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

SURGERY

The New Surgery

The discoveries of anesthesia in 1846 and antiseptics in 1865 as well as the rapid expansion of radiology not only set the stage for further developments in established surgical procedures but also opened new fields for surgeons. Because of improved methods and technology, surgical procedures that a generation before had been contemplated with anxiety were viewed in 1910 as almost routine. By the beginning of World War I a surgical revolution established new directions for surgical practice, especially in the realm of neurosurgery, and by the war's end other new contributions to surgery had been made.

Cushing

Modern neurosurgery began in 1907 when Harvey Williams Cushing performed an operation for trigeminal neuralgia (tic douloureux) at Johns Hopkins. Cushing's main contribution to the field of neurosurgery was to develop precision techniques that steadily improved operative effectiveness. One of the main difficulties faced in early brain surgery was almost uncontrollable bleeding; because the texture of brain tissue differed from that of other body tissues, it was not possible to stop bleeding in the brain by already established methods. Cushing developed tiny silver clips for bleeding points in the brain to achieve bloodless operations. Always teaching his students to handle tumors and brain material with gentleness, he also reintroduced simple trephining, sometimes called palliative decompression, to relieve headache and other tumor-related symptoms. Cushing's surgical skill made it possible to save the lives of people who would have died in an earlier era. Through his career as a surgeon and a teacher of surgeons, Cushing established a new basis for brain surgery and defined the techniques for future developments.

World War I and Brain Surgery

In 1912 Cushing became professor of surgery at Harvard and the first surgeon-in-chief of the Peter Bent Brigham Hospital. Early operations to remove brain tumors were discouraging, with many fatalities. But as Gushing gained experience and developed better methods for localization of tumors, he achieved a 90 percent reduction in the brain surgery mortality rate. By 1915 he had removed 130 tumors with 8 percent mortality. During World War I he put his extensive knowledge of the surgical treatment of brain injuries to work in France. In his war journals Gushing described his medical habits. When the wounded came pouring in, he would not permit himself to be rushed into giving up the slow, painstaking methods that were the mainstay of his success. Each time he operated on a wounded soldier, it was a personal matter between that patient and himself—the needs of war were to him insufficient reasons for abandoning the things he had fought for throughout his professional career. The greatest test of his inventive capabilities came one day when a man came in with a shell fragment at the base of his brain. Gushing tried to use a large magnet as well as different instruments and probes to extract the steel shrapnel, but with no success. Finally he inserted a nail with a rounded-off end down three and a half inches to the base of the brain, and the magnet was swung into position. Slowly the nail was withdrawn, but there was nothing on it. Three times he tried it, carefully, slowly, but each time without success. Gushing was about ready to give up, but after he took his gloves off, he decided to try once more. After he gloved up, again the magnet was swung into position, and this time when the nail was withdrawn, there was a small fragment of rough steel on its tip.

Reconstructive Surgery

Until World War I the techniques of plastic surgery were so primitive that such surgery was rarely performed. With the advances made in general surgery and the control of sepsis, however, men were surviving their wounds with features and limbs so shattered and distorted that a return to ordinary life was almost impossible. The need to repair such injuries became a necessity. British and French surgeons led the field, their teams composed of dental surgeons, artists, and physicians skilled in skin and bone grafting. In 1915 New York surgeon F, H. Albee introduced the important reconstructive technique later known as Albee's graft, which he had originally designed for the repair of damage caused to the vertebrae by tuberculosis. Medical personnel returning from the war told of the wonderful results achieved in reconstructive surgery by the surgeons of the American and other Allied armies. One Red Cross worker described a man who had come into the American Red Cross Hospital in Neuilly, France, with the greater part of his face intact but with no nose:

It had been shot off completely, she said, leaving his flesh flat from chin to forehead. We made him a nose to fit him. From the place where his nose had joined to his forehead there hung a little wisp of skin. This was pulled down, stretched every day, and kept dry and healthy by an antiseptic powder. Finally it grew to the correct length for a nose. Then we opened his wrist and grafted a piece of bone to the place where his nose should have been, binding arm and face together until the operation was completed. Then we adjusted the skin, which filled out with healthy flesh, and there was a new nose!

Urology

Another field that witnessed important advances in the 1910s was urology, the branch of medicine that deals with the diagnosis and treatment of diseases of the urinary tract and urogenital system. Hugh H. Young, a Johns Hopkins surgeon, won international fame for his perineal prostatectomy technique, first performed in 1896. He also invented the "punch operation" for removal of tumors of the small median lobe of the prostate. In 1912 he performed this surgery with such success on a wealthy patient, "Diamond Jim" Brady, that the grateful patient provided the funds to construct and partially endow the James Buchanan Brady Urological Institute, a separate unit of the Johns Hopkins Hospital. In 1917 Young founded the Journal of Urology. He continued to train many of the outstanding urologists in the United States in his institute and remained a leader in the field until his death in 1945.

Surgery at the Mayo Clinic

The Mayo Clinic in Rochester, Minnesota, was one of the most famous surgical clinics in the country. By the end of World War I the facilities and achievements of the Mayo Clinic were admired throughout the country and the rest of the world. Its corridors featured a system of colored lights that showed the whereabouts of the senior doctors. Outside the six operating theaters, where up to forty major operations could be performed in a morning, were illuminated signals showing the nature of the operation in progress. Visitors were able to observe without creating a disturbance. The clinic was laid out so that all necessary specialties were close at hand. For example, a pathology laboratory adjoined the theaters; the urology department was next to an X-ray room. The two founding Mayo brothers were brilliant surgeons who traveled throughout the world, watching surgeons at work in distant countries and bringing back to the clinic the best they had seen. Charles Mayo specialized on the abdomen, breast, thryoid, and prostate; and William J. Mayo was interested in the intestines and urinary tract. It was a smooth functioning clinic where all facilities were available, whatever the need of the patient, and was a model for others throughout the country.

Sources:

James Bordley III and A. McGehee Harvey, Two Centuries of American Medicine, 1776-1976 (Philadelphia: W. B. Saunders, 1976);

"Broken Men Remade by Army Doctors," in Medicine and Health Care, edited by Saul Jarcho and Gene Brown (New York: Arno, 1977), p. 84;

Frederick F. Cartwright, The Development of Modern Surgery from 1830 (New York: Crowell, 1967);

John F. Fulton, Harvey Cushing, A Biography (Springfield, I11.: Charles C. Thomas, 1946);

Robert G. Richardson, Surgery: Old and New Frontiers (New York: Scribners, 1968);

Elizabeth H. Thomson, Harvey Cushing, Surgeon, Author, Artist (New York: Collier, 1961).

surgery branch of medicine concerned with the diagnosis and treatment of injuries and the excision and repair of pathological conditions by means of operative procedures (see also anesthesia ; medicine ; radiology ).

Early History

In prehistoric times, sharpened flints and other sharp-edged devices were used to perform various surgical operations. Circumcision and other ritualistic operations were later performed with similar instruments. There are indications that in Neolithic times saws of stone and bone were used to perform amputations. Nearly all major operations were performed by the ancient Hindus nearly a thousand years before the advent of Greek medicine. Knowledge of the use of soporific potions to alleviate the pain caused by surgery can be traced to remote antiquity.

The early Greeks and Romans practiced surgery with great skill and with such cleanliness that infection of surgical and other wounds was relatively uncommon. Their cleanliness and their use of boiled water or wine for irrigating wounds was probably suggested by Hippocrates , a competent surgeon and diagnostician of that time. Other notable early surgeons were Erasistratus and Herophilus of the medical school at Alexandria, and Galen , whose numerous treatises were long influential.

The surgical and sanitary techniques employed by the Greeks and Romans were lost with the decline of their civilizations. During the Middle Ages in Europe there was a marked regression in surgical knowledge, and postoperative infection was common. Surgical practice soon fell into the hands of the unskilled and uneducated: the barber-surgeon, who performed the usual functions of a barber as well as surgical operations, became a common figure, especially in England and France. It was not until the 18th cent. that surgery began to reach a professional level. There were, nevertheless, notable figures in early surgery, among them Guy de Chauliac in the 14th cent., and in the 16th cent. Ambroise Paré , who developed sutures and ligatures to stop bleeding and sew up wounds.

The Birth of Modern Surgery

With the introduction of antiseptic methods, surgery entered its modern phase. Louis Pasteur established the fact that microbes are responsible for infection and disease. Using this knowledge, Dr. Ignaz Semmelweis reduced postpartum infections (puerperal sepsis) in the wards of Vienna's lying-in hospitals by urging doctors to wash their hands between patients. In the 1860s Joseph Lister introduced the use of carbolic acid as a cleansing and disinfecting agent, and his results in reducing infection were dramatic. It was found later that the carbolic acid spray that Lister used to cleanse the air about the patient was unnecessary, but the antiseptic treatment of instruments and other articles in contact with the patient continued until antisepsis was gradually replaced by the aseptic methods employed in modern hospitals. Before the discovery of antisepsis by Lister, about 80% of surgical patients contracted gangrene.

Ernst von Bergmann is credited with introducing steam sterilization under pressure for treating instruments and all other medical equipment used for a surgical patient. William Stewart Halsted , the famous surgeon at Johns Hopkins Hospital, introduced sterile rubber gloves when the hands of his fiancée became irritated from constant washings and antiseptics. The development of methods of anesthesia , especially the discovery in the 1840s of the value of ether, has also been of immeasurable value.

Surgery in the Twentieth Century

In the 20th cent., surgery has benefited from an improved understanding of the causes of shock and its treatment; knowledge of blood group typing and transfusion techniques; understanding of blood clotting and the use of anticoagulants ; and the development of antibiotics to control infection and analgesics to control pain. Surgical instruments have developed along with modern technology and are now sophisticated, meticulously designed devices. Electrically powered surgical instruments are invaluable for cautery and for separating hard tissues such as bone with minimal damage. Surgical stapling instruments, first developed in the Soviet Union, can join blood vessels or other tissues in less than half the time required by hand stitching. New medical glues, surgical tapes, and even zippers now enable surgeons to close some wounds effectively without stitches. With the development of X-ray techniques and fluoroscopy and, later, CAT scans and magnetic resonance imaging (MRI), surgery gained valuable diagnostic instruments. Some operations are now being conducted inside specially adapted MRI devices, allowing the surgeon to have live images for guidance during operations. Holograms can be created using data from MRI and other diagnostic instruments and are beginning to be used in the operating room to give surgeons a three-dimensional image of the area to be operated upon.

Cryogenic, or supercooled, probe beams have been used to precisely remove tissues and abnormal growths. Ultrasound techniques, using very-high-frequency sound waves, are used to break up kidney stones and are employed in brain and inner-ear operations, which require great precision and control. They are also used to scan the pregnant uterus, a process that, unlike X-ray scanning, does not endanger the fetus. Medical lasers , which produce amplified monochromatic light waves in a very narrowly focused beam, have become useful tools in various forms of surgery, notably that of the eye, and are now commonly used to remove or "spot-weld" tissues.

The heart-lung machine made open-heart surgery possible by taking over the blood-pumping and breathing functions of these organs during operations. Hypothermia, or cold surgery, by which the body is cooled to lower the rate of metabolism, thus reducing the need for oxygen, has made long operations, especially those involving transplantation , possible. Other recent transplantation advances include procedures involving the liver, lungs, pancreas, bone marrow, and the kidney. The first human heart transplant was performed in 1967 by South African surgeon Christiaan Barnard . The usefulness of transplantation is currently limited by the fact that drugs must be used constantly to halt the body's rejection of foreign tissue.

New techniques in orthopedic surgery (see also orthopedics ) have also been introduced, including the use of cementing substances to unite bones destroyed by tumor and the replacement of joints with metal or plastic devices. Plastic surgery and reconstructive surgery have made enormous strides, and microsurgery is making severed or injured limbs usable.

A trend toward less invasive surgery and shorter hospital stays began in the 1980s. By 1995 more than 56% of all surgical procedures in the United States were done on an outpatient basis, without an overnight stay in a hospital. Endoscopic surgery, using small incisions and tiny instruments attached to fiber-optic viewing devices (see endoscope ), has been used in place of more traditional procedures for gall-bladder surgery, and it has been used on the fetus in the womb to correct life-threatening birth defects before birth. Angioplasty is frequently used to circumvent or postpone the need for coronary artery bypass.

Bibliography

See O. H. Wangensteen and S. D. Wangensteen, The Rise of Surgery (1979); R. Selzer, Confessions of a Knife (1979); A. S. Earle, Surgery in America: From the Colonial Era to the Twentieth Century (1965, rev. ed. 1983); R. M. Youngson, The Surgery Book (1993).

Surgery. Surgery in colonial America was taught chiefly by apprenticeship and practiced in the patient's home. Unlike English surgeons, who formed a profession apart from physicians and apothecaries, American surgeons were distinguished from physicians neither by licensure nor societies. The establishment of hospitals and medical colleges in Philadelphia and New York City during the late Colonial Era and the resumption of European travel after the Revolutionary War offered surgeons educational options besides apprenticeship. Many prominent late eighteenth‐ and nineteenth‐century American physicians who advanced both the teaching and practice of surgery—such as Philip Syng Physick in Philadelphia, the nation's first professor of surgery; Valentine Mott and David Hosack in New York City; and Boston's Oliver Wendell Holmes Sr.—trained in European hospitals and imported European ideas and techniques. American physicians took pride in their surgical skills and in such innovations as Ephraim McDowell's 1809 ovariotomy and J. Marion Sim's 1849 vesicovaginal fistula.

After William T.G. Morton, a dentist, developed sulfuric ether as an anesthetic, John Collins Warren, of a prestigious Boston medical family, and Henry Jacob Bigelow introduced it on 16 October 1845 at the Massachusetts General Hospital. Within ten years, the surgical use of anesthesia had spread around the world, enhancing the prestige of American surgery.

Although anesthesia removed the fear of pain from surgery, surgical infections remained a problem. In 1867 the Scottish surgeon Joseph Lister announced an antiseptic method of treating surgical wounds. That same year, several American surgeons adopted Lister's carbolic acid spray—thereby touching off a twenty‐year debate over whether or not Louis Pasteur's and Robert Koch's newly announced germ theory of disease adequately explained surgical sepsis. By the 1890s aseptic surgery—performed in a germ‐free surgical area with sterilized equipment—became the norm in American surgery. William Stewart Halsted's popularization of the surgical rubber glove around 1890 proved a notable American contribution to asepsis.

In the 1870–1920 era, reforms of medical education at Harvard, the University of Pennsylvania, and especially Baltimore's Johns Hopkins University Medical School and Hospital improved the surgeon's education and professional status. Rigorous and lengthy clinical training replaced the short courses, European Wanderjahre, and apprenticeships of antebellum America. Although surgical education remained closely linked to medical education generally, surgeons began to form their own professional societies. The American Surgical Association, founded in 1880, first met in 1882, and launched a journal, the Transactions of the American Surgical Association, in 1883. A century later, several specialized associations and journals reflected surgery's diversity.

Throughout the nineteenth century, surgeons continued to operate mostly in the patient's home and limited themselves mainly to such procedures as amputations, hernia repair, and the excision of growths. After 1900, the hospital increasingly became the locus of surgical activity. The evolution of hospitals and operating rooms into complex institutions, technologically and organizationally, gave rise to ancillary disciplines such as surgical nursing, radiology, and anesthesiology and encouraged the growth of pharmaceutical and surgical‐instrument industries. Among the first surgeons to specialize were the pioneering neurosurgeons Harvey Cushing at the Harvard Medical School and the Peter Bent Brigham Hospital and Walter Dandy at the Johns Hopkins Memorial Hospital. In 1902 Alexis Carrel aseptically rejoined severed blood vessels without thrombosis; in 1905 he and Charles Claude Guthrie transplanted a dog's kidney. Although the dog died, the dream did not.

The application of ideas or inventions initially unconnected with surgery often spurred the development of the field. Karl Landsteiner's discovery of blood types in 1901 removed the theoretical barrier to blood transfusions; George Washington Crile performed the first successful transfusion between patients in 1905. When the pharmaceutical and technical problems of blood storage were solved by the end of World War II, blood loss and shock disappeared as major hurdles to surgical procedures. Advances in immunology, genetics, and pharmacology enabled Joseph Murray to accomplish the first successful kidney transplant in 1954. Thomas Starzl, using cyclosporin, developed the protocols for successful liver transplants, and Francis Moore and Norman Shumway, among others, developed them for heart transplants. Lasers transformed ophthalmic surgery, while CT (computerized tomography) scans and MRIs (magnetic resonance imaging) extended imaging technology far beyond the X ray. Helen Taussig and Alfred Blalock developed a surgical correction for the tetralogy of Fallot (“blue babies”) in 1944, using insights gained from fluoroscope images and advances on Carrel's method. If inventions stimulated surgery, the reverse was likewise true. Difficulties in thoracic and cardiac surgery, for example, motivated John H. Gibbon's invention of the heart‐lung machine during the 1940s. This, in turn, made open‐heart surgery possible, and prompted Medtronics, Inc., to develop the pacemaker in the 1950s. Orthopedic surgery grew with improvements in prosthetic devices.

The individualism and technical virtuosity of eighteenth‐ and nineteenth‐century surgery gave way in the twentieth to teamwork and a more solid scientific foundation. The Mayo Clinic in Rochester, Minnesota, for example, gained fame for its advancement of the surgical arts and for being one of the first American medical group practices. William Halsted's importance in the annals of surgery derives not only from his introduction of rubber gloves and improved surgical techniques, but also from his insistence that surgery be pursued collaboratively with the basic clinical sciences. Owen H. Wangensteen of the University of Minnesota Medical School, like Halsted, taught generations of future surgeons that surgery rests on scientific foundations. In 1952 a team at Minnesota headed by C. Walton Lillehei successfully conducted the first open‐heart surgery under direct vision, an achievement made possible by collaboration among cardiac physiologists, anatomists, and surgeons.
See also Heart Disease; Medicine; Pharmaceutical Industry.

Bibliography

Martin S. Pernick , A Calculus of Suffering: Pain, Professionalism, and Anesthesia in Nineteenth‐Century America, 1985.
Charles E. Rosenberg , The Care of Strangers: The Rise of America's Hospital System, 1987.
Ira M. Rutkow , The History of Surgery in the United States 1775–1900, 2 vols., 1988, 1992.
Christopher Lawrence, ed., Medical Theory, Surgical Practice: Studies in the History of Surgery, 1992.
Joel D. Howell , Technology in the Hospital: Transforming Patient Care in the Early Twentieth Century, 1995.

Thomas P. Gariepy

Surgery

Surgery is the treatment of disease or injury by cutting into the body to repair or remove the injured or diseased body part. Surgery is usually performed by surgeons in the operating room of a hospital or clinic.

Ancient surgeons

Surgery has been performed since ancient times. The earliest surgical operations were circumcision (removal of the foreskin of the penis) and trepanation (cutting a hole in the skull for the release of pressure or "demons"). Stone Age skulls bearing holes from trepanning have been found around the world. The ancient Egyptians practiced surgery as early as 2500 b.c. using sharp instruments made of copper. The ancient Hindus of India excelled at surgery, performing tonsillectomies, plastic surgery, and removal of bladder stones and cataracts (a clouding of the lens of the eye). The Greeks and Romans used a variety of instruments, including forceps, knives, probes, and scalpels, to operate on wounds and amputate limbs.

During the Middle Ages (400–1450), medical knowledge slowed, and those performing operations, called barber-surgeons, often possessed little education or skill. Without knowledge of antisepsis (techniques to prevent infection), surgery was extremely risky and often resulted in complications or death of the patient.

After the Middle Ages, efforts were made to elevate the status of surgery to a level of some prestige and professionalism. Instrumental in this effort was the great French surgeon Ambroise Paré (1517–1590). Paré introduced the use of ligature (material such as thread or wire) for the tying of blood vessels to prevent excessive bleeding during amputations. His medical writings, which include information on anatomy and discussion of new surgical techniques, greatly influenced his fellow barber-surgeons and advanced the surgical profession.

Era of modern surgery

The era of modern surgery began in the nineteenth century with the introduction of anesthesia (techniques to lessen pain), antiseptic methods, and sterilization of instruments. The discovery of the X ray in 1895 gave surgeons an invaluable diagnostic tool. X rays are a form of radiation that can penetrate solids and are used to generate images of bones and other tissues. Diagnoses using X rays were followed by diagnoses using ultrasound, computerized axial tomography (CAT) scanning, and magnetic resonance imaging (MRI).

Words to Know

Anesthesia: Method of decreasing sensitivity to pain in a patient so that a medical procedure may be performed.

Barber-surgeon: Name given to often unskilled and uneducated persons who practiced surgery during the Middle Ages.

Computerized axial tomography (CAT scan): An X-ray technique in which a three-dimensional image of a body part is put together by computer using a series of X-ray pictures taken from different angles along a straight line.

Endoscope: Instrument for examining internal body cavities or organs.

Laser: A device that sends out a high-intensity beam of light.

Ligature: Material such as thread used to tie a blood vessel or bind a body part.

Magnetic resonance imaging (MRI): A technique for producing computerized three-dimensional images of tissues inside the body using radio waves.

Trepanation: The removal of a circular piece of bone, usually from the skull.

Ultrasound: A diagnostic technique that uses sound waves to produce an image.

X ray: A form of electromagnetic radiation that can penetrate solids that are used to generate images of bones and other tissues.

Surgery advances in the twentieth century include techniques for performing blood transfusions, brain and heart operations (such as bypass surgery and valve replacement), organ transplantation, microsurgery, and laser surgery. Microsurgery allows surgeons to perform precise, delicate operations on various body structures while viewing the surgical area through a microscope. Lasers, high-intensity beams of light focused at targeted tissues, are used to treat eye disorders, break up kidney stones and tumors, and remove birthmarks, wrinkles, and spider veins.

Some types of surgery that previously required extensive cutting through body tissue can now be accomplished using less invasive techniques. Endoscopic surgery is a method of operating on internal body structures, such as knee joints or reproductive organs, by passing an instrument called an endoscope through a body opening or tiny incision. Tiny surgical instruments and a miniature video camera, allowing viewing of the area to be operated on, are attached to the endoscope.

Plastic surgery, including cosmetic surgery, has flourished in the twentieth century. Plastic surgery is the reconstruction or repair of damaged

tissue due to injury, birth defects, severe burns, or diseases such as cancer. Cosmetic surgery is increasingly popular for both men and women and includes facelifts, breast enlargement and reduction, nose reshaping, and liposuction (removal of fat from tissues).

A dramatic advance in recent years is fetal surgery, in which procedures such as blood transfusions or correction of a life-threatening hernia (rupture) or urinary tract obstruction are performed on the unborn fetus while the mother is under general anesthesia.

[See also Plastic surgery ]

388. Surgery

See also 266. MEDICAL SPECIALTIES .

ablation

Medicine. removal of part of the body by surgery.

apocope

excision or amputation.

cauterism

Obsolete, cautery.

cautery

the act of cauterization, or burning away of dead tissue.

centesis

a surgical perforation or puncture.

chirurgery

Archaic. surgery.

comminution

the breaking of a bone into small pieces. See also 52. BONES .

craniotome

a surgical instrument for opening a hole in the skull.

cryosurgery

a surgical technique using freezing to destroy tissue.

dermatoplasty

any form of plastic surgery of the skin, as skin grafts.

elytroplasty

surgery of the vagina.

neoplasty

repair or restoration of part of the body by plastic surgery.

osteoplasty

the surgical practice of bone-grafting.

osteotome

a serrated instrument for bone surgery.

osteotomy

1. the dissection or anatomy of bones.

2. the cutting of bones as part of a surgical operation. —osteotomist, n.

prosthetics

the branch of surgery dealing with the replacement of missing limbs or organs with artificial substitutes. — prosthetic, adj.

tomomania

an obsession with surgery.

traumatonesis

the process of suture.

vasectomy

surgical excision of part of the vas deferens, the duct which carries sperm from the testes, performed as a form of male contraception.

zooplasty

the process of surgically grafting tissue from a lower animal onto the human body. —zooplastic, adj.

sur·ger·y / ˈsərjərē/ • n. (pl. -ger·ies) 1. the branch of medicine concerned with treatment of injuries or disorders of the body by incision or manipulation, esp. with instruments: cardiac surgery. ∎  such treatment, as performed by a surgeon: he had surgery on his ankle. 2. Brit. a place where a doctor, dentist, or other medical practitioner treats or advises patients. ∎  [in sing.] an occasion on which such treatment or consultation occurs: Doctor Bailey had finished his evening surgery.

surgery Branch of medical practice concerned with treatment by operation. Traditionally, it has mainly involved open surgery: gaining access to the operative site by way of an incision. However, the practice of using endoscopes enabled the development of ‘keyhole surgery’, using minimally invasive techniques. Surgeons perform operations under sterile conditions, using local or general anaesthesia.

surgery (serj-er-i) n. the branch of medicine that treats injuries, deformities, or disease by operation or manipulation. See also cryosurgery, microsurgery.
—surgical adj.

surgery •beery, bleary, cheery, dearie, dreary, Dun Laoghaire, eerie, eyrie (US aerie), Kashmiri, leery, peri, praemunire, query, smeary, teary, theory, weary •Deirdre • incendiary • intermediary •subsidiary •auxiliary, ciliary, domiciliary •apiary • topiary • farriery • furriery •justiciary •bestiary, vestiary •breviary • aviary • hosiery •diary, enquiry, expiry, fiery, friary, inquiry, miry, priory, spiry, wiry •podiatry, psychiatry •dowry, floury, flowery, loury, showery, towery •brewery • jewellery (US jewelry) •curie, de jure, fioriture, fury, houri, Jewry, jury, Manipuri, Missouri, moory, Newry, tandoori, Urey •statuary • actuary • sanctuary •obituary • sumptuary • voluptuary •January • electuary • ossuary •mortuary •Bradbury, Cadbury •blackberry, hackberry •cranberry • waxberry •Barbary, barberry •Shaftesbury • raspberry •bayberry, blaeberry •Avebury • Aylesbury • Sainsbury •bilberry, tilbury •bribery •corroboree, jobbery, robbery, slobbery, snobbery •dogberry • Roddenberry • Fosbury •strawberry • Salisbury •crowberry, snowberry •chokeberry •Rosebery, Shrewsbury •blueberry, dewberry •Dewsbury • Bloomsbury • gooseberry •blubbery, rubbery, shrubbery •Sudbury • mulberry • huckleberry •Bunbury • husbandry • loganberry •Canterbury • Glastonbury •Burberry, turbary •hatchery • archery •lechery, treachery •stitchery, witchery •debauchery • butchery • camaraderie •cindery, tindery •industry • dromedary • lapidary •spidery • bindery • doddery •quandary • powdery • boundary •bouldery • embroidery •prudery, rudery •do-goodery • shuddery • thundery •prebendary • legendary • secondary •amphorae • wafery •midwifery, periphery •infantry • housewifery • spoofery •puffery • sulphury (US sulfury) •Calgary •beggary, Gregory •vagary •piggery, priggery, whiggery •brigandry • bigotry • allegory •vinegary • category • subcategory •hoggery, toggery •pettifoggery • demagoguery •roguery • sugary •buggery, skulduggery, snuggery, thuggery •Hungary • humbuggery •ironmongery • lingerie • treasury •usury • menagerie • pageantry •Marjorie • kedgeree • gingery •imagery • orangery • savagery •forgery • soldiery • drudgery •perjury, surgery •microsurgery •hackery, quackery, Thackeray, Zachary •mountebankery • knick-knackery •gimcrackery • peccary • grotesquerie •bakery, fakery, jacquerie •chickaree, chicory, hickory, Terpsichore, trickery •whiskery • apothecary •crockery, mockery, rockery •falconry • jiggery-pokery •cookery, crookery, rookery •brusquerie •puckery, succory •cuckoldry •calorie, gallery, Malory, salary, Valerie •saddlery • balladry • gallantry •kilocalorie • diablerie • chandlery •harlotry • celery • pedlary •exemplary •helotry, zealotry •nailery, raillery •Tuileries •ancillary, artillery, capillary, codicillary, distillery, fibrillary, fritillary, Hilary, maxillary, pillory •mamillary • tutelary • corollary •bardolatry, hagiolatry, iconolatry, idolatry •cajolery, drollery •foolery, tomfoolery •constabulary, vocabulary •scapulary • capitulary • formulary •scullery • jugglery • cutlery •chancellery • epistolary • burglary •mammary • fragmentary •passementerie • flimflammery •armory, armoury, gendarmerie •almonry •emery, memory •creamery • shimmery • primary •rosemary • yeomanry •parfumerie, perfumery •flummery, Montgomery, mummery, summary, summery •gossamery • customary • infirmary •cannery, granary, tannery •canonry •antennary, bimillenary, millenary, venery •tenantry • chicanery •beanery, bicentenary, catenary, centenary, deanery, greenery, machinery, plenary, scenery, senary, septenary •disciplinary, interdisciplinary •hymnary • missionary •ordinary, subordinary •valetudinary • imaginary • millinery •culinary • seminary • preliminary •luminary • urinary • veterinary •mercenary • sanguinary •binary, finery, pinery, quinary, vinery, winery •Connery • Conakry • ornery • joinery •buffoonery, poltroonery, sublunary, superlunary •gunnery, nunnery •consuetudinary • visionary •exclusionary • legionary • pulmonary •coronary • reactionary • expansionary •concessionary, confessionary, discretionary •confectionery, insurrectionary, lectionary •deflationary, inflationary, probationary, stationary, stationery •expeditionary, petitionary, prohibitionary, traditionary, transitionary •dictionary • cautionary •ablutionary, counter-revolutionary, devolutionary, elocutionary, evolutionary, revolutionary, substitutionary •functionary •diversionary, reversionary •fernery, quaternary, ternary •peppery • extempore • weaponry •apery, drapery, japery, napery, papery, vapoury (US vapory) •frippery, slippery •coppery, foppery •popery • dupery • trumpery •February • heraldry • knight-errantry •arbitrary • registrary • library •contrary • horary • supernumerary •itinerary • honorary • funerary •contemporary, extemporary, temporary •literary • brasserie • chancery •accessory, intercessory, pessary, possessory, tesserae •dispensary, incensory, ostensory, sensory, suspensory •tracery •pâtisserie, rotisserie •emissary • dimissory •commissary, promissory •janissary • necessary • derisory •glossary • responsory • sorcery •grocery • greengrocery •delusory, illusory •compulsory • vavasory • adversary •anniversary, bursary, cursory, mercery, nursery •haberdashery •evidentiary, penitentiary, plenipotentiary, residentiary •beneficiary, fishery, judiciary •noshery • gaucherie • fiduciary •luxury • tertiary •battery, cattery, chattery, flattery, tattery •factory, manufactory, olfactory, phylactery, refractory, satisfactory •artery, martyry, Tartary •mastery, plastery •directory, ex-directory, interjectory, rectory, refectory, trajectory •peremptory •alimentary, complementary, complimentary, documentary, elementary, parliamentary, rudimentary, sedimentary, supplementary, testamentary •investigatory •adulatory, aleatory, approbatory, celebratory, clarificatory, classificatory, commendatory, congratulatory, consecratory, denigratory, elevatory, gyratory, incantatory, incubatory, intimidatory, modificatory, participatory, placatory, pulsatory, purificatory, reificatory, revelatory, rotatory •natatory • elucidatory • castigatory •mitigatory • justificatory •imprecatory • equivocatory •flagellatory • execratory • innovatory •eatery, excretory •glittery, jittery, skittery, twittery •benedictory, contradictory, maledictory, valedictory, victory •printery, splintery •consistory, history, mystery •presbytery •inhibitory, prohibitory •hereditary • auditory • budgetary •military, paramilitary •solitary • cemetery • limitary •vomitory • dormitory • fumitory •interplanetary, planetary, sanitary •primogenitary • dignitary •admonitory, monitory •unitary • monetary • territory •secretary • undersecretary •plebiscitary • repository • baptistery •transitory •depositary, depository, expository, suppository •niterie •Godwottery, lottery, pottery, tottery •bottomry • watery • psaltery •coterie, notary, protonotary, rotary, votary •upholstery •bijouterie, charcuterie, circumlocutory •persecutory • statutory • salutary •executory •contributory, retributory, tributary •interlocutory •buttery, fluttery •introductory • adultery • effrontery •perfunctory • blustery • mediatory •retaliatory • conciliatory • expiatory •denunciatory, renunciatory •appreciatory, depreciatory •initiatory, propitiatory •dietary, proprietary •extenuatory •mandatary, mandatory •predatory • sedentary • laudatory •prefatory • offertory • negatory •obligatory •derogatory, interrogatory, supererogatory •nugatory •expurgatory, objurgatory, purgatory •precatory •explicatory, indicatory, vindicatory •confiscatory, piscatory •dedicatory • judicatory •qualificatory • pacificatory •supplicatory •communicatory, excommunicatory •masticatory • prognosticatory •invocatory • obfuscatory •revocatory • charlatanry •depilatory, dilatory, oscillatory •assimilatory • consolatory •voluntary • emasculatory •ejaculatory •ambulatory, circumambulatory, perambulatory •regulatory •articulatory, gesticulatory •manipulatory • copulatory •expostulatory • circulatory •amatory, declamatory, defamatory, exclamatory, inflammatory, proclamatory •crematory • segmentary •lachrymatory •commentary, promontory •informatory, reformatory •momentary •affirmatory, confirmatory •explanatory • damnatory •condemnatory •cosignatory, signatory •combinatory •discriminatory, eliminatory, incriminatory, recriminatory •comminatory • exterminatory •hallucinatory • procrastinatory •monastery • repertory •emancipatory • anticipatory •exculpatory, inculpatory •declaratory, preparatory •respiratory • perspiratory •vibratory •migratory, transmigratory •exploratory, laboratory, oratory •inauguratory • adjuratory •corroboratory • reverberatory •refrigeratory • compensatory •desultory • dysentery •exhortatory, hortatory •salutatory • gustatory • lavatory •inventory •conservatory, observatory •improvisatory •accusatory, excusatory •lathery •feathery, heathery, leathery •dithery, slithery •carvery •reverie, severy •Avery, bravery, knavery, quavery, Savery, savory, savoury, slavery, wavery •thievery •livery, quivery, shivery •silvery •ivory, salivary •ovary •discovery, recovery •servery • equerry • reliquary •antiquary • cassowary • stipendiary •colliery • pecuniary • chinoiserie •misery • wizardry • citizenry •advisory, provisory, revisory, supervisory •causerie, rosary