surgery

surgery The word ‘surgery’ comes from the Greek cheirourgen, made up of cheir — hand and ergo — to work. Literally the term means ‘to work with the hand’. Surgery can therefore be defined as those manual procedures used in the management of injuries and disease.

Throughout his existence, man has been an aggressive animal and has always been the subject of violence; contusions, fractures, dislocations, impalements, eviscerations, and so on. The earliest surgeons were no doubt those men and women who showed particular interest and skill in dealing with the injuries. Long before written records existed, we have to rely on the only available evidence, obtained from ancient skeletons, to learn something of the diseases which afflicted primitive man and of the earliest surgical endeavours. Archaeologists have unearthed evidence of arthritis, bone infections, and bone tumours from the earliest times. Fractures, of course, are obvious, and splints of wood and of bark recovered from excavations from tombs of the Fifth Dynasty in Egypt have been dated at approximately 2450 bc. However — remarkably and inexplicably — the earliest major surgery of which we have undoubted evidence is trephination of the skull, which dates back to at least 5000 bc in the Stone Age period. Not only did these primitive surgeons, using no more than crude flint or stone instruments, actually bore holes through the skull, but undoubtedly a proportion at least of their patients survived. We know this because about half of the skulls that have been excavated show evidence of healing around the edges of the bone defect. Others show that repeated operations had been performed. Moreover, this procedure was performed in widely different areas of the world. Trephined skulls have been excavated in Western Europe (including England), North Africa, Asia, the East Indies, and New Zealand. In the New World, evidence has been found of the operation in Alaska and down through the Americas to Peru.

There are many unanswered questions about this remarkable operation. There might be a single trephine defect or up to seven in number. Size could vary from a tiny hole to two or more inches in diameter. The operation was performed on men, women, and children. Did this operation, which is today regarded as a sophisticated procedure to be done by an expert neurosurgeon, arise spontaneously in numerous centres throughout the world, or did knowledge of the operation spread gradually from centre to centre? Why was the operation performed? In many cases it was undoubtedly carried out because of injury to the skull. This is particularly so in Peruvian skulls, where fractures in the region of the trephine were commonly found. Among the ancient Peruvians large clubs of wood and stone, and also hatchets have been excavated — reason enough for the production of serious skull injuries. In many other examples, however, there is no evidence of skull injury, and evidence that the operation was repeated at intervals of time. We can only guess that it might have been performed in patients who suffered from mental illness, intractable headache, or epilepsy in order to let out the demon which had possessed the patient — belief in such demons is still held in some primitive races.

To perform safe and effective surgical operations, four major hurdles had to be overcome:(i) The surgeon has to have an effective knowledge of the anatomy of the body.(ii) He must be able to control haemorrhage effectively, whether this is the result of trauma or follows his own surgical incision.(iii) Effective pain relief is necessary in order to spare the patient the agonies of the knife: the development of anaesthesia. Without this, the patient will only submit to the surgeon when his symptoms are intolerable, and then will only allow the shortest and quickest procedure to be carried out.(iv) There must be effective control of infection of the wound, both by the prevention of the access of bacteria (antiseptic and aseptic surgery) and by having the means of killing bacteria which have already invaded the tissues (antibiotics).

These four barriers were successfully overcome over a period of many centuries.

Appreciation of the body's anatomy

In the centuries before an understanding of human anatomy, surgical procedures were necessarily both limited and crude. The major advance was the introduction of human dissection in the European medical schools in the sixteenth century. An important landmark was the publication of the first comprehensive and fully illustrated textbook of human anatomy by Andreas Vesalius in 1543. Surgeons were now at least familiar with the location and relationships of anatomical structures, which enabled them, for example, to expose injured blood vessels and to appreciate what structures might be injured in deep body wounds. Of course, the scope of their endeavours was still seriously limited by the other three problems listed above.

Control of haemorrhage

For centuries, major haemorrhage from injured blood vessels was controlled by pressure or by the application of the cautery iron — what amounts to a red-hot poker. Not only was this inefficient but, of course, it was also horrifyingly painful. The alternative of tying the damaged vessel with a ligature had been employed by various surgeons dating back to Celsus, a Roman medical author in the first century ad. A great advance was made by the French surgeon Ambroise Paré (1510–90) — a contemporary of Vesalius, and who actually met him once in consultation; he taught that ligation of blood vessels was safer and far kinder in major operations, especially in amputations. From then on, the control of haemorrhage became a safer and more accurate procedure.

Relief of pain

The agonizing pain of surgical procedures, whether to deal with a major wound, a fractured bone, an amputation, or removal of a tumour, was a major obstacle to the development of surgery. Surgeons would attempt to stupefy the patient with alcohol, opium, or morphia, but with little effect. It was the discovery of the anaesthetic properties of ether by William Morton (1811–68), a dentist in Boston, in 1846, and of chloroform by Sir James Young Simpson (1811–70) of Edinburgh, in the following year, that at last allowed the surgeon to carry out his procedures painlessly and in an unhurried manner under general anaesthesia.

Control of infection

Infection, the fourth in our list of problems, was the greatest impediment to surgical progress and the last to be conquered. Over the centuries, the wounds which surgeons were tending, either as a result of injury or inflicted by themselves on their patients, would swell, redden, and suppurate with the discharge of pus. Indeed, this was regarded as the normal process of wound healing. The patient often became severely ill from the general manifestations of infection — fever, rigors, and toxaemia — and was very likely to die when this occurred. Nowadays, of course, we know that both the local and the general effects of infection are due to bacterial contamination of the wound. It was Louis Pasteur (1822–95) who proved conclusively that putrefaction of milk, urine, meat, and wine was due to bacteria and not merely to exposure to the air. It was the genius of Joseph Lister (1827–1919), the professor of surgery in Glasgow, to realize that it was these bacteria, carried into the wound, which resulted in the suppuration, pus, gangrene, and other dreaded complications which plagued the surgical wards of those days. It was obviously impossible to kill microbes in the wound by means of heat as Pasteur had shown in his experiments, so Lister developed chemical methods to destroy the bacteria, initially carbolic acid. Lister's first operation using this antiseptic method was in 1865, and he was soon able to show that major surgery could be performed with what had virtually never been seen before: healing without infection. The next stage was to progress beyond killing the bacteria that reached the wound to the prevention of contamination by eliminating bacteria from the operating theatre — aseptic surgery, with steam sterilization of instruments, dressings, and gowns, and the other rituals of the modern operating theatre.

Since the days of Lister, the dream had been to discover an agent that would kill the bacteria that spread through the body, without damaging the patient, as well as dealing with local contamination of the wound. It was Howard Florey, Ernst Chain, and their team in Oxford who succeeded in extracting penicillin in 1941. Its effects in both the prevention and the treatment of wound sepsis were dramatic and heralded the onset of today's ‘antibiotic era’.

The conquest of pain, haemorrhage, and infection, together with today's detailed knowledge of the anatomy and physiology of the human body and its derangements under pathological conditions, has opened the way to the extraordinary burgeoning of surgery in the past century or so, with advances being made in the past decades in what seems like geometrical progression. Only some aspects of this vast subject can be chosen here to illustrate this theme.

Abdominal surgery

Abdominal cancers are common and serious problems, and were among the first conditions to be dealt with in the post-Lister period. In 1881, Theodor Billroth (1829–94) carried out the first successful resection of a carcinoma of the stomach, soon to be followed by successes in dealing with cancers of the large bowel, kidney, and other structures. Abdominal emergencies, previously almost invariably fatal, were soon shown to be curable by surgery. Removal of the appendix for acute appendicitis, repair of perforated peptic ulcers, and removal of the ruptured spleen after trauma all became routine procedures.

Cardiac surgery

It was long thought that even touching the heart would be fatal, and it was not until 1897 that Ludwig Rehn (1849–1930) performed the first successful repair of a wound of the heart. Henry Souttar (1875–1964) made a considerable advance in 1925 when he passed his finger through the wall of the heart to dilate a stenosed mitral valve, an operation that was popularized by Harken in 1948. However, to perform careful procedures on the open heart itself under direct vision, the heart must be put out of circulation and stopped. This required the development of an effective pump oxygenator, which was developed successfully by Gibbon in the US and Melrose in London, allowing the first successful operation with this technique to be carried out by Lillehei in 1956. It was now possible to repair complicated congenital anomalies of the heart, replace diseased and defective valves (either with artificial valves or using pig or human cadaver valves preserved by freeze-drying), and, most commonly of all, to perform bypass operations on occluded coronary arteries, using either a superficial vein taken from the leg or an artery from the front of the ribs. This procedure, the coronary artery bypass graft, is now performed in tens of thousands of patients each year.

Minimal access surgery

Refinement in fibreoptic technology and engineering have produced instruments which are used for so-called ‘keyhole’ surgery. Fine tools can be passed into the abdominal and chest cavities so that many operations which previously required major incisions can now be performed through quite small puncture wounds. This is particularly well established in gynaecological surgery and in operations upon the gall bladder, and techniques are being devised for similar operations on other organs. This technology also involves the development of instruments to pass along every tube in the body, for example to remove obstructions in the oesophagus, bile ducts, bowel, prostate, and major blood vessels. Many procedures on joints — for example, removal of a torn cartilage from the knee — can now be performed safely, using these minimal access techniques.

Harold Ellis

See also anaesthesia, general; anatomy; dissection.