Technological Change in Modern Surgery: Historical Perspectives on Innovation ed. by Thomas Schlich and Christopher Crenner (review)

Some years ago I was working on the idea of holism between the wars and a colleague observed that it was something of a "slippery fish." The concept of innovation in surgery has rather the same character. Individual examples are easy enough to catch, but as a whole it evades the grasp. This admirable book, for me, still leaves the creature with a chimerical identity. In the first chapter the editors usefully introduce newer historiographical and sociological studies and models that treat innovations as rather more than the light bulb moment. They particularly stress how successful innovations should be studied in the context of their rejected alternatives. Anyone interested in the subject should add it to their bibliography. Following the introduction are seven substantive, accomplished studies that illuminate some aspect of innovation: economic, cognitive, social historical, ethical, even linguistic.

After the introduction the first two essays address Europe and the nineteenth century and the next five deal with the twentieth century and the United States. Four of these latter are studies of single innovations. Delia Gavrus's account of skull and brain membrane surgery for juvenile delinquency 1890–1920 was a revelation. The essay, which would grace a textbook of anthropology, explores a close-knit, self-confirming world of social and neurological theory and surgical practice all revolving around the concept of character. In relation to this volume its key contribution is showing how broad the factors are that enter into the acceptance of new surgical practices. Beth Linker's study of Paul Harrington's straightening of scoliotic spines with implanted rods and hooks in the 1950s and 1960s signposts the importance of patient choice to the adoption of innovation in a medical free market. It would have been interesting to have had a comparative study of innovation in a different economic world. Russians in this period, for instance, were particularly proud of their innovations in cardiovascular surgery. Cardiovascular surgery takes us neatly to the two other specific studies of America. Shelley McKellar looks at the surgical treatment of heart failure. In the 1990s the left ventricular assist device (LVAD) was introduced for a group of patients for whom other therapies were unavailable or inappropriate. The pertinence of McKellar's essay is that LVAD patients were entered into a clinical trial, the REMATCH study, against drug therapy, the results of which were published in 2001. The host of ethical and other issues revealed in this deeply researched article cannot be summarized here. But essentially, in terms of crude survival the results of REMATCH favored LVADs, but in terms of crude economics LVADs had little in their favor. The other single innovation study is David Jones's account of revascularization of the myocardium by coronary artery bypass grafting, CABG. Jones's work, while inevitably if incidentally pointing to economics, draws attention to another aspect of innovation: how a surgical intervention can change a disease model. In the case of coronary artery disease, Jones notes, the "operation re-created the therapeutic niche in its own image" (p. 205). This remark echoes a broad observation made by Owsei Temkin many years ago: "It is by no means true," he wrote, "that treatment is always adapted to the nature of the disease. Treatment can determine how a disease should be considered."¹ Christopher Crenner's essay does not deal with a single innovation but focuses on the idea of the placebo in surgery, which Crenner dates to a sham arterial ligation for angina in 1958. This study along with a tidal wave of others that followed helped deflate claims for many new procedures. Crenner also looks at gastric freezing and sham arthroscopy, the latter giving ammunition to anyone skeptical of medical ethicists since he shows them forcefully lined up on both sides of a debate about whether sham surgery should...