Journal of Investigative Surgery, 25, 415–418, 2012Copyright C© 2012 Informa Healthcare USA, Inc.ISSN: 0894-1939 print / 1521-0553 onlineDOI: 10.3109/08941939.2012.740389

BOOK REVIEW

Surgical Revolutions. A Historical and PhilosophicalView, by Luis H. Toledo-Pereyra, Singapore: WorldScientific Publishing Co. Pte. Ltd (Copyright 2011).Paperback. 194, pp., illus. 17, ISBN- 13 978-981-4329-62-0, ISBN-10 981-4329-62-2.

The book is divided into two sections. Section I is en-titled “Surgical Revolutions” and contains 11 chapters,Section II is entitled “History of Surgery and Medical Hu-manities” and comprises 9 chapters.

Luis H. Toledo-Pereyra, MD, PhD, is the author of18 chapters; whereas chapter 13 is authored by RobertM. Langer, MD, PhD, Surgeon at the Departmentof Surgery and Transplantation at the UniversitySemmelweis in Budapest, Hungary; and chapter14 is authored by Roberto Anaya-Prado, MD, PhD,Eduardo D. Aceves-Velazquez, MD, PhD, and SaraP. Carrillo-Cuenca, MD, from the Departments ofResearch and Education of the Western Medical Cen-ter of the Mexican Social Security Institute (IMSS) inGuadalajara, Jalisco, Mexico.

The word revolution denotes a total and radicalchange implied in a transformation; the surgical revo-lutions addressed in the book are precisely that and asthe author says “emanated mostly from non-surgicallyrelated events that were critically needed to advancethe science and better practice of surgery.”

In the chapter 1, the author poses and responds a se-ries of questions regarding surgical revolutions: Whatis a surgical revolution? How do we recognize a surgi-cal revolution? Are surgical revolutions different? Arethere different kinds of surgical revolutions? He revealsthe answers to these questions in the course of the text.

The chapter 2 entitled “De Humani Corporis Fabrica,”which is also the title of the book published in 1543 byAndreas Vesalius (Belgian) (1514–1546), describes thispublication as the first surgical revolution, and initi-ates the magnificent journey into which Toledo-Pereyrawill immerse the reader. The journey across five cen-turies and supported by extensive bibliographic docu-mentation (221 references) will eventually conclude inthe 20th century. De Humani Corporis Fabrica revolu-tionized the anatomical conception of the time and in-troduced a precise knowledge of the structure of thehuman body.

The next chapter is dedicated to William Harvey(English physician) (1578–1657) whose work “Excerci-tatio Anatomica de Motus Cordis et Sanguinis inAnimalibus” (1628) must be considered, in Toledo-Pereyra’s opinion, as a surgical revolution. In an ex-tremely synthesized statement of the work presentedin this book, Harvey’s work proved that blood flowsin a circular fashion and “established new paradigmsin the means and purpose of anatomy and physiology,revolutionizing experimental medicine to propel, centurieslater, cardiac, vascular, and transplant surgery.”

In chapters 4 and 5 the reader is surprisingly grati-fied by the author’s keen observation, reasoning, anddeductive powers and vision as he addresses two sci-entific phenomena described as major surgical revolu-tions. A distracted reader may overlook these events orfail to recognize the relationship they bear to surgery,but the author manages to prove his point in reviewingthese events. We are faced with the surgical revolutionfathered by Antony van Leeuwenhoek (1632–1723) ashe recorded a series of observations under the micro-scope of what he termed “The Strange Little Animals”and eventually led the “surgeons of the future,” as statedby Toledo-Pereyra to “identify postsurgical infections, rec-ognize surgical pathology entities and advance in the treat-ment of many surgically amenable diseases.”

Van Leeuwenhoek, who was neither a physician nora scientist, was led by his mystic work ethics and acutecapacity of observation to a significant contribution tothe advancement of microscopy and surgery.

The next chapter, entitled “Anesthesia SurgicalRevolution,” is one of the most extensive chapterscontaining 14 pages. In it, the author displays mag-nificent skills of inquiry, gathering data, dates, places,facts, and suppositions in the tradition of the bestdetective work to demonstrate that the introductionof the anesthetic procedure to the surgical act was amajor contribution of American Medicine during the20th century. Following the veins of history, the authorexplores how four different scientists, in different partsof the United States of America, were engaged in an ap-parent race to become the “forefathers of anesthesia”:Crawford Long (1815–1878), in Danielville, Georgia;Horace Wells (1815–1848), a dentist in Hartford, Ver-mont; William Thomas Green Morton (1819–1868),

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416 Book Review

another dentist in Charleston and Boston, Mas-sachusetts; and Charles Jackson (1805–1880) in Ply-mouth, Massachusetts. Ultimately, all four scientistsare recognized as authors of this surgical revolution.

Chapters 6 and 7 are dedicated to describe the sig-nificant impact on medicine accomplished by the in-troduction of systematic experimentation. This revolu-tion is owed to the French physician Claude Bernard(1813–1878) and the publication of his book “Intro-duction A L’ Etude de la Medicine Experimentale” inFrance in 1865. This noted physician “was an excellentexperimentalist and superb researcher who did not have allanswers . . . . but had a firm desire to resolve all vexing andcritical areas on the medicine of his days.” Bernard dividedthe experimental method in three phases: Observation,hypothesis, and experimentation. The renowned Ger-man surgeon Theodor Kocher (1841–1917), who wasBernard’s pupil, was responsible for promoting the lat-ter’s influence on modern American surgery. Kocher’spupils, William Halsted and Owen Wangesteen, inturn, developed surgical experimentation in the UnitedStates. Most American Universities instituted laborato-ries destined specifically to experimental surgery andToledo-Pereyra himself began his experimental activ-ity in 1972 in a surgical research laboratory at the Uni-versity of Minnesota, led by Professor John S. Najar-ian. The author confesses being an enthusiast reader ofBernard’s book, which he had first read and studied in1962, during his second year of medical training a theNational University of Mexico, under the tutelage ofhis physiology professor, Carlos Alcocer.

As exposed in Chapter 8, in March 1867, JosephLister (1827–1912) announced a new method to treatinfected wounds in bones and soft tissue “as heidentified the direct relationship between microorganismsand surgical infections.” In addition, by introducingantisepsis, he saved patients from a predictable death.The antiseptic method proposed by Lister entailed asurgical revolution that propelled significant advancesin the control of surgical infections and has given thesurgeon the possibility of performing his work in themost confident, calm, and safe manner.

In the next chapter (9), the author discusses the ori-gins and claims to fatherhood of scientific surgery, con-fronting the work of two great surgeons in the historyof medicine: John Hunter and Lister. He concludes that,though these surgeons evidently lived in different cen-turies, in his opinion, Lister should be considered as thefather of scientific surgery.

In chapter 10, Toledo-Pereyra surprises the readeragain as he introduces the discovery of X-rays by Wil-helm Conrad Roentgen (1845–1923) in 1895 as a majorsurgical revolution. As in Leeuwenhoek’s case, in 1674,Roentgen was neither a surgeon nor a physician; he hadgraduated as a mechanical engineer from the Polytech-nic at Zurich in Switzerland and, unknowingly to himand paraphrasing Toledo-Pereyra, “he unfolded a newimagenology field with substantial medical implications on

human anatomy and diagnostics as well a noticeable utilityin the surgical field.”

As time went on, there were other significant ad-vances in the area of radio diagnosis: computed tomog-raphy, ultrasonography, magnetic resonance imaging,etc.

The use of these procedures had a significant impacton orthopedic, cardiovascular, gastroenterological, andneurological surgery, giving rise to a further surgicalrevolution.

In the second half of the book, the authors Toledo-Pereyra, Robert M. Langer, Roberto Anaya Prado,Eduardo D. Aceves Velazquez, and Sara P. CarrilloCuenca develop themes, which are, to a certain de-gree, consequence of the notable surgical revolutionsdetailed in the first section. The title of this sectionis History of Surgery and Medical Humanities and ismerited for two reasons: it describes historical facts rel-evant to North American surgery in the 19th and 20thcenturies with worldwide repercussions, and exposesthe philosophical thinking of Toledo-Pereyra as relatedto science and surgical research.

Thus, chapter 12, entitled “Surgical Research,” de-scribes the influence exerted on surgery in the UnitedStates by the works of William Beaumont (1785–1853),who is named as the first Scientific Surgeon for his stud-ies in gastric physiology; Samuel D. Gross (1805–1884),considered as the father of Surgical Experimentationin Basic Sciences; and William Halsted (1852–1922),who should be recognized as the Modern Surgical Re-searcher.

In a turn of 360 degrees, the book escorts the readerinto further amazement as it explores the lives oftwo extraordinary men and surgeons of Hungarianorigin. In the words of Dr. Robert M. Langer, himself aHungarian author, we learn about the work of ArpadGerster (1848–1923) and Max Thorek (1880–1960)(chapter 13).

Arpard Gerster, a general surgeon, had performedsurgical procedures in trauma, brain, neck, and ab-domen, and arrived in the U.S. in 1874 at the age of 26,by recommendation of Theodor Billroth. He was oneof the founders of the American Surgical Associationand its President from 1911 to 1912. One of his greatestcontributions was the notion of surgical disseminationof cancer (On the surgical dissemination of cancer. NYMed J. 1885; 41:233-6).

Max Thorek was also born in Hungary and, like Ger-ster, became a United States citizen. His family em-igrated in 1897 from Hungary to Chicago, where hefinished his medical degree in 1904. He was an ex-traordinary surgeon and clinical professor at the Uni-versity of Illinois from 1906 to 1998. In 1911, togetherwith Solomon Greenspahn, he founded the AmericanHospital, which mainly served the immigrant and low-resource population and whose mission was to “be ahospital with a unique humanitarian approach in which ev-ery patient is regarded as a person rather than a case.” He

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G. L. Lopez 417

also founded the International College of Surgeons inGeneva in 1935.

The next three chapters abridge the epic of mankindand modern surgery (20th century) as the history ofcardiac transplantation is detailed.

Chapter 14 entitled “Michael E. DeBakey: Re-former of Cardiovascular Surgery” is authored byAnaya-Prado, Aceves-Velazquez, Carrillo Cuenca, andToledo-Pereyra. The chapter describes the story be-hind this man, a colossus of North American surgeryin the 20th century, portraying his personal life, hisLebanese origins, his participation in the preservation,safeguarding, and organization of the National Libraryof Medicine in Bethesda, Maryland, his active partici-pation in the organization of the famous Mobile ArmySurgical Hospital (M.A.S.H.) during World War II andthe creation of Veteran’s Hospitals associated to Med-ical Schools. At the end of the war he preferred to ac-cept the position as Head of the Department of Surgeryat Baylor College of Medicine in Houston, Texas. Hisundisputed contributions to cardiovascular surgerywere the introduction of the Dacron graft for largeblood vessels and the so-called artificial heart or “leftventricular assist device.” He had a long life (100 years),and in his early nineties he still practiced surgery.

In chapter 15, Luis Horacio Toledo-Pereyra recountsthe story of Christiaan Neethling Barnard (1922–2002),in the best literary prose tradition, portraying him asa man, a scientist, an educator, a surgeon, a researcher,and an innovator. He goes on to reveal his family andmarital life and even some aspects of his life as a busi-nessman. It is noteworthy that he studied medicineat the University of Cape Town in South Africa at theheight of the governmental policy generically termedApartheid. He completed his internship and residencyat the Groote Schuur Hospital. In 1956, he received ascholarship to study cardiac surgery at the Universityof Minneapolis, in Minnesota under the tutelage ofDr. Owen Wangensteen and direct orders from Dr.C. Walton Lillehei. He returned to his hospital inCape Town and established a team of cardiovascularsurgery, in possession of an extracorporeal circulationpump, donated by his American mentors and, prob-ably, envisioning or dreaming of performing a cardiactransplantation.

The subsequent chapter, 16, continues the descrip-tion of the amazing human adventure in the field oftransplants, primarily cardiac transplants. The intro-ductory dedication of the chapter is especially moving:

Dedicated to the courage and determination ofLouis Washkansky and the Darvall family as well asto the innovative spirit and determination of Christi-aan Barnard and his team.

In the chapter “Heart Transplantation,” the authorstates “transplants pertain to a field that resembles sci-ence fiction, enclosing an unlikely dream that seems dif-ficult to envision in our lives,” as he embarks in a vi-

brant description of the long path from ancient timesto the venturous 20th century, culminating on Decem-ber 3rd 1967, on which the knowledge of the organ, itsfunctions, and myths were unraveled. The author un-derlines the important role of the lessons learned byBernard at the universities and cardiovascular surgicalclinics of the United States, specifically in Minnesota,Virginia, and Denver. He also recognizes the pleiad ofNorth American Surgeons who so generously trans-mitted their experience and knowledge to Barnard, in-cluding Wangensteen, Lillehei, David Hume, RichardLower, Shumway, and Thomas Starzl.

In the final four chapters (from 17 to 20) the au-thor displays his thoughts on art, humanism, and phi-losophy. Chapter 17 “Art, Surgery and Transplanta-tion” discusses and stresses the close relationship ofthese disciplines. The author describes how his viewof the arts and their immediate relation to surgery andtransplants was greatly influenced by another surgeonand artist, Roy Calne (born 1942) and his book “Art,Surgery and Transplantation.”

Chapter 18, “Believing in yourself,” summarizesthe authors ideas on philosophical precepts that aidthe surgeon in his intense personal and professionallife. He emphasizes that believing in oneself meansaccepting the good and the bad, or incomplete; andthus make one a better human being and an excellentsurgeon. But, How does one achieve the conviction tobelieve in oneself?

1. Knowing the theoretical aspects of the medical problem oneencounters2. Establishing strategies for the surgical procedure before-hand and designing the steps to follow to avoid complications3. Knowing the possible complications of the surgical proce-dure and how to resolve them4. Never hurrying during surgery5. Following one’s patient closely

Chapter 19 examines the figure of the “mentor”whom he defines as “someone who has a specialinterest in helping another person (the disciple) andcontributes to his successful development.” Accordingto Toledo-Pereyra’s perspective a mentor is not only aprofessor, as the mentor-pupil relationship involves aseries of responsibilities and total commitment that goboth ways. The mentor’s disposition should includetime, making a true commitment, having and givingconfidence, determination, and patience. The mentorshould also succeed in giving the pupil independence.

The book finishes (chapter 20) with a philosophicaldisquisition on what the author considers a gentlemansurgeon, a surgeon who is dedicated full time to theart and science of surgery, drives the discipline inthe appropriate direction, and can care for, help, andrespect others.

C© 2012 Informa Healthcare USA, Inc.

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Luis Horacio Toledo-Pereyra was born in Nogales,Arizona, but has strong family roots in Mexico,and lived during his infancy and adolescence inHuatabampo, Sonora. His book is a workmanshipthat reveals the surgeon- writer-historian-scientist-researcher-humanist at the height of his creative

power, with thorough command of the discipline hecultivates and, of course, a true “Gentleman Surgeon.”

Guillermo Leon LopezAsociacion Mexicana de Cirugıa General

Mexico D.F., Mexico

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