Surgery

From Wikipedia, the free encyclopedia

Surgeons repairing a ruptured Achilles tendon on a man

 

Surgery is a medical specialty that uses operative manual and instrumental techniques on a patient to investigate or treat a pathological condition such as a disease or injury, to help improve bodily function or appearance or to repair unwanted ruptured areas. 

The act of performing surgery may be called a "surgical procedure", "operation", or simply "surgery". In this context, the verb "operate" means to perform surgery. The adjective "surgical" means pertaining to surgery; e.g. surgical instruments or surgical nurse. The patient or subject on which the surgery is performed can be a person or an animal. A surgeon is a person who practices surgery and a surgeon's assistant is a person who practices surgical assistance. A surgical team is made up of surgeon, surgeon's assistant, anaesthesia provider, circulating nurse and surgical technologist. Surgery usually spans minutes to hours, but it is typically not an ongoing or periodic type of treatment. The term "surgery" can also refer to the place where surgery is performed, or, in British English, simply the office of a physician, dentist, or veterinarian.

Definitions

Surgery is a technology consisting of a physical intervention on tissues. 

As a general rule, a procedure is considered surgical when it involves cutting of a patient's tissues or closure of a previously sustained wound. Other procedures that do not necessarily fall under this rubric, such as angioplasty or endoscopy, may be considered surgery if they involve "common" surgical procedure or settings, such as use of a sterile environment, anesthesia, antiseptic conditions, typical surgical instruments, and suturing or stapling. All forms of surgery are considered invasive procedures; so-called "noninvasive surgery" usually refers to an excision that does not penetrate the structure being excised (e.g. laser ablation of the cornea) or to a radiosurgical procedure (e.g. irradiation of a tumor).

Types of surgery

Surgical procedures are commonly categorized by urgency, type of procedure, body system involved, the degree of invasiveness, and special instrumentation.

• Based on timing: Elective surgery is done to correct a non-life-threatening condition, and is carried out at the patient's request, subject to the surgeon's and the surgical facility's availability. A semi-elective surgery is one that must be done to avoid permanent disability or death, but can be postponed for a short time. Emergency surgery is surgery which must be done promptly to save life, limb, or functional capacity.
• Based on purpose: Exploratory surgery is performed to aid or confirm a diagnosis. Therapeutic surgery treats a previously diagnosed condition. Cosmetic surgery is done to subjectively improve the appearance of an otherwise normal structure.
• By type of procedure: Amputation involves cutting off a body part, usually a limb or digit; castration is also an example. Resection is the removal of all of an internal organ or body part, or a key part (lung lobe; liver quadrant) of such an organ or body part that has its own name or code designation. Excision is the cutting out or removal of only part of an organ, tissue, or other body part from the patient. Replantation involves reattaching a severed body part. Reconstructive surgery involves reconstruction of an injured, mutilated, or deformed part of the body. Transplant surgery is the replacement of an organ or body part by insertion of another from different human (or animal) into the patient. Removing an organ or body part from a live human or animal for use in transplant is also a type of surgery.
• By body part: When surgery is performed on one organ system or structure, it may be classed by the organ, organ system or tissue involved. Examples include cardiac surgery (performed on the heart), gastrointestinal surgery (performed within the digestive tract and its accessory organs), and orthopedic surgery (performed on bones or muscles).
• By degree of invasiveness of surgical procedures: Minimally-invasive surgery involves smaller outer incision(s) to insert miniaturized instruments within a body cavity or structure, as in laparoscopic surgery or angioplasty. By contrast, an open surgical procedure such as a laparotomy requires a large incision to access the area of interest.
• By equipment used: Laser surgery involves use of a laser for cutting tissue instead of a scalpel or similar surgical instruments. Microsurgery involves the use of an operating microscope for the surgeon to see small structures. Robotic surgery makes use of a surgical robot, such as the Da Vinci or the ZEUS robotic surgical systems , to control the instrumentation under the direction of the surgeon.

Terminology

• Excision surgery names often start with a name for the organ to be excised (cut out) and end in -ectomy.
• Procedures involving cutting into an organ or tissue end in -otomy. A surgical procedure cutting through the abdominal wall to gain access to the abdominal cavity is a laparotomy.
• Minimally invasive procedures, involving small incisions through which an endoscope is inserted, end in -oscopy. For example, such surgery in the abdominal cavity is called laparoscopy.
• Procedures for formation of a permanent or semi-permanent opening called a stoma in the body end in -ostomy.
• Reconstruction, plastic or cosmetic surgery of a body part starts with a name for the body part to be reconstructed and ends in -oplasty. Rhino is used as a prefix for "nose", therefore a rhinoplasty is reconstructive or cosmetic surgery for the nose.
• Repair of damaged or congenital abnormal structure ends in -rraphy.
• Reoperation (return to the operating room) refers to a return to the operating theater after an initial surgery is performed to re-address an aspect of patient care best treated surgically. Reasons for reoperation include persistent bleeding after surgery, development of or persistence of infection.

Description of surgical procedure

Location

Inpatient surgery is performed in a hospital, and the patient stays at least one night in the hospital after the surgery. Outpatient surgery occurs in a hospital outpatient department or freestanding ambulatory surgery center, and the patient is discharged the same working day. Office surgery occurs in a physician's office, and the patient is discharged the same working day.

At a hospital, modern surgery is often performed in an operating theater using surgical instruments, an operating table for the patient, and other equipment. Among United States hospitalizations for nonmaternal and nonneonatal conditions in 2012, more than one-fourth of stays and half of hospital costs involved stays that included operating room (OR) procedures. The environment and procedures used in surgery are governed by the principles of aseptic technique: the strict separation of "sterile" (free of microorganisms) things from "unsterile" or "contaminated" things. All surgical instruments must be sterilized, and an instrument must be replaced or re-sterilized if, it becomes contaminated (i.e. handled in an unsterile manner, or allowed to touch an unsterile surface). Operating room staff must wear sterile attire (scrubs, a scrub cap, a sterile surgical gown, sterile latex or non-latex polymer gloves and a surgical mask), and they must scrub hands and arms with an approved disinfectant agent before each procedure.

Preoperative care

Prior to surgery, the patient is given a medical examination, receives certain pre-operative tests, and their physical status is rated according to the ASA physical status classification system. If these results are satisfactory, the patient signs a consent form and is given a surgical clearance. If the procedure is expected to result in significant blood loss, an autologous blood donation may be made some weeks prior to surgery. If the surgery involves the digestive system, the patient may be instructed to perform a bowel prep by drinking a solution of polyethylene glycol the night before the procedure. Patients are also instructed to abstain from food or drink (an NPO order after midnight on the night before the procedure), to minimize the effect of stomach contents on pre-operative medications and reduce the risk of aspiration if the patient vomits during or after the procedure. 

Some medical systems have a practice of routinely performing chest x-rays before surgery. The premise behind this practice is that the physician might discover some unknown medical condition which would complicate the surgery, and that upon discovering this with the chest x-ray, the physician would adapt the surgery practice accordingly. In fact, medical specialty professional organizations recommend against routine pre-operative chest x-rays for patients who have an unremarkable medical history and presented with a physical exam which did not indicate a chest x-ray. Routine x-ray examination is more likely to result in problems like misdiagnosis, overtreatment, or other negative outcomes than it is to result in a benefit to the patient. Likewise, other tests including complete blood count, prothrombin time, partial thromboplastin time, basic metabolic panel, and urinalysis should not be done unless the results of these tests can help evaluate surgical risk.

Staging for surgery

In the pre-operative holding area, the patient changes out of his or her street clothes and is asked to confirm the details of his or her surgery. A set of vital signs are recorded, a peripheral IV line is placed, and pre-operative medications (antibiotics, sedatives, etc.) are given. When the patient enters the operating room, the skin surface to be operated on, called the operating field, is cleaned and prepared by applying an antiseptic such as chlorhexidine gluconate or povidone-iodine to reduce the possibility of infection. If hair is present at the surgical site, it is clipped off prior to prep application. The patient is assisted by an anesthesiologist or resident to make a specific surgical position, then sterile drapes are used to cover the surgical site or at least a wide area surrounding the operating field; the drapes are clipped to a pair of poles near the head of the bed to form an "ether screen", which separates the anesthetist/anesthesiologist's working area (unsterile) from the surgical site (sterile).

Anesthesia is administered to prevent pain from an incision, tissue manipulation and suturing. Based on the procedure, anesthesia may be provided locally or as general anesthesia. Spinal anesthesia may be used when the surgical site is too large or deep for a local block, but general anesthesia may not be desirable. With local and spinal anesthesia, the surgical site is anesthetized, but the patient can remain conscious or minimally sedated. In contrast, general anesthesia renders the patient unconscious and paralyzed during surgery. The patient is intubated and is placed on a mechanical ventilator, and anesthesia is produced by a combination of injected and inhaled agents. Choice of surgical method and anesthetic technique aims to reduce the risk of complications, shorten the time needed for recovery and minimise the surgical stress response.

Surgery

An incision is made to access the surgical site. Blood vessels may be clamped or cauterized to prevent bleeding, and retractors may be used to expose the site or keep the incision open. The approach to the surgical site may involve several layers of incision and dissection, as in abdominal surgery, where the incision must traverse skin, subcutaneous tissue, three layers of muscle and then the peritoneum. In certain cases, bone may be cut to further access the interior of the body; for example, cutting the skull for brain surgery or cutting the sternum for thoracic (chest) surgery to open up the rib cage. Whilst in surgery aseptic technique is used to prevent infection or further spreading of the disease. The surgeons' and assistants' hands, wrists and forearms are washed thoroughly for at least 4 minutes to prevent germs getting into the operative field, then sterile gloves are placed onto their hands. An antiseptic solution is applied to the area of the patient's body that will be operated on. Sterile drapes are placed around the operative site. Surgical masks are worn by the surgical team to avoid germs on droplets of liquid from their mouths and noses from contaminating the operative site.

Work to correct the problem in body then proceeds. This work may involve:

• excision – cutting out an organ, tumor, or other tissue.
• resection – partial removal of an organ or other bodily structure.
• reconnection of organs, tissues, etc., particularly if severed. Resection of organs such as intestines involves reconnection. Internal suturing or stapling may be used. Surgical connection between blood vessels or other tubular or hollow structures such as loops of intestine is called anastomosis.
• Reduction – the movement or realignment of a body part to its normal position. e.g. Reduction of a broken nose involves the physical manipulation of the bone or cartilage from their displaced state back to their original position to restore normal airflow and aesthetics.
• ligation – tying off blood vessels, ducts, or "tubes".
• grafts – may be severed pieces of tissue cut from the same (or different) body or flaps of tissue still partly connected to the body but resewn for rearranging or restructuring of the area of the body in question. Although grafting is often used in cosmetic surgery, it is also used in other surgery. Grafts may be taken from one area of the patient's body and inserted to another area of the body. An example is bypass surgery, where clogged blood vessels are bypassed with a graft from another part of the body. Alternatively, grafts may be from other persons, cadavers, or animals.
• insertion of prosthetic parts when needed. Pins or screws to set and hold bones may be used. Sections of bone may be replaced with prosthetic rods or other parts. Sometimes a plate is inserted to replace a damaged area of skull. Artificial hip replacement has become more common. Heart pacemakers or valves may be inserted. Many other types of prostheses are used.
• creation of a stoma, a permanent or semi-permanent opening in the body
• in transplant surgery, the donor organ (taken out of the donor's body) is inserted into the recipient's body and reconnected to the recipient in all necessary ways (blood vessels, ducts, etc.).
• arthrodesis – surgical connection of adjacent bones so the bones can grow together into one. Spinal fusion is an example of adjacent vertebrae connected allowing them to grow together into one piece.
• modifying the digestive tract in bariatric surgery for weight loss.
• repair of a fistula, hernia, or prolapse
• other procedures, including:

• clearing clogged ducts, blood or other vessels
• removal of calculi (stones)
• draining of accumulated fluids
• debridement – removal of dead, damaged, or diseased tissue

Blood or blood expanders may be administered to compensate for blood lost during surgery. Once the procedure is complete, sutures or staples are used to close the incision. Once the incision is closed, the anesthetic agents are stopped or reversed, and the patient is taken off ventilation and extubated (if general anesthesia was administered).

Post-operative care

After completion of surgery, the patient is transferred to the post anesthesia care unit and closely monitored. When the patient is judged to have recovered from the anesthesia, he/she is either transferred to a surgical ward elsewhere in the hospital or discharged home. During the post-operative period, the patient's general function is assessed, the outcome of the procedure is assessed, and the surgical site is checked for signs of infection. There are several risk factors associated with postoperative complications, such as immune deficiency and obesity. Obesity has long been considered a risk factor for adverse post-surgical outcomes. It has been linked to many disorders such as obesity hypoventilation syndrome, atelectasis and pulmonary embolism, adverse cardiovascular effects, and wound healing complications. If removable skin closures are used, they are removed after 7 to 10 days post-operatively, or after healing of the incision is well under way. 

It is not uncommon for surgical drains (see Drain (surgery)) to be required to remove blood or fluid from the surgical wound during recovery. Mostly these drains stay in until the volume tapers off, then they are removed. These drains can become clogged, leading to abscess.

Postoperative therapy may include adjuvant treatment such as chemotherapy, radiation therapy, or administration of medication such as anti-rejection medication for transplants. Other follow-up studies or rehabilitation may be prescribed during and after the recovery period. 

The use of topical antibiotics on surgical wounds to reduce infection rates has been questioned. Antibiotic ointments are likely to irritate the skin, slow healing, and could increase risk of developing contact dermatitis and antibiotic resistance. It has also been suggested that topical antibiotics should only be used when a person shows signs of infection and not as a preventative. A systematic review published by Cochrane (organisation) in 2016, though, concluded that topical antibiotics applied over certain types of surgical wounds reduce the risk of surgical site infections, when compared to no treatment or use of antiseptics. The review also did not find conclusive evidence to suggest that topical antibiotics increased the risk of local skin reactions or antibiotic resistance. 

Through a retrospective analysis of national administrative data, the association between mortality and day of elective surgical procedure suggests a higher risk in procedures carried out later in the working week and on weekends. The odds of death were 44% and 82% higher respectively when comparing procedures on a Friday to a weekend procedure. This “weekday effect” has been postulated to be from several factors including poorer availability of services on a weekend, and also, decrease number and level of experience over a weekend.

While pain is universal and expected after surgery, there is growing evidence that pain may be inadequately treated in many patients in the acute period after surgery. It has been reported that incidence of inadequately controlled pain after surgery ranged from 25.1% to 78.4% across all surgical disciplines.

Epidemiology

United States

In 2011, of the 38.6 million hospital stays in U.S. hospitals, 29% included at least one operating room procedure. These stays accounted for 48% of the total $387 billion in hospital costs.

The overall number of procedures remained stable from 2001 to 2011. In 2011, over 15 million operating room procedures were performed in U.S. hospitals.

Data from 2003 to 2011 showed that U.S. hospital costs were highest for the surgical service line; the surgical service line costs were $17,600 in 2003 and projected to be $22,500 in 2013. For hospital stays in 2012 in the United States, private insurance had the highest percentage of surgical expenditure. in 2012, mean hospital costs in the United States were highest for surgical stays.

Special populations

Elderly people

Older adults have widely varying physical health. Frail elderly people are at significant risk of post-surgical complications and the need for extended care. Assessment of older patients before elective surgery can accurately predict the patients' recovery trajectories. One frailty scale uses five items: unintentional weight loss, muscle weakness, exhaustion, low physical activity, and slowed walking speed. A healthy person scores 0; a very frail person scores 5. Compared to non-frail elderly people, people with intermediate frailty scores (2 or 3) are twice as likely to have post-surgical complications, spend 50% more time in the hospital, and are three times as likely to be discharged to a skilled nursing facility instead of to their own homes. Frail elderly patients (score of 4 or 5) have even worse outcomes, with the risk of being discharged to a nursing home rising to twenty times the rate for non-frail elderly people.

Children

Surgery on children requires considerations which are not common in adult surgery. Children and adolescents are still developing physically and mentally making it difficult for them to make informed decisions and give consent for surgical treatments. Bariatric surgery in youth is among the controversial topics related to surgery in children.

Vulnerable populations

Doctors perform surgery with the consent of the patient. Some patients are able to give better informed consent than others. Populations such as incarcerated persons, people living with dementia, the mentally incompetent, persons subject to coercion, and other people who are not able to make decisions with the same authority as a typical patient have special needs when making decisions about their personal healthcare, including surgery.

In low- and middle-income countries

In 2014, The Lancet Commission on Global Surgery was launched to examine the case for surgery as an integral component of global health care and to provide recommendations regarding the delivery of surgical and anesthesia services in low and middle income countries. Amongst the conclusions in this study, two primary conclusions were reached:

• Five billion people worldwide lack access to safe, timely, and affordable surgical and anesthesia care. Areas in which especially large proportions of the population lack access include Sub-Saharan Africa, the Indian Subcontinent, Central Asia and, to a lesser extent, Russia and China. Of the estimated 312.9 million surgical procedures undertaken worldwide in 2012, only 6.3% were done in countries comprising the poorest 37.3% of the world's population.
• An additional 143 million surgical procedures are needed each year to prevent unnecessary death and disability.

Globally, 4.2 million people are estimated to die within 30 days of surgery each year, with half of these occurring in low- and middle-income countries. A prospective study of 10,745 adult patients undergoing emergency abdominal surgery from 357 centres across 58 countries found that mortality is three times higher in low- compared with high-human development index (HDI) countries even when adjusted for prognostic factors. In this study the overall global mortality rate was 1·6 per cent at 24 hours (high HDI 1·1 per cent, middle HDI 1·9 per cent, low HDI 3·4 per cent), increasing to 5·4 per cent by 30 days (high HDI 4·5 per cent, middle HDI 6·0 per cent, low HDI 8·6 per cent; P < 0·001). A sub-study of 1,409 children undergoing emergency abdominal surgery from 253 centres across 43 countries found that adjusted mortality in children following surgery may be as high as 7 times greater in low-HDI and middle-HDI countries compared with high-HDI countries. This translate to 40 excess deaths per 1000 procedures performed in these settings. Patient safety factors were suggested to play an important role, with use of the WHO Surgical Safety Checklist associated with reduced mortality at 30 days.

Human rights

Access to surgical care is increasingly recognized as an integral aspect of healthcare, and therefore is evolving into a normative derivation of human right to health. The ICESCR Article 12.1 and 12.2 define the human right to health as "the right of everyone to the enjoyment of the highest attainable standard of physical and mental health" In the August 2000, the UN Committee on Economic, Social and Cultural Rights (CESCR) interpreted this to mean "right to the enjoyment of a variety of facilities, goods, services, and conditions necessary for the realization of the highest attainable health". Surgical care can be thereby viewed as a positive right – an entitlement to protective healthcare.

Woven through the International Human and Health Rights literature is the right to be free from surgical disease. The 1966 ICESCR Article 12.2a described the need for "provision for the reduction of the stillbirth-rate and of infant mortality and for the healthy development of the child" which was subsequently interpreted to mean “requiring measures to improve… emergency obstetric services”. Article 12.2d of the ICESCR stipulates the need for “the creation of conditions which would assure to all medical service and medical attention in the event of sickness”, and is interpreted in the 2000 comment to include timely access to “basic preventative, curative services… for appropriate treatment of injury and disability.". Obstetric care shares close ties with reproductive rights, which includes access to reproductive health.

Surgeons and public health advocates, such as Kelly McQueen, have described surgery as "Integral to the right to health". This is reflected in the establishment of the WHO Global Initiative for Emergency and Essential Surgical Care in 2005, the 2013 formation of the Lancet Commission for Global Surgery, the 2015 World Bank Publication of Volume 1 of its Disease Control Priorities "Essential Surgery", and the 2015 World Health Assembly 68.15 passing of the Resolution for Strengthening Emergency and Essential Surgical Care and Anesthesia as a Component of Universal Health Coverage. The Lancet Commission for Global Surgery outlined the need for access to "available, affordable, timely and safe" surgical and anesthesia care; dimensions paralleled in ICESCR General Comment No. 14, which similarly outlines need for available, accessible, affordable and timely healthcare.

History

Plates vi & vii of the Edwin Smith Papyrus, an Egyptian surgical treatise

Trepanation

Surgical treatments date back to the prehistoric era. The oldest for which there is evidence is trepanation, in which a hole is drilled or scraped into the skull, thus exposing the dura mater in order to treat health problems related to intracranial pressure and other diseases.

Ancient Egypt

Prehistoric surgical techniques are seen in Ancient Egypt, where a mandible dated to approximately 2650 BC shows two perforations just below the root of the first molar, indicating the draining of an abscessed tooth. Surgical texts from ancient Egypt date back about 3500 years ago. Surgical operations were performed by priests, specialized in medical treatments similar to today, and used sutures to close wounds. Infections were treated with honey.

India

Sushruta, the author of Sushruta Samhita, one of the oldest texts on surgery

 

Remains from the early Harappan periods of the Indus Valley Civilization (c. 3300 BC) show evidence of teeth having been drilled dating back 9,000 years. Susruta was an ancient Indian surgeon commonly credited as the author of the treatise Sushruta Samhita. He is dubbed as the "founding father of surgery" and his period is usually placed between the period of 1200–600 BC. One of the earliest known mention of the name is from the Bower Manuscript where Sushruta is listed as one of the ten sages residing in the Himalayas. Texts also suggest that he learned surgery at Kasi from Lord Dhanvantari, the god of medicine in Hindu mythology. It is one of the oldest known surgical texts and it describes in detail the examination, diagnosis, treatment, and prognosis of numerous ailments, as well as procedures on performing various forms of cosmetic surgery, plastic surgery and rhinoplasty.

Ancient Greece

Hippocrates stated in the oath (c. 400 BC) that general physicians must never practice surgery and that surgical procedures are to be conducted by specialists

 

In ancient Greece, temples dedicated to the healer-god Asclepius, known as Asclepieia (Greek: Ασκληπιεία, sing. Asclepieion Ασκληπιείον), functioned as centers of medical advice, prognosis, and healing. In the Asclepieion of Epidaurus, some of the surgical cures listed, such as the opening of an abdominal abscess or the removal of traumatic foreign material, are realistic enough to have taken place. The Greek Galen was one of the greatest surgeons of the ancient world and performed many audacious operations – including brain and eye surgery – that were not tried again for almost two millennia.

Islamic World

Surgery was developed to a high degree in the Islamic world. Abulcasis (Abu al-Qasim Khalaf ibn al-Abbas Al-Zahrawi), an Andalusian-Arab physician and scientist who practiced in the Zahra suburb of Córdoba. His works on surgery, largely based upon Paul of Aegina's Pragmateia, were influential.

Al-Zahrawi specialized in curing disease by cauterization. He invented several surgical instruments, for purposes such as inspection of the interior of the urethra and for removing foreign bodies from the throat, the ear, and other body organs. He was also the first to illustrate the various cannulae and the first to treat a wart with an iron tube and caustic metal as a boring instrument.Al-Zahrawi also pioneeredneurosurgery and neurological diagnosis. He is known to have performed surgical treatments of head injuries, skull fractures, spinal injuries, hydrocephalus, subdural effusions and headache. The first clinical description of an operative procedure for hydrocephalus was given by Al-Zahrawi who clearly describes the evacuation of superficial intracranial fluid in hydrocephalic children.

Early modern Europe

Ambroise Paré (c. 1510–1590), father of modern military surgery.

 

12th century medieval eye surgery in Italy

 

In Europe, the demand grew for surgeons to formally study for many years before practicing; universities such as Montpellier, Padua and Bologna were particularly renowned. In the 12th century, Rogerius Salernitanus composed his Chirurgia, laying the foundation for modern Western surgical manuals. Barber-surgeons generally had a bad reputation that was not to improve until the development of academic surgery as a specialty of medicine, rather than an accessory field. Basic surgical principles for asepsis etc., are known as Halsteads principles. 

There were some important advances to the art of surgery during this period. The professor of anatomy at the University of Padua, Andreas Vesalius, was a pivotal figure in the Renaissance transition from classical medicine and anatomy based on the works of Galen, to an empirical approach of 'hands-on' dissection. In his anatomic treatis De humani corporis fabrica, he exposed the many anatomical errors in Galen and advocated that all surgeons should train by engaging in practical dissections themselves. 

The second figure of importance in this era was Ambroise Paré (sometimes spelled "Ambrose"), a French army surgeon from the 1530s until his death in 1590. The practice for cauterizing gunshot wounds on the battlefield had been to use boiling oil; an extremely dangerous and painful procedure. Paré began to employ a less irritating emollient, made of egg yolk, rose oil and turpentine. He also described more efficient techniques for the effective ligation of the blood vessels during an amputation.

Modern surgery

The discipline of surgery was put on a sound, scientific footing during the Age of Enlightenment in Europe. An important figure in this regard was the Scottish surgical scientist, John Hunter, generally regarded as the father of modern scientific surgery. He brought an empirical and experimental approach to the science and was renowned around Europe for the quality of his research and his written works. Hunter reconstructed surgical knowledge from scratch; refusing to rely on the testimonies of others, he conducted his own surgical experiments to determine the truth of the matter. To aid comparative analysis, he built up a collection of over 13,000 specimens of separate organ systems, from the simplest plants and animals to humans. 

He greatly advanced knowledge of venereal disease and introduced many new techniques of surgery, including new methods for repairing damage to the Achilles tendon and a more effective method for applying ligature of the arteries in case of an aneurysm. He was also one of the first to understand the importance of pathology, the danger of the spread of infection and how the problem of inflammation of the wound, bone lesions and even tuberculosis often undid any benefit that was gained from the intervention. He consequently adopted the position that all surgical procedures should be used only as a last resort.

Other important 18th- and early 19th-century surgeons included Percival Pott (1713–1788) who described tuberculosis on the spine and first demonstrated that a cancer may be caused by an environmental carcinogen (he noticed a connection between chimney sweep's exposure to soot and their high incidence of scrotal cancer). Astley Paston Cooper (1768–1841) first performed a successful ligation of the abdominal aorta, and James Syme (1799–1870) pioneered the Symes Amputation for the ankle joint and successfully carried out the first hip disarticulation. 

Modern pain control through anesthesia was discovered in the mid-19th century. Before the advent of anesthesia, surgery was a traumatically painful procedure and surgeons were encouraged to be as swift as possible to minimize patient suffering. This also meant that operations were largely restricted to amputations and external growth removals. Beginning in the 1840s, surgery began to change dramatically in character with the discovery of effective and practical anaesthetic chemicals such as ether, first used by the American surgeon Crawford Long, and chloroform, discovered by Scottish obstetrician James Young Simpson and later pioneered by John Snow, physician to Queen Victoria. In addition to relieving patient suffering, anaesthesia allowed more intricate operations in the internal regions of the human body. In addition, the discovery of muscle relaxants such as curare allowed for safer applications.

Infection and antisepsis

Unfortunately, the introduction of anesthetics encouraged more surgery, which inadvertently caused more dangerous patient post-operative infections. The concept of infection was unknown until relatively modern times. The first progress in combating infection was made in 1847 by the Hungarian doctor Ignaz Semmelweis who noticed that medical students fresh from the dissecting room were causing excess maternal death compared to midwives. Semmelweis, despite ridicule and opposition, introduced compulsory handwashing for everyone entering the maternal wards and was rewarded with a plunge in maternal and fetal deaths; however, the Royal Society dismissed his advice. 

Joseph Lister, pioneer of antiseptic surgery

 

Until the pioneering work of British surgeon Joseph Lister in the 1860s, most medical men believed that chemical damage from exposures to bad air (see "miasma") was responsible for infections in wounds, and facilities for washing hands or a patient's wounds were not available. Lister became aware of the work of French chemist Louis Pasteur, who showed that rotting and fermentation could occur under anaerobic conditions if micro-organisms were present. Pasteur suggested three methods to eliminate the micro-organisms responsible for gangrene: filtration, exposure to heat, or exposure to chemical solutions. Lister confirmed Pasteur's conclusions with his own experiments and decided to use his findings to develop antiseptic techniques for wounds. As the first two methods suggested by Pasteur were inappropriate for the treatment of human tissue, Lister experimented with the third, spraying carbolic acid on his instruments. He found that this remarkably reduced the incidence of gangrene and he published his results in The Lancet. Later, on 9 August 1867, he read a paper before the British Medical Association in Dublin, on the Antiseptic Principle of the Practice of Surgery, which was reprinted in The British Medical Journal. His work was groundbreaking and laid the foundations for a rapid advance in infection control that saw modern antiseptic operating theatres widely used within 50 years. 

Lister continued to develop improved methods of antisepsis and asepsis when he realised that infection could be better avoided by preventing bacteria from getting into wounds in the first place. This led to the rise of sterile surgery. Lister introduced the Steam Steriliser to sterilize equipment, instituted rigorous hand washing and later implemented the wearing of rubber gloves. These three crucial advances – the adoption of a scientific methodology toward surgical operations, the use of anaesthetic and the introduction of sterilised equipment – laid the groundwork for the modern invasive surgical techniques of today. 

The use of X-rays as an important medical diagnostic tool began with their discovery in 1895 by German physicist Wilhelm Röntgen. He noticed that these rays could penetrate the skin, allowing the skeletal structure to be captured on a specially treated photographic plate.

Philosophy of history

From Wikipedia, the free encyclopedia

Philosophy of history is the philosophical study of history and the past. The term was coined by Voltaire.

Types

In contemporary philosophy a distinction is made between critical philosophy of history (also known as analytic) and speculative philosophy of history. The names of these types are derived from C. D. Broad's distinction between critical philosophy and speculative philosophy.

The former studies the past itself whereas the latter is the equivalent of what the philosophy of science is for nature.

Though there is some overlap between the two aspects, they can usually be distinguished; modern professional historians tend to be skeptical about speculative philosophy of history. 

Sometimes critical philosophy of history is included under historiography. Philosophy of history should not be confused with the history of philosophy, which is the study of the development of philosophical ideas in their historical context.

Pre-modern history

In his Poetics, Aristotle (384–322 BCE) maintained the superiority of poetry over history because poetry speaks of what must or should be true rather than merely what is true. 

Herodotus, a fifth-century BCE contemporary of Socrates, broke from the Homeric tradition of passing narrative from generation to generation in his work "Investigations" (Ancient Greek: Ἱστορίαι; Istoríai), also known as Histories. Herodotus, regarded by some as the first systematic historian, and, later, Plutarch (46–120 CE) freely invented speeches for their historical figures and chose their historical subjects with an eye toward morally improving the reader. History was supposed to teach good examples for one to follow. The assumption that history "should teach good examples" influenced how writers produced history. Events of the past are just as likely to show bad examples that one should not follow, but classical historians would either not record such examples or would re-interpret them to support their assumption of history's purpose.

From the Classical period to the Renaissance, historians alternated between focusing on subjects designed to improve mankind and on a devotion to fact. History was composed mainly of hagiographies of monarchs or of epic poetry describing heroic gestures (such as The Song of Roland—about the Battle of Roncevaux Pass (778) during Charlemagne's first campaign to conquer the Iberian peninsula). 

In the fourteenth century, Ibn Khaldun, who is considered one of the fathers of the philosophy of history, discussed his philosophy of history and society in detail in his Muqaddimah (1377). His work represents a culmination of earlier works by medieval Islamic sociologists in the spheres of Islamic ethics, political science, and historiography, such as those of al-Farabi (c. 872 – c. 950), Ibn Miskawayh, al-Dawani, and Nasir al-Din al-Tusi (1201–1274). Ibn Khaldun often criticized "idle superstition and uncritical acceptance of historical data". He introduced a scientific method to the philosophy of history (which Dawood considers something "totally new to his age") and he often referred to it as his "new science", which is now associated with historiography. His historical method also laid the groundwork for the observation of the role of the state, communication, propaganda, and systematic bias in history.

By the eighteenth century historians had turned toward a more positivist approach—focusing on fact as much as possible, but still with an eye on telling histories that could instruct and improve. Starting with Fustel de Coulanges (1830–1889) and Theodor Mommsen (1817–1903), historical studies began to move towards a more modern scientific form. In the Victorian era, historiographers debated less whether history was intended to improve the reader, and more on what causes turned history and how one could understand historical change.

Cyclical and linear history

Narrative history tends to follow an assumption of linear progression: "this happened, and then that happened; that happened because this happened first". 

Many ancient cultures held mythical concepts of history and of time that were not linear. Such societies saw history as cyclical, with alternating Dark and Golden Ages. Plato taught the concept of the Great Year, and other Greeks spoke of aeons (eons). Similar examples include the ancient doctrine of eternal return, which existed in Ancient Egypt, in the Indian religions, among the Greek Pythagoreans' and in the Stoics' conceptions. In his Works and Days, Hesiod described five Ages of Man: the Golden Age, the Silver Age, the Bronze Age, the Heroic Age, and the Iron Age, which began with the Dorian invasion. Some scholars identify just four ages, corresponding to the four metals, with the Heroic age as a description of the Bronze Age. A four-age count would match the Vedic or Hindu ages known as the Kali, Dwapara, Treta and Satya yugas. According to Jainism, this world has no beginning or end but goes through cycles of upturns (utsarpini) and downturns (avasarpini) constantly. Many Greeks believed that just as mankind went through four stages of character during each rise and fall of history so did government. They considered democracy and monarchy as the healthy régimes of the higher ages; and oligarchy and tyranny as corrupted régimes common to the lower ages.

In the East, cyclical theories of history developed in China (as a theory of dynastic cycle) and in the Islamic world in the work of Ibn Khaldun (1332-1406). 

The story of the Fall of Man from the Garden of Eden, as recounted and elaborated in Judaism and Christianity, preserves traces of a moral cycle; this would give the basis for theodicies which attempt to reconcile the existence of evil in the world with the existence of a God, providing a global explanation of history with belief in a coming Messianic Age. Some theodicies claimed that history had a progressive direction leading to an eschatological end, such as the Apocalypse, organized by a superior power. Augustine of Hippo (354-430), Thomas Aquinas (1225-1274) and Bossuet (in his Discourse On Universal History of 1679) formulated such theodicies, but Leibniz (1646-1716), who coined the term Théodicée, developed the most famous philosophical theodicy. Leibniz based his explanation on the principle of sufficient reason, which states that anything that happens, does happen for a specific reason. Thus, while man might see certain events as evil (such as wars, epidemics and natural disasters), such a judgement in fact only reflected human perception; if one adopted God's view, "evil" events in fact only took place in the larger divine plan. In this way theodicies explained the necessity of evil as a relative element that forms part of a larger plan of history. Leibniz's principle of sufficient reason was not, however, a gesture of fatalism. Confronted with the antique problem of future contingents, Leibniz invented the theory of "compossible worlds", distinguishing two types of necessity, to cope with the problem of determinism. 

During the Renaissance, cyclical conceptions of history would become common, with proponents illustrating decay and rebirth by pointing to the decline of the Roman Empire. Machiavelli's Discourses on Livy (1513–1517) provide an example. The notion of Empire contained in itself ascendance and decadence, as in Edward Gibbon's The History of the Decline and Fall of the Roman Empire (1776) (which the Roman Catholic Church placed on the Index Librorum Prohibitorum). 

Cyclical conceptions continued in the nineteenth and twentieth centuries in the works of authors such as Oswald Spengler (1880–1936), Nikolay Danilevsky (1822–1885), and Paul Kennedy (1945– ), who conceived the human past as a series of repetitive rises and falls. Spengler, like Butterfield, when writing in reaction to the carnage of the First World War of 1914–1918, believed that a civilization enters upon an era of Caesarism after its soul dies. Spengler thought that the soul of the West was dead and that Caesarism was about to begin. 

The development of mathematical models of long-term secular sociodemographic cycles revived interest in cyclical theories of history (see, for example, Historical Dynamics (2003) by Peter Turchin, or Introduction to Social Macrodynamics by Andrey Korotayev et al.).

Sustainable history

"Sustainable History and the Dignity of Man" is a philosophy of history proposed by Nayef Al-Rodhan, where history is defined as a durable progressive trajectory in which the quality of life on this planet or all other planets is premised on the guarantee of human dignity for all at all times under all circumstances. This theory views history as a linear progression propelled by good governance, which is, in turn, to be achieved through balancing the emotional, amoral, and egoistic elements of human nature with the human dignity needs of reason, security, human rights, accountability, transparency, justice, opportunity, innovation, and inclusiveness.

Human dignity lies at the heart of this theory and is paramount for ensuring the sustainable history of humankind. Among other things, human dignity means having a positive sense of self and instilling individuals with respect for the communities to which they belong. Thus, reconciling humans' predisposition for emotionally self-interested behavior with the imperatives of human dignity appears as the one of the most important challenges to global policymakers. At national level, they have to protect their citizens against violence and provide them with access to food, housing, clothes, health care, and education. Basic welfare provision and security are fundamental to ensuring human dignity. Environment and ecological considerations need to be addressed as well. Finally, cultural diversity, inclusiveness and participation at all levels, of all communities are key imperatives of human dignity.

In this respect, the sustainable history philosophy challenges existing concepts of civilisations, such as Samuel Huntington's Clash of Civilisations. Instead, it argues that human civilisation should not be thought of as consisting of numerous separate and competing civilisations, but rather it should be thought of collectively as only one human civilisation. Within this civilisation are many geo-cultural domains that comprise sub-cultures. Nayef Al-Rodhan envisions human civilisation as an ocean into which the different geo-cultural domains flow like rivers, "The Ocean Model of one Human Civilization". At points where geo-cultural domains first enter the ocean of human civilisation, there is likely to be a concentration or dominance of that culture. However, over time, all the rivers of geo-cultural domains become one. There is fluidity at the ocean's centre and cultures have the opportunity to borrow between them. Under such historical conditions the most advanced forms of human enterprise can thrive and lead us to a 'civilisational triumph'. Nevertheless, there are cases where geographical proximity of various cultures can also lead to friction and conflict.

Nayef Al-Rodhan concludes that within an increasingly globalised, interconnected and interdependent world, human dignity cannot be ensured globally and in a sustainable way through sole national means. A genuine global effort is required to meet the minimum criteria of human dignity globally. Areas such as conflict prevention, socio-economic justice, gender equality, protection of human rights, environmental protection require a holistic approach and a common action.

The Enlightenment's ideal of progress

During the Aufklärung, or Enlightenment, history began to be seen as both linear and irreversible. Condorcet's interpretations of the various "stages of humanity" or Auguste Comte's positivism were one of the most important formulations of such conceptions of history, which trusted social progress. As in Jean-Jacques Rousseau's Emile (1762) treatise on education (or the "art of training men"), the Aufklärung conceived the human species as perfectible: human nature could be infinitely developed through a well-thought pedagogy. In What is Enlightenment? (1784), Immanuel Kant defined the Aufklärung as the capacity to think by oneself, without referring to an exterior authority, be it a prince or tradition:

Enlightenment is when a person leaves behind a state of immaturity and dependence (Unmündigkeit) for which they themselves were responsible. Immaturity and dependence are the inability to use one's own intellect without the direction of another. One is responsible for this immaturity and dependence, if its cause is not a lack of intelligence or education, but a lack of determination and courage to think without the direction of another. Sapere aude! Dare to know! is therefore the slogan of the Enlightenment.

In a paradoxical way, Kant supported in the same time enlightened despotism as a way of leading humanity towards its autonomy. He had conceived the process of history in his short treaty Idea for a Universal History with a Cosmopolitan Purpose (1784). On one hand, enlightened despotism was to lead nations toward their liberation, and progress was thus inscribed in the scheme of history; on the other hand, liberation could only be acquired by a singular gesture, Sapere Aude! Thus, autonomy ultimately relied on the individual's "determination and courage to think without the direction of another." 

After Kant, G. W. F. Hegel developed a complex theodicy in the Phenomenology of Spirit (1807), which based its conception of history on dialectics: the negative (wars, etc.) was conceived by Hegel as the motor of history. Hegel argued that history is a constant process of dialectic clash, with each thesis encountering an opposing idea or event antithesis. The clash of both was "superated" in the synthesis, a conjunction that conserved the contradiction between thesis and its antithesis while sublating it. As Marx famously explained afterwards, concretely that meant that if Louis XVI's monarchic rule in France was seen as the thesis, the French Revolution could be seen as its antithesis. However, both were sublated in Napoleon, who reconciled the revolution with the Ancien Régime; he conserved the change. Hegel thought that reason accomplished itself, through this dialectical scheme, in History. Through labour, man transformed nature so he could recognize himself in it; he made it his "home." Thus, reason spiritualized nature. Roads, fields, fences, and all the modern infrastructure in which we live is the result of this spiritualization of nature. Hegel thus explained social progress as the result of the labour of reason in history. However, this dialectical reading of history involved, of course, contradiction, so history was also conceived of as constantly conflicting: Hegel theorized this in his famous dialectic of the lord and the bondsman. 

According to Hegel,

One more word about giving instruction as to what the world ought to be. Philosophy in any case always comes on the scene too late to give it... When philosophy paints its gray in gray, then has a shape of life grown old. By philosophy's gray in gray it cannot be rejuvenated but only understood. The owl of Minerva spreads its wings only with the falling of the dusk.

— ^[16]

Thus, philosophy was to explain Geschichte (history) afterward. Philosophy is always late, it is only an interpretation of what is rational in the real—and, according to Hegel, only what is recognized as rational is real. This idealist understanding of philosophy as interpretation was famously challenged by Karl Marx's 11th thesis on Feuerbach (1845): "Philosophers have hitherto only interpreted the world in various ways; the point, however, is to change it."

Social evolutionism

Inspired by the Enlightenment's ideal of progress, social evolutionism became a popular conception in the nineteenth century. Auguste Comte's (1798–1857) positivist conception of history, which he divided into the theological stage, the metaphysical stage and the positivist stage, brought upon by modern science, was one of the most influential doctrines of progress. The Whig interpretation of history, as it was later called, associated with scholars of the Victorian and Edwardian eras in Britain, such as Henry Maine or Thomas Macaulay, gives an example of such influence, by looking at human history as progress from savagery and ignorance toward peace, prosperity, and science. Maine described the direction of progress as "from status to contract," from a world in which a child's whole life is pre-determined by the circumstances of his birth, toward one of mobility and choice. 

The publication of Darwin's The Origin of Species in 1859 introduced human evolution. However, it was quickly transposed from its original biological field to the social field, in "social Darwinism" theories. Herbert Spencer, who coined the term "survival of the fittest", or Lewis Henry Morgan in Ancient Society (1877) developed evolutionist theories independent from Darwin's works, which would be later interpreted as social Darwinism. These nineteenth-century unilineal evolution theories claimed that societies start out in a primitive state and gradually become more civilised over time, and equated the culture and technology of Western civilisation with progress. 

Ernst Haeckel formulated his recapitulation theory in 1867, which stated that "ontogeny recapitulates phylogeny": the evolution of each individual reproduces the species' evolution, such as in the development of embryos. Hence, a child goes through all the steps from primitive society to modern society. This was later discredited.^{[citation needed]} Haeckel did not support Darwin's theory of natural selection introduced in The Origin of Species (1859), rather believing in a Lamarckian inheritance of acquired characteristics. 

Progress was not necessarily, however, positive. Arthur Gobineau's An Essay on the Inequality of the Human Races (1853–55) was a decadent description of the evolution of the "Aryan race" which was disappearing through miscegenation. Gobineau's works had a large popularity in the so-called scientific racism theories that developed during the New Imperialism period. 

After the first world war, and even before Herbert Butterfield (1900–1979) harshly criticized it, the Whig interpretation had gone out of style. The bloodletting of that conflict had indicted the whole notion of linear progress. Paul Valéry famously said: "We civilizations now know ourselves mortal." 

However, the notion itself didn't completely disappear. The End of History and the Last Man (1992) by Francis Fukuyama proposed a similar notion of progress, positing that the worldwide adoption of liberal democracies as the single accredited political system and even modality of human consciousness would represent the "End of History". Fukuyama's work stems from a Kojevian reading of Hegel's Phenomenology of Spirit (1807). 

Unlike Maurice Godelier who interprets history as a process of transformation, Tim Ingold suggests that history is a movement of autopoiesis. 

 

A key component to making sense of all of this is to simply recognize that all these issues in social evolution merely serve to support the suggestion that how one considers the nature of history will impact the interpretation and conclusions drawn about history. The critical under-explored question is less about history as content and more about history as process. 

In 2011 Steven Pinker wrote a history of violence and humanity from an evolutionary perspective in which he shows that violence has declined statistically over time.

The validity of the "great man theory" in historical studies

After Hegel, who insisted on the role of "great men" in history, with his famous statement about Napoleon, "I saw the Spirit on his horse", Thomas Carlyle argued that history was the biography of a few central individuals, heroes, such as Oliver Cromwell or Frederick the Great, writing that "The history of the world is but the biography of great men." His heroes were political and military figures, the founders or topplers of states. His history of great men, of geniuses good and evil, sought to organize change in the advent of greatness. 

Explicit defenses of Carlyle's position have been rare in the late twentieth century. Most philosophers of history contend that the motive forces in history can best be described only with a wider lens than the one he used for his portraits. A.C. Danto, for example, wrote of the importance of the individual in history, but extended his definition to include social individuals, defined as "individuals we may provisionally characterize as containing individual human beings amongst their parts. Examples of social individuals might be social classes [...], national groups [...], religious organizations [...], large-scale events [...], large-scale social movements [...], etc." (Danto, "The Historical Individual", 266, in Philosophical Analysis and History, edited by Williman H. Dray, Rainbow-Bridge Book Co., 1966). The Great Man approach to history was most popular with professional historians in the nineteenth century; a popular work of this school is the Encyclopædia Britannica Eleventh Edition (1911), which contains lengthy and detailed biographies about the great men of history. For example, to read about (what is known today as) the "Migrations Period," consult the biography of Attila the Hun. 

After Marx's conception of a materialist history based on the class struggle, which raised attention for the first time to the importance of social factors such as economics in the unfolding of history, Herbert Spencer wrote "You must admit that the genesis of the great man depends on the long series of complex influences which has produced the race in which he appears, and the social state into which that race has slowly grown....Before he can remake his society, his society must make him."

The Annales School, founded by Lucien Febvre and Marc Bloch, were a major landmark on the shift from a history centered on individual subjects to studies concentrating in geography, economics, demography, and other social forces. Fernand Braudel's studies on the Mediterranean Sea as "hero" of history, Emmanuel Le Roy Ladurie's history of climate, etc., were inspired by this School.

Is history predetermined?

There is disagreement about the extent to which history is ultimately deterministic. Some argue that geography, economic systems, or culture prescribe "the iron laws of history" that decide what is to happen. Others see history as a long line of acts and accidents, big and small, each playing out its consequences until that process gets interrupted by the next. 

Even determinists do not rule that, from time to time, certain cataclysmic events occur to change course of history. Their main point is, however, that such events are rare and that even apparently large shocks like wars and revolutions often have no more than temporary effects on the evolution of the society. 

Karl Marx is, perhaps, the most famous of the exponents of economic determinism. For him social institutions like political system, religion and culture were merely by-products of the basic economic system (see Base and superstructure).

However, even he did not see history as completely deterministic. His essay The Eighteenth Brumaire of Louis Napoleon contains the most famous formulation of Marx's view of the role of the individual in history: Men make their own history, but they do not make it just as they please; they do not make it under circumstances chosen by themselves, but under given circumstances directly encountered and inherited from the past.

Does history have a teleological sense?

Theodicy claimed that history had a progressive direction leading to an eschatological end, given by a superior power. However, this transcendent teleological sense can be thought as immanent to human history itself. Hegel probably represents the epitome of teleological philosophy of history. Hegel's teleology was taken up by Francis Fukuyama in his The End of History and the Last Man (see Social evolutionism above). Thinkers such as Nietzsche, Michel Foucault, Althusser, or Deleuze deny any teleological sense to history, claiming that it is best characterized by discontinuities, ruptures, and various time-scales, which the Annales School had demonstrated. 

Schools of thought influenced by Hegel also see history as progressive, but they saw, and see, progress as the outcome of a dialectic in which factors working in opposite directions are over time reconciled (see above). History was best seen as directed by a Zeitgeist, and traces of the Zeitgeist could be seen by looking backward. Hegel believed that history was moving man toward "civilization", and some also claim he thought that the Prussian state incarnated the "End of History". In his Lessons on the History of Philosophy, he explains that each epochal philosophy is in a way the whole of philosophy; it is not a subdivision of the Whole but this Whole itself apprehended in a specific modality.

Historical accounts of writing history

A classic example of history being written by the victors—or more precisely, by the survivors—would be the scarcity of unbiased information that has survived to the present about the Carthaginians. Roman historians left tales of cruelty and human sacrifice practiced by their longtime enemies; however no Carthaginian was left alive to give their side of the story. 

Similarly, we only have the Christian side of how Christianity came to be the dominant religion of Europe. However, we know very little about other European religions, such as Paganism. We have the European version of the conquest of the Americas, with an interpretation of the native version of events only emerging to popular consciousness since the early 1980s. We have Herodotus's Greek history of the Persian Wars, but the Persian recall of the events is little known in Western Culture. 

In many respects, the head of state may be guilty of cruelties or even simply a different way of doing things. In some societies, however, to speak of or write critically of rulers can amount to conviction of treason and death. As such, in many ways, what is left as the "official record" of events is oft influenced by one's desire to avoid exile or execution. 

However, "losers" in certain time periods often have more of an impetus than the "winners" to write histories that comfort themselves and justify their own behavior. Examples include the historiography of the American Civil War, where it can be argued that the losers (Southerners) have written more history books on the subject than the winners and, until recently, dominated the national perception of history. Confederate generals such as Lee and Jackson are generally held in higher esteem than their Union counterparts. Popular films such as Cold Mountain, Gone with the Wind, and The Birth of a Nation have told the story from the Southern viewpoint. Also, despite "losing" the Vietnam War, the United States produces more scholarship on the war than any other country, including Vietnam. Popular history abounds with condemnations of the cruelty of African slave traders and colonists, despite the "winning" status of those people in their heyday.

As is true of pre-Columbian populations of America, the historical record of America being "discovered" by Europeans is now sometimes presented as a history of invasion, exploitation and dominance of a people who had been there before the Europeans. This reinterpretation of the historical record is called historical revisionism, which can take the form of negationism, which is the denial of genocides and crimes against humanity. The revision of previously accepted historical accounts is a constant process in which "today's winners are tomorrow's losers", and the rise and fall of present institutions and movements influence the way historians see the past. In the same sense, the teaching, in French secondary schools, of the Algerian War of Independence and of colonialism, has been criticized by several historians, and is the subject of frequent debates. Thus, in contradiction with the February 23, 2005 law on colonialism, voted by the UMP conservative party, historian Benjamin Stora notes that:

As Algerians do not appear in their "indigenous" conditions and their sub-citizens status, as the history of nationalist movement is never evoqued, as none of the great figures of the resistance — Messali Hadj, Ferhat Abbas — emerge nor retain attention, in one word, as no one explains to students what has been colonisation, we make them unable to understand why the decolonisation took place.

Michel Foucault's analysis of historical and political discourse

The historico-political discourse analyzed by Michel Foucault in Society Must Be Defended (1975–76) considered truth as the fragile product of a historical struggle, first conceptualized under the name of "race struggle"—however, the meaning of "race" was different from today's biological notion, being closer to the sense of "nation" (distinct from nation-states; its signification is here closer to "people"). Boulainvilliers, for example, was an exponent of nobility rights. He claimed that the French nobility were the racial descendants of the Franks who invaded France (while the Third Estate was descended from the conquered Gauls), and had right to power by virtue of right of conquest. He used this approach to formulate a historical thesis of the course of French political history—a critique of both the monarchy and the Third Estate. Foucault regarded him as the founder of the historico-political discourse as political weapon. 

In Great Britain, this historico-political discourse was used by the bourgeoisie, the people and the aristocracy as a means of struggle against the monarchy—cf. Edward Coke or John Lilburne. In France, Boulainvilliers, Nicolas Fréret, and then Sieyès, Augustin Thierry, and Cournot reappropriated this form of discourse. Finally, at the end of the nineteenth century, this discourse was incorporated by racialist biologists and eugenicists, who gave it the modern sense of "race" and, even more, transformed this popular discourse into a "state racism" (Nazism). According to Foucault, Marxists also seized this discourse and took it in a different direction, transforming the essentialist notion of "race" into the historical notion of "class struggle", defined by socially structured position: capitalist or proletarian. This displacement of discourse constitutes one of the bases of Foucault's thought: discourse is not tied to the subject, rather the "subject" is a construction of discourse. Moreover, discourse is not the simple ideological and mirror reflexion of an economical infrastructure, but is a product and the battlefield of multiples forces—which may not be reduced to the simple dualist contradiction of two energies. 

Foucault shows that what specifies this discourse from the juridical and philosophical discourse is its conception of truth: truth is no longer absolute, it is the product of "race struggle". History itself, which was traditionally the sovereign's science, the legend of his glorious feats and monument building,he(the sovereign) built monuments,fought in wars and claims victory on behalf of himself which ultimately became the discourse of the people (modern population), a political stake. The subject is not any more a neutral arbitrator, judge, or legislator, as in Solon's or Kant's conceptions. Therefore, what became the "historical subject" must search in history's furor, under the "juridical code's dried blood", the multiple contingencies from which a fragile rationality temporarily finally emerged. This may be, perhaps, compared to the sophist discourse in Ancient Greece. Foucault warns that it has nothing to do with Machiavelli's or Hobbes's discourse on war, for to this popular discourse, the Sovereign is nothing more than "an illusion, an instrument, or, at the best, an enemy. It is {the historico-political discourse} a discourse that beheads the king, anyway that dispenses itself from the sovereign and that denounces it".

History and education

Since Plato's Republic, civic education and instruction has had a central role in politics and the constitution of a common identity. History has thus sometimes become the target of propaganda, for example in historical revisionist attempts. Plato's insistence on the importance of education was relayed by Rousseau's Emile: Or, On Education (1762), a necessary counterpart of The Social Contract (also 1762). Public education has been seen by republican regimes and the Enlightenment as a prerequisite of the masses' progressive emancipation, as conceived by Kant in Was Ist Aufklärung? (What Is Enlightenment?, 1784). 

The creation of modern education systems, instrumental in the construction of nation-states, also passed by the elaboration of a common, national history. History textbooks are one of the many ways through which this common history was transmitted. Le Tour de France par deux enfants, for example, was the Third Republic's classic textbook for elementary school: it described the story of two French children who, following the German annexation of the Alsace-Lorraine region in 1870, go on a tour de France during which they become aware of France's diversity and the existence of the various patois. 

In most societies, schools and curricula are controlled by governments. As such, there is always an opportunity for governments to impose. Granted, often governments in free societies serve to protect freedoms, check hate speech, and breaches of constitutional rights; but the power itself to impose is available to use the education system to influence thought of malleable minds, positively or negatively, towards truth or towards a version of truth. A recent example of the fragility of government involvement with history textbooks was the Japanese history textbook controversies.

Narrative and history

A current popular conception considers the value of narrative in the writing and experience of history. Important thinkers in this area include Paul Ricœur, Louis Mink, W.B. Gallie, and Hayden White. Some have doubted this approach because it draws fictional and historical narrative closer together, and there remains a perceived "fundamental bifurcation between historical and fictional narrative" (Ricœur, vol. 1, 52). In spite of this, most modern historians, such as Barbara Tuchman or David McCullough, consider narrative writing important to their approaches. The theory of narrated history (or historicized narrative) holds that the structure of lived experience, and such experience narrated in both fictional and non-fictional works (literature and historiography) have in common the figuration of "temporal experience." In this way, narrative has a generously encompassing ability to "'grasp together' and integrate ... into one whole and complete story" the "composite representations" of historical experience (Ricœur x, 173). Louis Mink writes that, "the significance of past occurrences is understandable only as they are locatable in the ensemble of interrelationships that can be grasped only in the construction of narrative form" (148). Marxist theorist Fredric Jameson also analyzes historical understanding this way, and writes that "history is inaccessible to us except in textual form ... it can be approached only by way of prior (re)textualization" (82).

History and causality

Narrative and causal approaches to history have often been contrasted or, even, opposed to one another, yet they can also be viewed as complementary. Some philosophers of history such as Arthur Danto have claimed that "explanations in history and elsewhere" describe "not simply an event—something that happens—but a change". Like many practicing historians, they treat causes as intersecting actions and sets of actions which bring about "larger changes", in Danto's words: to decide "what are the elements which persist through a change" is "rather simple" when treating an individual's "shift in attitude", but "it is considerably more complex and metaphysically challenging when we are interested in such a change as, say, the break-up of feudalism or the emergence of nationalism".

Much of the historical debate about causes has focused on the relationship between communicative and other actions, between singular and repeated ones, and between actions, structures of action or group and institutional contexts and wider sets of conditions. John Gaddis has distinguished between exceptional and general causes (following Marc Bloch) and between "routine" and "distinctive links" in causal relationships: "in accounting for what happened at Hiroshima on August 6, 1945, we attach greater importance to the fact that President Truman ordered the dropping of an atomic bomb than to the decision of the Army Air Force to carry out his orders." He has also pointed to the difference between immediate, intermediate and distant causes. For his part, Christopher Lloyd puts forward four "general concepts of causation" used in history: the "metaphysical idealist concept, which asserts that the phenomena of the universe are products of or emanations from an omnipotent being or such final cause"; "the empiricist (or Humean) regularity concept, which is based on the idea of causation being a matter of constant conjunctions of events"; "the functional/teleological/consequential concept", which is "goal-directed, so that goals are causes"; and the "realist, structurist and dispositional approach, which sees relational structures and internal dispositions as the causes of phenomena".

History as propaganda: Is history always written by the victors?

In his "Society must be Defended", Michel Foucault posited that the victors of a social struggle use their political dominance to suppress a defeated adversary's version of historical events in favor of their own propaganda, which may go so far as historical revisionism. (See Michel Foucault's analysis of historical and political discourse above.) Nations adopting such an approach would likely fashion a "universal" theory of history, a manifest destiny in the US, to support their aims, with a teleological and deterministic philosophy of history used to justify the inevitableness and rightness of their victories. 

Wolfgang Schivelbusch's Culture of Defeat took a completely different view—according to him, defeat is a major driver for the defeated to reinvent himself, while the victor—confirmed in his attitudes and methods, dissatisfied by the high losses and paltry gains made, may be less creative and fall back. The concept evokes Hegel's Master–slave dialectics—the master is dependent of the work of the slave, the slave has to take his master's and his own interests into account, gets more knowledge and more insight as the master; and in realising that the world around him was created by his own hands he may gain self-consciousness and emancipation. Schivelbusch worked on three basic examples, the South and its Lost cause after the Civil War, France after the Franco-Prussian War 1870/71, and Germany following World War I. Wolfgang Schivelbusch view includes complex psychological and cultural responses of vanquished nations, from every level of society and sees a need and rise of creativity and various narratives for the defeated.

Within a society Walter Benjamin believed that Marxist historians must take a radically different view point from the bourgeois and idealist points of view, in an attempt to create a sort of history from below, which would be able to conceive an alternative conception of history, not based, as in classical historical studies, on the philosophical and juridical discourse of sovereignty—an approach that would invariably adhere to major states (the victors') points of view. Philosopher Paul Ricoeur asked instead for a plurality in history writing. "We carry on several histories simultaneously, in times whose periods, crises, and pauses do not coincide. We enchain, abandon, and resume several histories, much as a chess player who plays several games at once, renewing now this one, now the another" (History and Truth 186). George Orwell's Nineteen Eighty-Four is a fictional account of the manipulation of the historical record for nationalist aims and manipulation of power.

To some degree, all nations are active in the promotion of such "national stories", with ethnicity, nationalism, gender, power, heroic figures, class considerations and important national events and trends all clashing and competing within the narrative.

With regard to the history of science, the introduction of new paradigms is depicted by Thomas Kuhn's The Structure of Scientific Revolutions. Innovation in science or technology is not based on single experiments or ideas per se, but needs a supportive environment and technical achievements to allow for a change of perspective. In all sorts of science (for e.g. mathematics see Bair et al. 2013) innovative concepts are often being made in parallel (compare Zeitgeist), and the "winning" concept or individual contribution depends not on the idea per se, but other aspects as supportive circumstances, personal networks, usability or simple wording. The process may lead to format wars, which leaves losers and winners behind. 

The Semmelweis reflex is a metaphor for the reflex-like tendency to reject new evidence or new knowledge because it contradicts established norms, beliefs or paradigms, Semmelweis himself being driven into insanity, but his concept prevailing after his death grew in a strong narrative of the history of medicine.

Judgement of history

For Hegel, the history of the world is also the Last Judgement. Hegel adopted the expression "Die Weltgeschichte ist das Weltgericht" ("world history is a tribunal that judges the world"; a quote from Friedrich Schiller's poem "Resignation" (published in 1786) and used to assert the view that History is what judges men, their actions and their opinions.

Since the twentieth century, Western historians have disavowed the aspiration to provide the judgement of history. The goals of historical judgements or interpretations are separate to those of legal judgements, that need to be formulated quickly after the events and be final. The issue of collective memory is related to the issue of the "judgement of history". 

Related to the issue of historical judgement are those of the pretension to neutrality and objectivity. Analytical and critical philosophers of history have debated whether historians should express judgements on historical figures, or if this would infringe on their supposed role. In general, positivists and neopositivists oppose any value-judgement as unscientific.