‘Crucial Interventions: An Illustrated Treatise on the Principles and Practice of Nineteenth-Century Surgery’ reviewed by Dr Alice McLachlan

‘Crucial Interventions: An Illustrated Treatise on the Principles and Practice of Nineteenth-Century Surgery’ by Richard Barnett in association with Wellcome Collection (Thames & Hudson, 2015).

Following our initial call for clinical and academic reviews of ‘Crucial Interventions,’ Dr Alice McLachlan offers her perspective as a junior doctor. You can see the accompanying review offered by Laura Neff here

Crucial-Interventions[2]Having reviewed its predecessor, ‘The Sick Rose, I was flattered to be asked to share my thoughts on ‘Crucial Interventions,’ although I should say that I am not a surgeon (and have zero desire to be one). In fact, as I touched upon in Richard Barnett’s previous book, you don’t need to be in the medical field at all to have a gory fascination with the human body. Whether you are a consultant colorectal surgeon or don’t know your stomach from your spleen — this is a great read.

The layout of this book follows that of ‘The Sick Rose,’ a carefully balanced combination of literature and art. Barnett intertwines detailed images of surgical ailments and techniques with written narration. In ‘Crucial Interventions,’ the chapters are not based on groups of illnesses, but short essays that focus on time periods and surgical advancement. In contrast the groups of illustrations demonstrate surgical techniques on different body parts, from the head down to the feet. Although these are beautiful illustrations, for me it is the written tour through history which really drew me in, and which I will briefly touch upon in chronological order.

The first chapter in the book, The Thinking Hand introduces the concept of surgery in the early centuries, teaching us that surgical techniques have been around as long as medicine — and that in the Middle Ages it was barbers, rather than physicians, who carried out surgical procedures. In these years, physicians were academics who considered surgery to be beneath them. Today with surgery being one of the most competitive training programmes in the medical field this is hard to imagine, and indeed by the end of the eighteenth-century, leading surgeons had reached the same professional parity as physicians.

The following chapters explore specific ideas, breakthroughs and perspectives in the changing face of surgery. What Barnett compiles as ‘The Yankee Dodge’ is perhaps my favourite section in the book, as it covers a topic I’m sure we are all obscenely grateful for — Anaesthesia. November 1842 marked a turning point, as the first operation carried out under general anaesthetic, and no longer was surgery the cause of nightmares  unless the patients were having particularly unfortunate dreams as they lay unconscious.

‘Let us Spray’ explores the idea of antisepsis in surgery, and when this really began to gain momentum. Again, extreme surgical cleanliness is something we take for granted in modern operating theatres, but was not always the case. Influential writings, such as those by Florence Nightingale highlighted the high post-operative mortality rates in large urban city hospitals (compared to smaller hospitals or wealthy homes) and began to change the way of thinking. ‘Scrubbing Up’ builds on this and examines the push towards a completely aseptic environment, influenced by a shift in European bacteriological thinking. This in turn led to a change in operating theatre, surgical tools and operation technique. No longer was surgery a bloody battlefield and a race against time. Armed with anaesthesia and a quiet, aseptic environment, surgeons began to see themselves (as Barnett so perfectly describes,) as “meticulous scientists”. Ministers of Hygiene further explores the growth of the hygienic hospital, and the role of other health care professionals, largely nurses, who helped to make this a success. Suddenly in the nineteenth-century, hospitals were seen as a place one may wish to undergo a surgical procedure; rather than a dumping ground for those who could not afford to be operated on at home.

The Smart of the Knife takes a slightly different turn and examines the role of surgery in the battlefield. Advancement in weaponry meant that military surgeons were working with injuries caused by powerful explosives. The use of chloroform on the battlefield soon became widespread, and operating techniques were forced to be advanced and adapted rapidly. ‘Paris medicine’ also greatly influenced medical and surgical teachings, and this is explored in Walking the Wards. Towards the end of the 1800s, surgery had established itself as a specialist field within Western medicine. For these surgeons, further specialisation was a way to build a reputation in an increasingly crowded marketplace. This era was also the start of the “multi-disciplinary team” approach — by the end of the century, surgeons worked heavily with pathologists for tissue diagnosis following (or during!) surgical procedures.

So Simple & So Grand summarises the height that surgery had reached at the turn of the twentieth-century, and is again one of my favourite parts of the book. It uses the case of Edward VII, who had an appendiceal abscess drained in 1902, to illustrate how far the art of surgery had progressed. Surgeons had been chosen over physicians, had recognised a curative operation and had performed it painlessly and (relatively) safely — the procedure was entirely successful and Edward was crowned a month later.

The final chapter Under the Knife looks at the patient’s perspective. As a doctor working in the modern day NHS, with a heavy focus on patient-centred care, much of this article is quite disturbing. As surgical techniques improved, patients were more inclined to explore surgical options early — rather than as a last resort. Sadly, this was something which many surgeons used to their economical advantage, inventing imaginary surgical ailments for which they could charge there patient’s huge financial sums. Equally disturbing is the “itch to cut” manifesto, an attempt to control female behaviour through operations such as ovariotomies or clitoridectomies. It is a reminder that even in a time of such rapid technical progression, attitudes and understanding still had a long way to go to reach the point we are at today.

So jumping forward to the present day, what does surgery look like now? Aside from a few shared years at the beginning of training, it remains a separate career path to that of a physician, and in many ways an entire lifestyle choice. Although certain specialities allow you to incorporate both medicine and surgery, many healthcare professionals will tell you that ‘you are either born a surgeon, or you aren’t’; and I have to say I largely agree with this. As a junior doctor, I have now worked alongside both surgical and medical teams, and (at least in my hospital) they work almost entirely separately. There is no doubt that they regard each other with huge respect; which is often clouded in (painfully accurate) stereotypes. Physicians joke about surgeons as ‘arrogant’ or ‘brainless,’ whose only solution is to cut people open. Conversely, surgeons see themselves as the heroes, rolling up their sleeves and getting stuck in to fix the problem at its source. The way in which these stereotypes have stuck, amongst highly intelligent and educated professionals, reflects back to Barnett’s excellent description of the nineteenth-century physicians, educated primarily through academia, and surgeons through repeated hands-on experience. Whilst many aspects of nineteenth-century surgery seem ancient and barbaric, this generalisation is still prevalent today.

To end on a more personal note, I have gone through medical school (and now into my early years as a Junior Doctor) knowing that surgery isn’t for me. Frankly, I find it gory and mechanical, both painfully dull and overwhelmingly stressful. Therefore I secretly think of surgeons as being a tiny bit crazy. But thank goodness these crazy people exist. Just two hundred years ago, surgery was a “fast and furious” bloodbath. It could certainly be curative, but it was also excruciatingly painful, and if you survived the initial operation there was a high chance you would die anyway from wound infection. Today, surgeons can remove a donor’s kidney and transplant it into a recipient with incredible success for both individuals. They can whip out a gallbladder in under an hour, close holes in hearts, repair aneurysms and decompress the spinal cord. The future of surgery is bold, exciting, and almost without limits. There is no doubt in my mind that the next century will be every bit as influential as the last – and in the next twenty years we might be “going under” for operations that were never thought possible.

Reviewed by Dr Alice McLachlan, a Foundation Year 2 doctor currently working in West Middlesex University Hospital, London. She graduated from the University of Dundee in July 2015, and has a BMSc in International Health with a dissertation exploring the ethical implications of research in developing countries. She has a keen interest in global and public health, and the increasingly complicated world of medical ethics. As well as aspiring to a career in palliative care, public health or general practice (she remains a little undecided), she secretly hopes to become a published author herself one day.

Correspondence to Dr Alice McLachlan.

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