The surgical community continually emphasizes the importance of history. Common justifications focus on the value of knowing whence we came, the advantage of learning from yesterday to prevent errors tomorrow, the benefit of belonging to a continuous professional tradition, the inspiration of recognizing previous accomplishments, and the purpose of infusing humility into our daily practice.1,2 Recently, the field of surgery has demonstrated its commitment to the subject through a variety of initiatives, including the creation of the History and Archives Committee within the American College of Surgeons, an active online community, a surgical history poster competition at the annual Clinical Congress, allocating grants to investigate the subject, and, most recently, establishing this journal, which has emerged as a forum dedicated to its study.
This article explores the engagement of surgery with its past by examining the number and proportion of historical publications in the surgical literature from 1885 to 2018. Percentage of printed articles does not definitively determine the historical enthusiasm of a specialty, a relationship that is impossible to quantify. But the metric does serve as a useful proxy for constituents’ interest (in both submitting and reading articles) and the willingness of leadership, the journal editors, to commit limited resources (journal pages) to the subject’s exposition. Interrogating these trends through time and across categories can provide insight into how attention to surgical history has varied over the last century.
We performed a retrospective statistical analysis of 4 major surgical journals and quantified the number of historical articles published annually compared to the total articles published in each journal, hypothesizing that in recent years the percent of history articles declined. The general surgical journals examined were as follows: Annals of Surgery; Surgery, Gynecology, and Obstetrics (SGO)/The Journal of the American College of Surgeons; The American Journal of Surgery; and The Archives of Surgery/JAMA Surgery. Those titles were chosen as representatives of broad, general surgery journals with long publication records that serve as the official voice for several surgical societies. Surgery would have been another possible journal to include, particularly given the historical interest and writings of its first editor-in-chief and his spouse, Owen and Sarah Wangensteen. It started publishing in 1937—a decade after Am J Surg—and was not analyzed after data from the first 4 journals proved so consistent.
For the 4 journals, each issue was reviewed individually; every article was hand-counted. All publications except SGO were online. SGO was analyzed in hard copy until July 1997, when it too became available digitally. Papers with a historical title were accessed and read to confirm and evaluate their content. The following were excluded: letters to the editor and responses thereto; obituaries; abstracts; book reviews; reprints of old articles; festschrifts; material published in a supplemental issue; anything categorized as “online only”; papers in the “epub ahead of print section”; non-textual content (eg, video-only, audio-only, image only); and other marginalia. Historical articles were categorized as primarily biographical, history of an institution/school/society, history of a specific technique/technology/drug, history of an operation/disease, history of a specialty, or other. Many articles were suitable for multiple groups; we selected the single most appropriate classification. The starting point of our analysis was in 1885 when Annals of Surgery was first published; data were collected through December 2018. Data were entered into Microsoft Excel for analysis.
In all 4 journals, there were 1608 history articles out of 98,874 total articles (1.65%); this percentage ranged annually from 0% to 4.77%. Annals of Surgery included 179 history articles out of 25,908 total or 0.69% (range, 0%–5.83%). In The American J. Surgery, there were 494 history articles out of 28,417 total or 1.74% (range, 0%–7.93%). Within SGO, there were 646 history articles of 24,727 total or 2.61% (range, 0%–9.33%). Reviewing Archives of Surgery, there were 289 history articles of 19,822 total or 1.46% (range, 0%–12.56%). Figure 1 presents the moving average (interval = 3) of the percent of history articles in these 4 journals over the time span; for depictions of individual journals see Fig. 2.
From a categorization perspective, 44% of the articles were biographical; 8% described the history of an institution (eg, Johns Hopkins) or society (eg, American Surgical Association); 7% evaluated the development of an operative technique, technology (eg, x-rays), or drug; 10% addressed the history of a particular operation or disease process; 6% discussed the history of a subspecialty (eg, vascular surgery); and 26% fell into the category of “other” (Fig. 3). Individual journals followed these percentages relatively closely, although Annals had a greater proportion (19%) of articles addressing the history of institutions and societies—primarily the history of the American Surgical Association—and relatively fewer biographies (27%).
Results from hand-counting closely paralleled available data from automated PubMed searches. Journals were reviewed by hand for several reasons. First, PubMed only archives the most recent decades, whereas we sought data from the inception of American surgical journals. Second, hand-counting allowed for more precise discrimination of what was considered historical. Third, tallying by hand permitted the review and classification of articles. Fourth, PubMed categorization reflects a librarians’ judgment and is not a computerized function, leaving the process similarly susceptible to the confounders of human error, and with an adjudicator who is not a trained historian. Nonetheless, we tabulated percentages from PubMed to compare to our findings. Data for these 4 journals exist only from 1946, and over the 1946–2018 span, 1.87% of articles published covered historical topics. In comparison, our hand-counting over these same years revealed a 1.55% rate of historical articles. Although the difference in these percentages is statistically significant (P < 0.0001 by Pearson χ2 test), they are functionally equivalent. Individual journals were comparably similar. Interestingly, hand-counted tallies for both total publications and those dedicated to history were lower than numbers PubMed provided, suggesting that the database captures material (eg, book reviews) our analysis excluded.
The commitment to printing historical articles varied over time and by publication. Anniversary years—particularly for the journal, for the societies that it represented, and also for major advances like anesthesia—brought a spike in historical writings. Some of the periodicals instituted history series, such as “Moments in Surgical History” featured in the Archives of Surgery from 1996 to 2003. These series published one short history piece per issue, often biographical in nature and commonly repeating topics from journal to journal. Usually lasting only a few years, they boosted the percent of history when present.
Before the 1920s, historical articles were sparse but then began to climb precipitously, peaking at 4.78% in 1931 and hovering in that range for several years. Although this zenith represented a substantial relative change, with the average percentage increasing 15-fold, the actual values remained within a narrow band of 0%–5%. We hypothesized that this trend was exclusive to American surgery and performed additional research to evaluate our theory. Surprisingly, only one British journal dedicated to surgery, The British Journal of Surgery (BJS), published continually through these years. Articles in the BJS from its founding in 1915 through 1941 were analyzed as above. There was no peak circa 1920 but rather a steady rate that hovered around 6%, reflecting its practice of featuring a historical piece in almost every issue.
But was this 1920s apex specific to American surgery, or did it demonstrate a broader American sensibility following its victory in World War I?3 The Archives of Internal Medicine (later JAMA Internal Medicine), one of the only national journals specifically focused on internal medicine during these years, was analyzed using the same methodology.4 From 1915 to 1941, it featured a mere 6 major articles on history, without any spike in the 1920s. Of note, the 4 surgery journals averaged 111 history articles apiece in these years (range, 11–221), despite 2 of them not launching until 1920 and 1926. This difference presents an interesting, albeit incomplete, comparison of the perceived value of history in medicine versus surgery.
Lacking internal medicine-specific periodicals for this era, we instead reviewed 2 general medical journals, The Journal of the American Medical Association (JAMA) and The New England Journal of Medicine (NEJM, called The Boston Medical and Surgical Journal for many of these years). Neither JAMA nor NEJM demonstrates any similar increase in history articles around 1920. Taken together, the findings from BJS, Arch Int Med, JAMA, and NEJM suggest that the 1920 increase in historical articles is truly specific to American surgery. This pattern fits the overall trajectory of the profession of surgery in the United States, where the newly ascendant American College of Surgeons was establishing the field as a legitimate specialty, distinct from general practitioners, flush with the success of operations like appendectomies, and eager to rise to the top of the medical hierarchy.5 The emphasis on history grounded such ambitions in a storied past that provided a heritage and foundation for the future.
World War II led to a significant decline in historical titles, nadiring at 0.13% in 1942, the lowest percentage since 1917, another war-year when no historical articles were published. The BJS demonstrated a similar plunge, unsurprising given the attention to war-related topics. Moreover, with doctors either overseas or overwhelmed with work at home, few had time to author material about the past. However, by the late 1940s, historical articles had returned, and multiple histories of medicine in World War II peppered the tables of contents. Percentages climbed gradually until 1999 when they peaked at 4.11%, a value-driven largely by a robust history of medicine series in Archives of Surgery.
Since 1999, the percentage of historical articles has steadily decreased to 0.086% in 2018, which may be attributable to multiple factors. With the near elimination of medical history in medical schools over the last few decades, perhaps fewer people are interested in reading, writing, and publishing history, although recent activities by the American College of Surgeons’ History and Archives Committee undermine this argument. Journals, in an ever-increasing competition toward higher impact factors, are likely omitting historical articles, which garner lower citation counts than traditional scientific or clinical contributions. Furthermore, the proliferation of journals has dispersed historical articles among varied periodicals, extricating them from these 4 core titles and thus lowering the percentages.
We hypothesized that many societal presidential addresses and other named lectures would discuss the past. Overall, 10.7% of all historical articles came in these formats (annual range, 0%–100%). The first presidential address to focus on history appeared in 1909; after decades of it being a rare occurrence, by 1960, they had become a standard and consistent feature in journals (Fig. 4). They frequently reviewed the history of the society over which the author presided, partly contributing to the unexpectedly large number of papers on the history of specialties/societies. Removing presidential addresses and named lectures from the data lowered over all percentages marginally but did not significantly affect the curve.
Anesthesia was the only field found to have conducted a similar study, documenting publication trends of historical articles in 6 core clinical journals between 2001 and 2010.6 Their methodology differed in several notable ways. First, they relied exclusively on the PubMed categorization of articles and performed their search electronically, compared to our hand-counting. Thus, they were unable to classify or further characterize the articles. The 10-year timespan that they analyzed was markedly shorter than the 133 years this study investigated. They also included book reviews, editorials, correspondence, and other brief notes that did not qualify for our study. Only 1.25% of the articles published in their journals were historical (range, 0.41%–2.87%). In comparison, during the same time span, the 4 general surgery journals featured 2.03% historical articles (0.85%–4.04%). The anesthesia paper noted that for major articles in their field (excluding book reviews and the like), there was a significant decrease from 2001 to 2010; this trend was evident for surgical articles as well (Fig. 5).
Although our review did not methodically assess the quality of the articles, they generally reflected less effort and engagement than basic science or clinical research. Few relied on primary sources or achieved a level of excellence expected in an academic journal dedicated to history. Several topics appeared repetitively, with scores of biographical pieces about famous surgeons such as John Hunter, Ephraim McDowell, and William Halsted; seminal events like the introduction of anesthesia also received an overabundance of coverage. Subjects were almost exclusively western, from the 19th and 20th centuries, and predominately focused on the Anglo-American tradition, where language presented less of an obstacle for research. These themes were also most likely to appeal to the readership of an American surgical journal. Interestingly, not all historical articles discussed surgical or even medical matters; for example, some covered the history of the transcontinental railroad and labor rights. Although the vast majority of authors were surgeons, a few were medical librarians or professional historians.
Our methodology led to some limitations in this review. Only published articles were assessed, ignoring unaccepted submissions. This strategy accounts for editorial vetting, thus commenting on the professional valuation of these articles, but it also disregards the historical interest of surgeons who are submitting pieces that are rejected. Second, the time-consuming process of hand-counting limited the number of journals analyzed, forcing us to exclude numerous publications such as Surgery. This omission likely had a greater effect in more recent decades as increasing numbers of subspecialty journals siphoned material—and particularly specialty-specific history—away from the general surgery journals. Third, we tallied the number of articles. This enumeration does not directly correspond with the proportion of journals dedicated to history, as many historical articles were only 1–2 pages in length, whereas medical contributions were significantly longer, with some over 50 pages in the early 20th century. Finally, this project relied on human judgment to discern which articles were historical and their categorization; undoubtedly, this methodology resulted in some errors among the over 100,000 articles processed, but the close correlation with numbers from PubMed affirms the general validity of this strategy.
CONCLUSIONS: HERITAGE AND HISTORY IN THE SURGICAL LITERATURE
This study investigated the number of history articles published in 4 major surgical journals between the years 1885 and 2018. The metric served to evaluate the level of professional enthusiasm for the history of surgery. Following a lengthy lull in the late 19th and early 20th centuries, historical articles increasingly appeared in the 1920s, likely both reflecting and supporting a time of professionalization in American surgery. Since then, their popularity has fluctuated as a result of myriad variables ranging from World Wars to impact factor considerations, but importantly such publications have maintained a regular presence in the literature. Unfortunately, over the last 20 years, their frequency appears to be diminishing, as both the absolute number and the percentage of historical articles in these 4 journals has declined. Possibly, other periodicals are capturing these contributions, but the fact that the anesthesia study observed a similar dwindling of its historical literature exposes a potentially concerning trend. Certainly, journals are not the only venue for publishing history, as the weekly, popular posts on the American College of Surgeons’ History and Archives Committee online community by Don Nakayama and others have amply demonstrated. With over 800 members, this virtual colloquium saw more than 1600 posts in 2019. But official periodicals provide the imprimatur of legitimacy, peer-reviewed accuracy, and archived permanence.
Here, the new Annals of Surgery—Open Access provides a crucial role by dedicating itself to publishing the history of surgery. Led by Keith Lillemoe, current editor-in-chief of both Annals of Surgery and this new spinoff, Annals Open was championed by both authors and Ted Pappas, current chair of the American College of Surgeons’ History and Archives Committee, to create a forum for history, broadly conceived. It will combine formal academic scholarship with more popularly oriented writings to serve and enlighten a wide audience. Although the increasingly common open access format requires authors pay an article processing fee, the editorial team and publisher are entirely separate, guaranteeing strong, independent peer-review that ensures only high-quality original articles will be accepted.
In Tom Clancy’s spy-thriller Patriot Games, protagonist Jack Ryan and his wife Cathy Ryan, MD, visit the Tower of London, where the guards are retired and often decorated members of Britain’s elite military units. After performing a traditional ceremony, a retired sergeant major of the Paras explained to the Ryans:
Tradition is important … for a soldier, tradition is often the reason one carries on when there are so many reasons not to. Its more than just yourself, more than just your mates—but it is not just something for soldiers, is it? It is true—or should be true—of any professional community. “It is” Cathy said, “any good medical school beats that into your head.”7
Although pedagogy has hopefully moved beyond beating, imparting historical traditions remains critical to our profession. It was no accident that the nascent BJS began every issue with a biography of a famous British surgeon, starting with Joseph Lister, attempting to ground itself in the proud tradition of British surgery. Beyond the celebratory aspects, such articles connect us to the roots of our origins. They remind us of our successes and our failures, cautioning against the perilous ease of mumpsimus practice while heralding triumphant discoveries. Heritage reduces the anxiety of uncertainty surrounding the future and shapes expectations of communal behavior.
History is the core of heritage. When Marines sing “From the halls of Montezuma to the shores of Tripoli,” they are reliant on historians having elucidated what exactly occurred in those battles to bring glory to the Corps. Similarly, when surgeons recall the empirical investigations of Ambrose Paré that rejected boiling oil for gunshot wounds or William Halsted’s invention of rubber gloves to protect his future wife’s hands, they are dependent on painstaking scholarship that exposes, analyzes, and documents those discoveries. If heritage is the heartwarming storytelling that entertains and inspires us, then history is the sedulous work undergirding that legacy. Relying on hours spent in dusty archives, interviews of key participants, knowledge of surrounding context, and a thorough grounding in extant literature, historical scholarship not only reports what transpired but also explores the “how” and “why” shaping events. It challenges traditional understandings of the past, advancing new arguments and interpretations. Rigorous history has the power to change practice, reform our thinking, expand our perspectives, and sear new ideas into our consciousness.
Both history and heritage appear to be disappearing from mainstream surgical journals, a trajectory that threatens our professional fabric. The benefit of hindsight and a lens that is decades, if not centuries, long can reveal patterns and themes in practice that are difficult to discern in the moment yet provide valuable lessons for the future. To lose or minimize this prism would be tragic. Annals of Surgery—Open Access promises to keep this vital portal patent as it delivers both heritage and history to our readership to maintain the foundation of who we are as surgeons.
The authors thank Dr. LaMar McGinnis for his support of this project; Dr. Mirza Mujadzic provided early assistance on this project; and Drs. Ted Pappas and Dale Smith graciously read earlier drafts of the manuscript, providing helpful feedback.