Of Life and Limb: Surgical Repair of the Arteries in War and Peace, 1880–1960 by Justin Barr (review)

Justin Barr has written a valuable history of medical innovation. His case study—operations to repair injured arteries—presents a classic puzzle. Innovations by surgeons had "revolutionized the potential for vascular surgery" by 1910 (p. 32). Yet forty years later artery repair remained rare. Surgeons instead continued to amputate limbs or ligate arteries. Barr explains this gap between invention and implementation with analyses that explore the causes of therapeutic change, the relationship between war and medicine, and the meaning of efficacy in surgery.

At first pass, Of Life and Limb offers a narrow explanation. Artery repair was a simple idea, one that required neither new technology nor elaborate infrastructure. Since the decision to amputate, ligate, or repair was an emergency, patients played little role in the decision. All that mattered was surgeons' skill and judgment: "In contrast to histories of many surgical innovations that were profoundly shaped by exterior forces, the story of arterial repair revolves around the operation itself, who could perform it, and under what specific conditions" (p. 4). Training was crucial. Barr credits the American Board of Surgery and the American College of Surgeons for increasing the rigor and availability of surgical residencies in the 1930s and 1940s. The average surgeon who worked in MASH units in Korea was more skilled than those in prior wars, and they were able to implement artery repair on a large scale for the first time. When these combat surgeons returned to civilian life, with data that showed the value of artery repair, they transformed vascular surgery. While this might seem like an old-fashioned, internalist argument, Barr executes it convincingly. It is notable that this argument about the primacy of surgical training is made by an author in the midst of his own surgical residency.

However, it quickly becomes clear that Barr's arguments reach much farther. He considers "vectors of stasis and change ranging from the broadest social and cultural factors to the most specific technical details" (p. 157). Barr, for instance, acknowledges that war provides a crucible for surgical innovation: "This human carnage and its dehumanizing conditions also instilled an attitude of experimentalism and risk tolerance among some doctors" (p. 7). But only certain kinds of warfare: when combat is dynamic, with field hospitals racing to keep up with advancing and retreating battalions as casualties flood in, surgeons can do little more than triage and amputate. Only when battle lines stabilize, casualties slow, and armies erect more elaborate hospitals can surgeons work more deliberately. This is what happened in the final months of World War II in Europe (but not in the Pacific), and again during the final phase of the Korean War (1951–53). It was there that residency-trained surgeons finally succeeded with artery repair.

Many subtler issues contributed. The manure-laden fields of French farms fueled wound infections during World War I; surgeons had little choice but to amputate (p. 42). Antibiotics largely solved this problem in Korea (p. 111). Surgical researchers took advantage of the "governmental penchant for documentation" that produced detailed medical records (p. 7). They benefitted from the professionalization of anesthesiology in the 1930s (p. 92). When surgeons returned to civilian life, the burden of disease had shifted: the rising tide of atherosclerotic vascular disease, urban violence, and motor vehicle trauma created growing demand for vascular surgery. These "contextual changes all occurred outside the operating room but nonetheless proved crucial to the eventual adoption of arterial repair by creating a fertile milieu" (p. 92). One last argument emerges in the conclusion. Surgical innovation is not just about improving efficacy: amputation, after all, offers decisive management of hemorrhaging arteries. Instead, innovation is driven by a desire to develop "less morbid operations" that are better tolerated by patients (p. 159).

Barr also highlights crucial mistakes. When Michael DeBakey and Fiorendo...