not because anesthesia and antisepsis were introduced, but anesthesia and antisepsis were found because surgery was to become great; because surgery was the anatomical method of therapy.” Lawrence goes on to state that

the conclusion seems inescapable; early nineteenth-century surgeons were making their assault on the body with or without pain relief or, put less crudely, so great was the determination to invade by the 1840s that, in retrospect, the invention of technologies to facilitate this invasion seems inevitable.

Medical Theory, Surgical Practice tends to depreciate the achievements of individual physicians and to attribute them to social trends and some of the currents in medical thought of the time. This is somewhat like asking whether the British would have won the battle of Trafalgar without Lord Nelson. It is probably true that ether anesthesia would have come into practice without Morton and Warren (indeed, it had already been used by Crawford Long) and very likely that x-rays would have been discovered without Roentgen (for an x-ray was produced inadvertently at the University of Pennsylvania a number of months earlier). But the thought that “the Tudor identification of ugliness and deformity as mirrors of morals and metaphors of social order shaped the goals and techniques of surgical practice” stretches one's credulity. Some, like myself, may prefer to honor the individual heroes in the progress of civilization.

Even so, this book broadens the interpretation of the events of surgical and medical history, and the full bibliographies at the end of each chapter are a treasure for anyone exploring medical and surgical history, especially during the past four centuries.

Jonathan E. Rhoads, M.D.
Hospital of the University of Pennsylvania, Philadelphia, PA 19104