The Evolution of Surgical Instruments: An Illustrated History from Ancient Times to the Twentieth Century (review)

There has not been a comprehensive history in English of surgical instruments until now—and perhaps there still has not, for this valuable book might be better described as a historical encyclopedia (or perhaps even a natural history in the eighteenth-century sense) of surgical instruments. John Kirkup has eschewed the temptation of the obvious: this is not a volume devoted to surgical operations that incidentally treats of instruments. Rather, almost completely faithful to the subject, he has built his novel study mainly on two foundations: "Materials," and "Structure and Form." A final section, "Applied Instrumentation," could alternatively be called "Examples of Use." A first section, "Historical Introduction and Origins," contains a most useful chapter on sources for the investigation of instruments, surveying historical studies, surgical works, instrument makers' and museum catalogues, and more. Chapter 4, written as an objective account, is more contentious and develops a heavily naturalistic basis—the use of body parts—for the creation and form of surgical instruments. This approach presumably explains the (arguably) rather unfortunate Evolution in the title of the whole work. Nonetheless, here, as everywhere else in the book, Kirkup employs an impressive range of evidence from Western and non-Western cultures to make his case.

It is in the middle two sections that Kirkup really hits his stride and displays an unrivaled (so far as I know) knowledge of the composition and types of surgical instruments. Chapter 6, misleadingly titled "Organic Materials," works through animal products (e.g., bristle) and plant matter (e.g., thorns) to stones and minerals. In each case, Kirkup draws on the historical evidence to give examples of the use of these materials; his range encompasses archaeological findings and surgical writings from Paul of Aegina to the twentieth century. Chapter 7 continues in the same vein and concentrates on nonferrous metals. Chapter 8 follows suit with ferrous metals, and chapter 9 winds up with "Gum, Rubber and Plastics." In the section on "Structure and Form," ten chapters survey types of instruments from probes to retractors, with a score of devices in between; again, Kirkup richly illustrates his text with rare and well-known examples from the historical literature. These two sections will, no doubt, be improved by future additions, but it is hard to imagine any work supplanting them in their entirety.

Any criticisms of this volume are vastly overshadowed by its immense worth. There are meta-arguments that could be had with the book. It is striking, for example, how many of the 548 illustrations are from texts and not pictures of extant historical instruments. Similarly, the patient's body is treated as a given, not as something whose anatomical structure is recurrently made, by instruments, in operative practice, in the surgeon's mind's eye. There is thankfully a very large index, although surely it would have been better to have had one for instruments and another for people, institutions, and other topics. There is a large bibliography, but with more than its share of irritating errors (Kenneth Dewhirst [sic] for example). Illustrations are sometimes used uncritically: fig. 116 looks to me more like an eighteenth-century pornographic print than a "Mid-nineteenth century pewter enema apparatus for self administration." Finally, I was alarmed to discover that a putative, male subliminal fear had a basis in surgical reality: "Two-handed retraction, such as that used when distending the vagina or holding the mouth open, entails drawbacks of visual inefficiency and risks injury to the fingers by teeth" (p. 45).