The surgeon Johann Friedrich Dieffenbach is often referred to as one of the most innovative characters in the development of German surgery during the early nineteenth century, particularly in the area of plastic surgery. But for a figure that has become almost emblematic of surgical innovation, Dieffenbach's case also challenges two common assumptions about innovation in surgery. One is that innovation in surgery during the nineteenth century was largely the product of technological change, particularly the introduction of anesthetic and aseptic techniques. The other, that a vital factor in the success of surgical innovations is the degree to which they can be reproduced and diffused. As for the first, Dieffenbach's work is located in the early part of the nineteenth century, rendering explanations of the growth of surgery based solely on technological determinism problematic, and opening up new questions about the driving forces behind innovation in surgery. With regard to the second, Dieffenbach's brand of innovation was formulated in a way that made it essentially inimitable. Dieffenbach's writings therefore provide an opportunity to reexamine these assumptions and offer alternative explanations.

The flourishing of plastic surgery in the early nineteenth century is a particular puzzle. Why would a technique dedicated to non-life-threatening conditions gain such momentum in the pre-anesthesia world? Many histories of plastic surgery avoid this question altogether and merely chart the diffusion of plastic surgical techniques, from the moment of the “rediscovery” of a technique for reconstructing the nose developed in India in the late eighteenth century, to the uptake of this and similar techniques by a number of surgeons in the German states and other countries in the early decades of the nineteenth century. More analytically oriented works have vaguely relied on a certain spirit of the age for answers. “Innovation was in the air,” writes Roy Porter about the introduction of a number of new plastic surgical techniques by the German surgeon Johann Friedrich Dieffenbach. Other authors have expressed surprise that plastic surgery boomed in spite of, not because of, the Zeitgeist. “The German enthusiasm for plastic surgery was a puzzling development,” observes David Hamilton, “because German-speaking thinkers were the origin of Naturphilosophie and the Romantic movement, whose antiscience stance rejected the scholarly achievements of Enlightenment thinking and substituted a free-floating theorizing and philosophical stance. Somehow,” he concludes, “plastic surgery, a fundamentally mechanistic human endeavor without the slightest hint of the mystical, flourished.”

Heart failure is a progressive, life-threatening condition that affects an estimated twenty-six million people worldwide, including 5.8 million Americans. For the patient in heart failure, their heart is simply not pumping blood as it should, and most die within five years after diagnosis owing to complications arising from poor or inadequate blood flow (such as organ failure) or from contracting infections in their weakened condition (such as pneumonia). The problem may be a case of left-sided heart failure (most common), right-sided heart failure, or both. The heartfailure patient may feel extreme fatigue, a shortness of breath, and possibly an increased heart rate, which will make everyday activities like walking and climbing stairs increasingly difficult. As the condition worsens, the patient experiences a buildup of fluid in the feet, ankles, and legs (edema), a congestion of blood in the lungs, perhaps memory problems, and even impaired thinking. There is no cure for heart failure. As one physician commented, “Heart failure is a lethal disease with a worse life expectancy than many types of cancer.”

In the United States, heart failure is among the most costly cardiovascular disorders owing to its intensive use of medical resources, including lengthy hospital stays and expensive medications. The number of new cases of heart failure increases with patient age, and with the rising number of elderly people in the United States, a greater proportion of the American population suffers from heart failure each decade. In 2013, the direct and indirect costs of caring for the heart-failure patient in the United States, including hospitalization and medications, is about $31 billion, and this number is expected to more than double by 2030. More people are surviving heart attacks and other cardiac conditions, perhaps because of more successful therapies or better education about heart disease. This means that people are living longer with damaged hearts and thus carry the risk of heart failure. To be clear, mortality rates from coronary heart disease have been declining since the 1960s yet it still remains the leading cause of death in many developed countries.

In November 1960, Time magazine ran a splashy medical news report with the rather futuristic title “Spines of Steel.” The article featured the work of the orthopedic surgeon Paul H. Harrington (1911–80), who had devised a method of straightening scoliotic spines using a series of implantable metal rods and hooks embedded in the vertebral column. So as to visualize the sleekness of Harrington's instrumentation, Time included a black-and-white photograph of the physically imposing surgeon, his large hands gracefully clutching one of his metal rods, slender as a soda straw. Although Harrington did not have a definitive cure—or a method to prevent the occurrence of spinal curvatures caused by scoliosis—his rods promised a new era in scoliosis treatment, with traditional and seemingly more cumbersome modes of medical intervention left behind (figs. 5.1–5.2).

To many surgeons today, Harrington's innovation is seen as a pivotal moment in the surgical management of severe scoliosis. From the 1960s onward, Harrington's instrumentation would become the standard method of scoliosis correction and fusion throughout the world for more than a quarter of the century. In the words of two orthopedic surgeons writing in 1999, Harrington's “instrumentation was a clear milestone in scoliosis surgery providing for the first time, a reliable means of obtaining and maintaining maximal deformity correction.” The advantages of Harrington's system, they write, “were obvious.”

Whereas the success of Harrington's surgery may seem obvious to orthopedists practicing now, the advantage of metal implantation was not at all clear to his contemporaries. In the mid-twentieth century, leading practitioners in the field endorsed various forms of scoliosis treatment. According to a 1941 study of sixteen US orthopedic clinics in prominent university research centers, postural exercise was one of the most commonly prescribed modalities of treatment, even though many orthopedists doubted its efficacy. Other popular forms of treatment included body casts, bone fusions, or a combination of the two. Of the sixteen clinics surveyed, thirteen used the Risser turnbuckle cast, named after the inventor-orthopedist Joseph C. Risser (1892–1982).

Speaking at a conference in Houston in 1985, the surgeon René Favaloro described 1968 as “the year of revolution.” He was not referring to the assassinations of Martin Luther King Jr. or Robert Kennedy or the protests against the Vietnam War. Instead, his revolution was the development of coronary artery bypass grafting (CABG) to treat coronary artery disease (CAD). For that operation, 1968 was indeed transformative. In April Favaloro published the results from his first fifty-five patients. By the summer of 1970 he and his colleagues at the Cleveland Clinic had performed CABG on over one thousand patients. Their success was matched by surgical teams in Milwaukee and New York City. Surgeons throughout the country took note. By 1977, surgeons in the United States completed over one hundred thousand CABG operations each year.

The CABG “revolution” provides an important case study of surgical innovation. Over a single decade the procedure emerged from obscurity to become one of the most common major surgical procedures. Many aspects of the innovation are interesting. First, its rise was not the result of a new discovery: Alexis Carrel had first attempted to place a bypass graft between the aorta and a coronary artery in 1910. Second, it was not the result of a lone genius, or the group at the Cleveland Clinic. Instead, researchers worldwide had tried to make Carrel's technique a success for decades, conducting extensive animal research and occasional human trials in the 1950s and 1960s. They had also developed dozens of other surgical techniques to treat CAD. Third, it was not the result of a landmark clinical trial, of the sort described by Shelley McKellar in this volume. In fact, Favaloro later downplayed the magnitude of the innovation, describing it in 1998 as a simple progression through a series of related procedures: “The evolution took place in just a few months from patch graft to interposition graft to bypass graft.”

At the turn of the twentieth century, an operation purporting to relieve “pressure on the brain” flourished at the unlikely intersection between a newly interventionist branch of surgery and a Progressive Era jurisprudence that was undergoing its own radical transformation. From the 1890s to the 1920s, hundreds of men, women, and children all over the United States were subjected to brain surgery as a means of “curing” “criminal tendencies” that were ascribed to injury-induced temporary changes in the brain. The surgeons were appropriating a new surgical procedure called “decompression,” itself based on older craniotomy techniques, which had recently been developed to alleviate acute intracranial pressure from brain tumors or life-threatening trauma, but was rapidly being applied to an array of other conditions. In a radically different context, the same procedure was reinvented as a “cure” for the misbehavior of children who appeared before juvenile court. To relieve the alleged pressure and remake the social identity of the “delinquent” child, the surgeons permanently removed buttons of bone, or cut long furrows into their patients’ skulls, or resected parts of the membranes that cover the brain. Thus they claimed they could instantly alter, with their scalpels and trephines, the complicated socially contingent human behaviors that society deemed problematic. Both the surgical practice itself and the rhetoric that sustained it draw attention to an unexplored continuity in the history of psychosurgery and demonstrate that lobotomy developed in the 1930s in a context in which the American public had already been exposed for decades to the idea of altering human behavior, thought, and emotion by surgical intervention.

For the surgeons of the Progressive Era, asserting expertise and claiming social relevance in questions of “delinquency” became a means of acquiring cultural and economic capital at a moment when science was conceived as a privileged tool for social and judicial renewal. These were often civically minded surgeons who were interested in Progressive reform, were part of the local elite, and had the eager attention of the Progressive judges they advised. Although Juvenile judges made their recommendation under the guise of parental consent, in making surgery a part of jurisprudence they created a coercive legal environment that mandated the medicalization of children's behavior and its aggressive and dangerous “treatment.”

Surgery over the last two hundred years has gone through enormous technological transformations and continues to be a hotbed of technical innovation, as recent developments in transplantation, osteosynthesis, minimally invasive surgery, artificial organs, and implanted assistive devices testify. Surgery is thus an ideal field for examining the processes of technological change in medicine. It is also a field that has some specific and distinct features, which makes it particularly interesting for investigating technological change: Within medicine, surgery is most closely associated with bodily practices. Surgery is performed on the living body of the patient, which becomes the material of the surgeon's craft. It is further linked to the manual skills and the immediate physical presence of the surgeon. All of this makes it a practice with high and highly visible stakes for all involved, especially in the implementation of new technologies.

Surgery itself can be described as a technology. Under the comprehensive definition proposed by scholars in science and technology studies, the word “technology” has three layers of meaning. First, there is the physical level. In surgery, this involves the instruments, the operating room, and so on. Second, technology can be seen as an activity, as a means to accomplish a specific goal. This refers to what the surgeon does in the operative procedure. Finally, technology is what people know: having instruments and starting to use them on bodies was not enough for successful surgery; surgeons also had to know how to apply the tools and the techniques within their sphere of activity. A surgical technology cannot be spread without the relevant knowledge, know-how, and practical skills. In surgery, the provider-user relationship is also unusually complex. The primary user of surgical technology is the surgeon, but the surgeon applies the technology to another participant in the setting, a patient, who thus becomes in a way the end-user of surgical technology and, in certain instances, an active participant in the employment of new tools and techniques.