In 1954 the British public flocked to cinemas to see Doctor in the House, an adaptation of the popular novel of the same name authored by doctor-turned writer Richard Gordon. Ostensibly following the travails of young medical student Simon Sparrow, the undeniable star of the film is the towering figure of Sir Lancelot Spratt, the swaggering, bombastic chief surgeon, whose fearsome demeanor toward patients and students alike strikes terror across the hospital.
The huge success at the box office of Doctor in House is of little surprise when one considers the appeal—both then and now—of looking “behind the curtain into an otherwise closed and restricted world” (242). Enveloped within the confines of the operating theater, where patients are usually in a state of blissful anesthetic sleep, surgery can feel like a distant realm to us mere mortals. As Agnes Arnold-Forster makes a strong case for in Cold, Hard Steel: The Myth of the Modern Surgeon, the figure of the surgeon is steeped in mythology. Their experiences and their cultural representation cannot be separated, each informing one other.
Indeed, it is important to note that it is the surgeon, rather than surgery that Arnold-Forster has under scrutiny here. As she sets out in chapter 1, surgeons have form in creating their own mythology. History has proved a flexible tool for multiple generations of surgeons, keen to perpetuate the idea that their own era has progressed from the former. For surgery, perhaps more than other medical disciplines, history has assumed central importance to their identity, tainted as it is with long-held stereotypes about their thirst for large and bloody operations, and a seeming lack of compassion for the patients they encounter on the operating table. These stereotypes of course belie a much more complex relationship between surgery and feeling; surgeons have in fact long spoken openly about the emotional ramifications of their challenging work.
Arnold-Forster's intervention to this literature is twofold: first, she expands the spectrum of emotions that come under historical scrutiny. As she puts it, “I thought I was going to be investigating the past and present of compassion, sympathy, anxiety, doubt and grief” (12). Instead, the author's oral history interviews with surgeons both retired and in practice reveal a preoccupation with a less studied, emotional landscape “of professional identity, problematic colleagues and paperwork” (12). Arnold-Forster's deft investigation into these everyday emotional experiences of surgeons leads to a second critical intervention—a robust contextualization of postwar British surgery and the effect of changing political and organizational structures upon surgical identity. Merging sociological and historical approaches, Arnold-Forster finds a culture of surgery that has fostered exclusion; where tropes of masculinity, militarism, and elitism have helped surgery retain its powerful status while preventing many from finding a place in the profession. The statistics on the contemporary surgical workforce make for depressing reading. Just thirteen percent of surgical consultants are women, while statistics about the ethnic make-up of the surgical workforce are not even known. As Arnold-Forster argues, this suggests “that the racial and ethnic diversity of the surgical workforce has never been a top priority for the profession's leadership” (149). For both women and racially minoritized people, informal old boys networks, lack of mentorship from senior staff, and discriminatory patients have caused real damage to the profession's ability to form a demographic that reflects the patient populace.
This leads to the penultimate and perhaps most fascinating chapter of the book that delves into the concept of surgical time. Working hours are curiously under-researched in the history of medicine, but, as Arnold-Forster contends, they have been a critical aspect to surgical identity. The ideal of a selfless surgeon who could be called upon at all hours to operate was a stereotype long maintained, and to an extent, encouraged by the surgical profession, bathing in the cultural capital that the vocational ideal of surgery brought. But by the latter decades of the century the excessive working hours of surgeons were under question. The implementation of the European Working Time Directive in 1998 slowly phased in a forty-eight-hour limit on doctors’ working week and signaled the slow decline of a normative culture of days-long shifts among junior surgeons. The surgical firm—a tight-knit unit of clinicians, led by one or two permanent members of medical staff—to which junior doctors would temporarily be attached began to disappear. The cut in working hours as well as the shift away from onsite accommodation gave surgeons greater freedom in their personal lives. However, from the perspective of some of Arnold-Forster's interviewees it has also led to a lack of continuity in patient care.
This is an exhaustive and elegantly penned account of postwar surgery. It does have its minor issues. For example, the media controversies over heart transplants in the 1960s feel like a curious omission from the chapter on surgery and films, fiction, and TV. As historians such as Ayesha Nathoo and Kelly Loughlin have shown, the introduction of heart transplants had a huge influence on popular understandings of surgeons in Britain, and it would have been interesting to see more on the porous boundaries between fictional and non-fictional media accounts of surgery. I was also left pondering, at times, how vast the differences in surgeons’ and physicians’ experiences really were and in what ways their postwar histories have in fact reflected one another's. Nonetheless, this is a welcome and significant contribution to both the history of surgery and the history of the National Health Service, which will undoubtedly be of interest to a wide audience.
