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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.

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surgery

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, and models created using 3D printers may be used in preparing for complex surgeries.

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. and S. D. Wangensteen, The Rise of Surgery (1979); R. Selzer, Confessions of a Knife (1979); A. S. Earle, Surgery in America (1965, rev. ed. 1983); R. M. Youngson, The Surgery Book (1993); N. L. Tilney, Invasion of the Body (2011).

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Surgery

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 (4001450), 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 (15171590). 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 ]

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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.

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surgery

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.

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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.

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surgery

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.

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surgery

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Surgery

Surgery

Ancient surgeons

The sponge of sleep

Beyond boiling oil

A sanitary leap forward

The modern era

Heart of hearts

A prettier face

Fetal surgery

Surgery of the future

Resources

Surgery is the part of medicine that employs operative or manual treatment of disease or injury. Although surgery was practiced in ancient times, modern anesthesia was not developed until the nineteenth century. For centuries, most types of operative surgery involved high risk to patients due to infection. With the development of antiseptic surgical methods in the nineteenth century, the risks linked to surgery diminished. Some types of surgery remain risky, but many have high rates of success. Advances in technological knowledge offer new horizons in surgery.

Ancient surgeons

Traditionally, wars have been the proving ground of surgeons and new types of surgery. Early surgeons developed methods to anesthetize their patients and tools to operate effectively. Because there was no global communication, many surgical advances

remained geographically isolated. The Western tradition of medicine developed independently of traditions in India, South America, and elsewhere, although traders and others reported some medical advances.

One of the earliest operative practices was trepanation, or the making of a hole in the head. Evidence of trepanation is present in skulls of individuals who lived as long ago as 10,000 BC in areas ranging from Northern Africa to Tahiti, France, and Peru. Ancient surgeons appear to have performed trepanation for reasons ranging from the relief of pressure on the brain, due to head injury, to the release of demons. The practice is still used in some cases to relieve pressure on the brain.

Ancient Egyptians also practiced surgery. According to the Smith Papyrus, a document written about 1600 BC, Egyptians were well acquainted with a variety of surgical problems. They set broken collarbones using splints, treated medical problems ranging from tumors to fractures, and treated wounds with an adhesive plaster.

Surgery was also mentioned in the Code of Hammurabi, the code of law developed in 1760 BC during the reign of the Mesopotamian King Hammurabi. The code called for strict discipline of surgeons. Surgeons who caused the death of a free man in surgery were to have their right hand amputated as punishment, while surgeons who damaged a slave had to repay the owner for the value of the slave.

Greeks and Romans used surgery as a last resort. The Greeks used herbs mixed in wine or water to dress and clean wounds, and performed surgical procedures ranging from trepanation to the cauterization of blood vessels.

The Greeks used a number of natural anesthetics, including opium and the mandrake, a plant that can have a narcotic affect. A first century Greek physician in Neros army wrote that after using mandrake, patients receiving surgery do not apprehend the pain, because they are overborn with dead sleep. The Greeks also developed anatomical studies based on the dissection of human bodies. Dissection for the advance of medical knowledge was forbidden during the Roman Era and during the Middle Ages, and was not revived until the fifteenth century.

The Romans developed many new surgical procedures. Roman surgeons used dilators to take barbed arrows out of wounds, amputated limbs, performed plastic surgery, and developed techniques for removing bladder stones, hernias, and cataracts.

Surgery also flourished in the first century AD in India. Medical texts document the practice of operations ranging from tonsillectomy to plastic surgery. Certain practices sound familiar, such as the use of an operating room, the use of various types of forceps, and the use of anesthesia to reduce pain. One anesthetic used was burning hemp, the plant used today in the drug marijuana. Indians also fumigated the area where surgery was to take place to reduce infection.

Other practices suggest a far different place and time, including the use of large black ants as clips for tears in the intestines. As India continued to develop its medical tradition, the Middle Ages descended on Western Europe, casting a cloud of religious fervor over surgery, science, and the development of medicine as a whole.

The sponge of sleep

The Roman Catholic Church was the overwhelming authority in Medieval life, dictating everything from worship to medical care. Medical teaching was seen as less important than theology. While the Greeks had idealized good health, Christian doctrine in the Middle Ages considered suffering a potentially valuable entity, which could test ones faith. As a result, the idea of healing the sick was controversial, particularly in the early Middle Ages. Some religious authorities suggested that medical treatment could be sinful. This climate was not conducive to an expansion of knowledge about surgery.

During the early Middle Ages, traveling surgeons often wandered the countryside, operating on individuals for hernias, stones, and cataracts, then frequently leaving town before complications developed. By this time, surgery was separate from medicine, and surgeons, whose work was often of low quality, had little prestige.

As the Middle Ages progressed in Europe, medical training changed. Medical doctors moved from an education based on apprenticeship to an education that included formal instruction at a university. With the founding of universities in Europe in the thirteenth and fourteenth centuries, the idea of a central well of medical knowledge expanded. Surgeons were left out of this formal educational world, with most learning their trade as apprentices. Eventually, colleges specifically for surgeons were developed. Those with the least education were called barber-surgeons.

By the thirteenth century, technical guides to surgery started to emerge, complete with records of innovative techniques. These techniques included the use of the soporific sponge, a sponge soaked in a mixture of ingredients to promote sleep. The sponge could include opium, mandrake, and other ingredients. Such ingredients were difficult to regulate, and could cause drug dependence, death, or other less serious side effects.

During the Middle Ages in Europe, the golden era of Islamic medicine transformed surgery. An Arab text from the eleventh century documented the use of cauterization to stop hemorrhaging and as therapy for chronic migraine headaches and epilepsy.

Beyond boiling oil

The Scientific Revolution in the sixteenth and seventeenth centuries revolutionized medicine. William Harvey (15781657) advanced all branches of medicine with his discoveries about circulation of the blood. A fascination with the human body, and the renewed study of anatomy helped forge dramatic advances in the understanding of how the body worked. The era also saw the innovations of great surgeons such as Ambroise Paré (15101590).

Trained as a barber-surgeon, Parès writings on surgery influenced the profession for centuries. His books were translated into Japanese, Latin, German, English, and Dutch. Parè, a military surgeon for four kings of France, made his first great innovation at the Siege of Turin in 1537. At the time, conventional treatment of gunshot wounds called for treatment that today would be considered sadistic torture: the cleansing of wounds by boiling oil.

Stationed at the battle field where many soldiers were wounded, Pare´ used up the supply of boiling oil before all the mens wounds could be treated. To treat the others, he developed a milder mixture consisting of egg yolk, turpentine, and oil of roses. The soldiers who had received Pare´s mixture looked better the next morning, while the other soldiers wounds remained unchanged. The success of the milder treatment lead to abandonment of the boiling oil dressing.

Pare´s books on surgery related everything from effective treatment of gunpowder wounds to methods for removing arrows and treatment of urinary-tract infections. He also discussed the use of ligature to repair damaged blood vessels. Paré and other surgeons enhanced the reputation of the profession. But until the nineteenth century, surgeons and their patients were limited by their inability to fend off infection or control pain. Their failure to do so meant that surgery was generally painful and life-threatening.

The limits of anesthesia in the pre-modern era shaped the way doctors operated on patients. One measure of the need to limit pain was the value placed on speed in surgery. Reportedly, Scottish surgeon Robert Liston could amputate a limb in 29 seconds. Long operations were impossible, because patients died on the operating table due to shock, pain, and heart failure.

Surgeons from ancient times developed anesthetics drawn from plants or plant products, such as opium from the poppy plant and wine drawn from grapes. But all of these substances had flaws, such as dangerous side effects. All were difficult to control for dosage, and none provided surgeons with what they most neededa patient who would lie still and not feel pain during surgery, then awaken after the procedure was over.

This changed with the development of effective anesthesia in the eighteenth century. There was no single inventor of anesthesia. Indeed, controversy marked the early use of anesthesia, with many different individuals claiming credit. Ether, the first gas to be used widely, was described as early as 1540 as a solvent that could also be used to aid patients with pleurisy and pneumonia. The gas gained new life in the early 1800s, when American and British pleasure-seekers marveled at the changes in behavior and perception induced by inhaling ether or nitrous oxide.

The story of the first public display of anesthesia by dentist William Thomas Green Morton is a story of claims, counterclaims, and frustration. The first to have his claims of innovation overlooked was Crawford Williamson Long, a physician in Jefferson, Georgia. Long reported the safe removal of a tumor in the neck of a patient anesthetized with ether in 1842. His failure to promptly report his use of the substance to medical journals resulted in the eclipse of his achievement by Morton in 1846.

Another dentist, Horace Wells, also was frustrated in his claim to be the first to successfully use a gas anesthetic. Wells used nitrous oxide in 1844 to anesthetize patients while their teeth were being pulled. Wells attempted to perform a dental procedure under anesthesia before a class of Harvard Medical students. The 1845 demonstration was a failure. The patient cried out in pain, and Wells was ridiculed. Eventually he committed suicide, after a bitter campaign to gain credit for his discovery.

Morton did not know about the use of nitrous oxide as an anesthetic until after Wells, a former teacher, traveled to Boston (Massachusetts) to display the new technology in 1845. Taking a more careful and politic route than Wells, Morton conducted a series of experiments using ether with dogs, goldfish, and other animals. He applied for a patent, and in 1846 performed a successful tooth extraction on a patient who had inhaled ether. He also associated himself with a number of prestigious physicians, and then scheduled a public display of ether anesthetic. The 1846 display, during which a prominent surgeon operated on a vascular tumor, was a success.

Though Morton received credit for the first successful use of ether anesthesia, his credit was challenged a second time after the procedure was deemed successful. This time, he was accused by a chemist who had advised him, Charles T. Jackson, who said he was the true inventor.

A sanitary leap forward

The development of anesthesia cleared the way for more ambitious types of surgery and more careful surgical endeavors. Without the need to operate so quickly, surgeons could focus on operating more carefully. Yet surgery still had not entered the modern era, for infection continued to make recovery treacherous.

Patients who survived surgery in the middle nineteenth century continued to face frightening odds of dying from infection. An 1867 report noted that 60% of patients who received a major amputation in a Paris (France) hospital died. Physicians routinely plunged their unwashed hands inside the body and often wore the same outfit for repeated surgical operating, unknowingly passing one patients germs on to the next.

Ignorance about the nature of germs lead to drastic surgical measures. For example, individuals with compound fractures, in which the bone protruded through the skin, faced serious risk of infection and death in the early nineteenth century. To avoid infection, surgeons often amputated the limb.

Joseph Lister (18271912), the British surgeon who is credited with bringing antiseptic surgery to medicine, drew upon the work of his French contemporary, Louis Pasteur (18221895). Pasteur observed that germs could be present in the air and on certain surfaces. Lister was the first to apply Pasteurs observation to surgery.

Lister shook the medical world with his use of carbolic acid on compound fracture wounds after surgery. Because surgery for such fractures had a high rate of infection, Listers report of success with nine out of 11 patients in 1867 was a dramatic finding. Cheered by the success of this effort, Lister continued his drive to remove germs from surgery. His efforts included immersing surgical instruments in a carbolic acid solution, requiring surgical assistants to wash their hands in soap and water, and careful washing of the area to be operated upon.

The success of the sterile surgical technique transformed surgery, over time, from a risky endeavor to one which carried a low risk for most procedures. The new safety of surgery made the practice more familiar, less risky, and far more open to innovation.

A third discovery helped clear the way for the dramatic surgical developments of the twentieth century. This was the finding by immunologist Karl Landsteiner (18681943) that blood varied by blood group types. Landsteiner, who received the Nobel Prize in 1930 for his work, described four different blood groups. Knowledge about the compatibility of certain blood types and the incompatibility of others, enabled the development of safe blood transfusions during surgery.

The modern era

By the late nineteenth century, surgery was still performed rarely. For example, in 1867, only 3.2% of the hospital admissions involved surgery at the Charity hospital in New Orleans (Louisiana). By 1939, surgery was involved in about 40% of admissions.

But surgeons of the nineteenth century broke many barriers. As recently as the 1880s, most surgeons would not intentionally operate on the head, the chest, or the abdomen unless an injury already existed. Over the next few years, surgeons mastered numerous abdominal operations, including surgery for appendicitis, new types of hernia operations, and surgery for ovarian disorders.

During the twentieth century, surgeons created successful techniques to operate on the brain and the heart and even techniques for organ transplantation. Surgeons became elite members of the medical establishment, earning more money than general practitioners and gaining celebrity as medical trailblazers.

Once a last resort, surgery is now performed frequently. Each year, a total of 25 million surgical operations calling for anesthesia are conducted in the United States. These operations cost a total of about $125 billion annually.

Heart of hearts

The emergence of heart surgery in the twentieth century defied earlier beliefs that the heart was invio late and untouchable. Contemporary surgeons replace hearts in heart transplant operations, create new pathways for the blood using tissue from other parts of the body in coronary bypass operations, and clear out the blood vessels of the heart using special tools in coronary angioplasty. But the story of the development of heart surgery makes clear the high cost in human lives of medical advancement in this area.

As early as 1882, German physician M.H. Block wrote of his successful suturing of rabbit hearts and suggested that human hearts could also be sutured. Surgeons in the early twentieth century who attempted surgery on heart valves found limited success. A 1928 survey of the 12 known cases of surgery on heart valves reported that 83% of those who received the procedure had died.

Due to overwhelming death rates, heart valve surgery waned until the 1940s and 1950s, when the procedure was reintroduced and surgeons could take advantage of several research advances. These included procedures that enabled surgeons to maintain circulation during surgery and to slow the beating of the heart. In 1950, the first electric pacemaker was developed. The race to add new ways to preserve the precious heart intensified.

In 1967, the first successful human heart transplant was performed by South African surgeon Christian Barnard. Although the patient died in 18 days, Barnard was celebrated internationally for his surgical skill. The thrill of transplanting hearts and the great potential for saving lives encouraged surgeons around the world to try the operation. The results were disappointing, as patient after patient died in a number of days or, sometimes, months. Most died after their bodies rejected the donated organ. Enthusiasm for the operation faded. While 99 transplants had been conducted in 1968, nine were performed in 1971.

As a small number of surgeons continued performing transplants, success rates for the operation improved. In addition, effective drugs to fight organ rejection were developed. By the early 1980s, heart transplants had regained popularity and in 1984, about 300 heart transplants were performed in the United States. In 1994, a total of 83% of individuals receiving heart transplants were expected to survive one or more years, making the surgery far safer than life with a failing heart.

A more common, and safer, procedure for individuals whose hearts are weak but not in need of complete replacement is the coronary artery bypass, a procedure developed in the late 1960s. The procedure takes tissue from elsewhere in the body to form new, clear pathways for blood to flow through the heart. A total of 309,000 coronary artery bypass grafts were performed in the United States in 1992. In 2003, the following numbers of procedures were performed: 95,000: valve replacements; 467,000: bypass (cardiac revascularization); 2,016: heart transplants (in 2004); 666,000: total open-heart procedures. The coronary artery bypass procedure, and similar procedures, is not without risk, and the death rate linked to bypass surgery is from one to two individuals out of 100. Yet the prospect of a limited life without the surgery makes coronary bypass a common procedure.

One vivid measure of the extent to which surgery has become routine is the high number of babies born using caesarian section, the surgical delivery of a baby. In 1992, a total of 921,000 caesarian sections were performed, making the procedure the most common type of major inpatient surgery. In 2003, according to the National Center for Health Statistics, 684,484 primary cesarean deliveries were made and 434,699 repeat cesarean deliveries were made in the United States; which was 27.5% of the total deliveries made in the United States. The procedure is used when labor fails to progress, when a child being born is in distress, and in other situations where normal birth is considered unwise or dangerous. The frequency of the procedure is controversial, with many critics saying that cesareans are used too frequently, placing mothers at risk and adding to the high cost of health care.

Many contemporary experts challenge the long-told story that cesarean birth was named after the birth of Roman statesman Julius Caesar. They say that had Caesar been delivered using caesarian section, his mother probably would have died, due to the high risk of infection. Historical evidence suggests that she survived the birth of her son. Cesarean sections were mentioned in ancient Indian medical texts, although the outcomes are unclear. In the modern era, the first cesarean births in which mother and child were expected to survive were performed in the early 1800s. Death due to infection still occurred frequently following the surgery. Cesarean births did not become popular until the late 1920s and they did not approach their current popularity until recently.

A prettier face

Another type of surgery which has recently flourished is plastic surgery. Evidence of the reconstruction of noses, ears, and lips can be found as early as the first century AD, in ancient Indian medical texts. In the contemporary era, surgery to repair injuries or to treat disease, particularly cancer, continues to be the most common type of plastic surgery.

But cosmetic plastic surgery has also become popular, and procedures to make breasts larger, noses smaller, and buttocks less saggy have gained in popularity. For example, in 1992, a total of 50,175 procedures for nose reshaping were performed, and 32,607 procedures to increase the size of the breast were performed. Nearly nine out of 10 individuals who received plastic surgery in 2002 were women, but men were also recipients of facelifts, buttock lifts and so-called tummy tucks. In 2005, according to the American Society for Aesthetic Plastic Surgery, almost 11.5 million cosmetic surgical and nonsurgical procedures were conducted in the United States. This statistic was an increase of 1% from 2004 surgical procedures (2.1 million) and a decrease of 4% for nonsurgical procedures (9.3 million). The popularity of cosmetic plastic surgery testifies to the public perception of surgery as a safe, predictable activity.

Fetal surgery

Contemporary surgeons have taken the concept of surgery well beyond what their counterparts as little as 100 years ago believed to be their domain. One of the most dramatic types of surgery is fetal therapy on the unborn. The first successful effort to address fetal problems in the womb took place in the early 1960s, with the first prenatal blood transfusion. Effective techniques for human fetal surgical therapy were first performed in the 1980s and are still being developed. Because such surgery presents a risk to the fetus and the mother, surgery on the fetus is performed rarely. Such procedures are only performed if the potential benefit to the fetus is deemed to be great. Successful surgery has been performed on fetuses suffering from certain types of life-threatening hernias and urinary-tract obstructions.

The procedure involves placing the mother under anesthesia and opening the uterus to expose the fetus. Following the surgery, amniotic fluid is replaced with a liquid solution containing antibiotics. The uterus is then stitched closed.

Surgery of the future

Technological advances in robotics and imaging devices suggest dramatic changes in the operating room of the future. Robots have already performed certain procedures in clinical trials. One such trial involves using a robot in surgery to help replace non-functioning hips with prosthesis. Hip-replacement procedures are commonly performed and have a high rate of success. But surgeons have long been concerned about the procedures that do not succeed due, in part, to the difficulty of creating an exact fit for the prosthesis.

Developers of the robot used in the clinical trials hope the robot will be able to do a better job. The robot is linked to a CT (computed tomography) scanner that measures the exact dimensions of the thigh bone. These measurements are used to help the robot hollow out a cavity in the thigh bone which will be an exact fit for the prosthesis. Successful use of such robots could change the role of the surgeon, whose tasks may include robot supervision in the future.

New imaging devices should also help surgeons operate more safely and efficiently in the future. Researchers are currently working on imaging devices that combine powerful computer technology with existing imaging technology to produce images of the body during surgery. Such images could be used for surgeons in training, to see how the body changes during surgery. They may also be used during surgery to limit the amount of potentially harmful cutting that is done. As technology enables surgeons to be more precise about where they cut, surgery could become more effective and less invasive.

KEY TERMS

Cauterization The use of heat, electricity, or other substance to destroy tissue.

Ligature Material used to tie a blood vessel or body part.

Prosthesis An artificial body part.

Sutures Substance used to stitch closed a surgical wound.

Trepanation The operation in which a circular area is removed, usually in the skull.

Uterus Organ in female mammals in which embryo and fetus grow to maturity.

One possible result of this could be what has been dubbed trackless surgery, procedures performed without cutting the patient. If images of harmful tissue, such as a breast tumor, could be sharpened, surgeons may be able to operate by simply focusing ultrasound waves on the tissue. Mastery of such techniques could make scalpels, sutures, and other conventional surgical tools obsolete.

Surgery of the future may bear little resemblance to the bloody, messy surgery of the present. But certain elements of surgery are unlikely to change. Surgical innovation will continue to require patients willing to take a risk and surgeons willing to challenge convention. Surgical skill will continue to require the traits Hippocrates urged surgeons to honor in ancient Greece: ability, grace, speed, painlessness, elegance, and readiness. Finally, surgical progress will continue to depend on the ability of skilled surgeons to use their physical ability and their medical knowledge to heal patients.

See also Laser surgery; Neurosurgery; Prenatal surgery; Psychosurgery; Thoracic surgery; Transplant, surgical.

Resources

BOOKS

Del Nido, Pedro J., and Scott J. Swanson, eds. Sabiston & Spencer surgery of the Chest. Philadelphia, PA: Elsevier Saunders, 2005.

Drake, Richard, et al., eds. Grays Anatomy for Students. Philadelphia, PA: Elsevier Churchill Livingstone, 2005.

Ford, Norman M. The Prenatal Person: Ethics from Conception to Birth. Malden, MA: Blackwell, 2002.

Kaiser, Larry R., Irving L. Kron, and Thomas L. Spray, eds. Mastery of Cardiothoracic Surgery. Philadelphia, PA: Lippincott, Williams & Wilkins, 2007.

Lawrence, Peter F. ed. Essentials of General Surgery. Philadelphia, PA: Lippincott Williams & Wilkins, 2006.

Standring, Susan, ed. Grays Anatomy: The Anatomical Basis of Clinical Practice. Edinburgh, UK: Elsevier Churchill Livingstone, 2005.

Stonebridge, Peter, ed. Surgery: An Oxford Core Text. Oxford, UK: Oxford University Press, 2006.

Thibodeau, Gary A. Anatomy & Physiology. St. Louis, MP: Elsevier Mosby, 2007.

Townsend, Jr., Courtney M. Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice. Philadelphia, PA: Elsevier Churchill Livingstone, 2005.

Van De Graaff, Kent M., and R. Ward Rhees, eds. Human Anatomy and Physiology: Based on Schaums Outline of Theory and Problems of Human Anatomy and Physiology. New York: McGraw-Hill, 2001.

OTHER

Current Science and Technology Center. Robotic Surgery. <http://www.mos.org/cst/article/1623/> (accessed December 2, 2006).

Johns Hopkins Medicine, Johns Hopkins University. Robot-assisted Minimally-invasive Cardiac Surgery at Johns Hopkins Hospital. <http://www.hopkinsmedicine.org/CardiacSurgery/PatientCare/robot.html> (accessed November 19, 2006).

Patricia Braus

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Surgery

Surgery

Surgery is the part of medicine which employs operative or manual treatment of disease or injury. Although surgery was practiced in ancient times, modern anesthesia was not developed until the nineteenth century. For centuries, most types of operative surgery involved high risk to patients due to infection . With the development of antiseptic surgical methods in the nineteenth century, the risks linked to surgery diminished. Some types of surgery remain risky, but many have high rates of success. Advances in technological knowledge offer new horizons in surgery.

Ancient surgeons

Traditionally, wars have been the proving ground of surgeons and new types of surgery. Early surgeons developed methods to anesthetize their patients and tools to operate effectively. Because there was no global communication, many surgical advances remained geographically isolated. The Western tradition of medicine developed independently of traditions in India, South America , and elsewhere, although traders and others reported some medical advances.

One of the earliest operative practices was trepanation, or the making of a hole in the head. Evidence of trepanation is present in skulls of individuals who lived as long ago as 10,000 b.c. in areas ranging from Northern Africa to Tahiti, France, and Peru. Ancient surgeons appear to have performed trepanation for reasons ranging from the relief of pressure on the brain , due to head injury, to the release of demons. The practice is still used in some cases to relieve pressure on the brain.

Ancient Egyptians also practiced surgery. According to the Smith Papyrus, a document written about 1600 b.c., Egyptians were well acquainted with a variety of surgical problems. They set broken collarbones using splints, treated medical problems ranging from tumors to fractures, and treated wounds with an adhesive plaster.

Surgery was also mentioned in the Code of Hammurabi, the code of law developed in 1760 b.c. during the reign of the Mesopotamian King Hammurabi. The code called for strict discipline of surgeons. Surgeons who caused the death of a free man in surgery were to have their right hand amputated as punishment, while surgeons who damaged a slave had to repay the owner for the value of the slave.

Greeks and Romans used surgery as a last resort. The Greeks used herbs mixed in wine or water to dress and clean wounds, and performed surgical procedures ranging from trepanation to the cauterization of blood vessels.

The Greeks used a number of natural anesthetics, including opium and the mandrake, a plant which can have a narcotic affect. A first century Greek physician in Nero's army wrote that after using mandrake, patients receiving surgery "do not apprehend the pain , because they are overborn with dead sleep." The Greeks also developed anatomical studies based on the dissection of human bodies. Dissection for the advance of medical knowledge was forbidden during the Roman Era and during the Middle Ages, and was not revived until the fifteenth century.

The Romans developed many new surgical procedures. Roman surgeons used dilators to take barbed arrows out of wounds, amputated limbs, performed plastic surgery , and developed techniques for removing bladder stones, hernias, and cataracts.

Surgery also flourished in the first century a.d. in India. Medical texts document the practice of operations ranging from tonsillectomy to plastic surgery. Certain practices sound familiar, such as the use of an operating room, the use of various types of forceps, and the use of anesthesia to reduce pain. One anesthetic used was burning hemp , the plant used today in the drug marijuana . Indians also fumigated the area where surgery was to take place to reduce infection.

Other practices suggest a far different place and time , including the use of large black ants as clips for tears in the intestines. As India continued to develop its medical tradition, the Middle Ages descended on Western Europe , casting a cloud of religious fervor over surgery, science, and the development of medicine as a whole.

The sponge of sleep

The Roman Catholic Church was the overwhelming authority in Medieval life, dictating everything from worship to medical care. Medical teaching was seen as less important than theology. While the Greeks had idealized good health, Christian doctrine in the Middle Ages considered suffering a potentially valuable entity, which could test one's faith. As a result, the idea of healing the sick was controversial, particularly in the early Middle Ages. Some religious authorities suggested that medical treatment could be sinful. This climate was not conducive to an expansion of knowledge about surgery.

During the early Middle Ages, traveling surgeons often wandered the countryside, operating on individuals for hernias, stones, and cataracts, then frequently leaving town before complications developed. By this time, surgery was separate from medicine, and surgeons, whose work was often of low quality, had little prestige.

As the Middle Ages progressed in Europe, medical training changed. Medical doctors moved from an education based on apprenticeship to an education which included formal instruction at a university. With the founding of universities in Europe in the thirteenth and fourteenth centuries, the idea of a central well of medical knowledge expanded. Surgeons were left out of this formal educational world, with most learning their trade as apprentices. Eventually, colleges specifically for surgeons were developed. Those with the least education were called barber-surgeons.

By the thirteenth century, technical guides to surgery started to emerge, complete with records of innovative techniques. These techniques included the use of the soporific sponge, a sponge soaked in a mixture of ingredients to promote sleep . The sponge could include opium, mandrake, and other ingredients. Such ingredients were difficult to regulate, and could cause drug dependence, death, or other less serious side effects.

During the Middle Ages in Europe, the golden era of Islamic medicine transformed surgery. An Arab text from the eleventh century documented the use of cauterization to stop hemorrhaging and as therapy for chronic migraine headaches and epilepsy .


Beyond boiling oil

The Scientific Revolution in the sixteenth and seventeenth centuries revolutionized medicine. William Harvey (1578-1657) advanced all branches of medicine with his discoveries about circulation of the blood. A fascination with the human body, and the renewed study of anatomy helped forge dramatic advances in the understanding of how the body worked. The era also saw the innovations of great surgeons such as Ambroise Pare (1510-1590).

Trained as a barber-surgeon, Pare's writings on surgery influenced the profession for centuries. His books were translated into Japanese, Latin, German, English and Dutch. Pare, a military surgeon for four kings of France, made his first great innovation at the Siege of Turin in 1537. At the time, conventional treatment of gunshot wounds called for treatment that today would be considered sadistic torture: the cleansing of wounds by boiling oil.

Stationed at the battle field where many soldiers were wounded, Pare used up the supply of boiling oil before all the men's wounds could be treated. To treat the others, he developed a milder mixture consisting of egg yolk, turpentine, and oil of roses. The soldiers who had received Pare's mixture looked better the next morning, while the other soldiers' wounds remained unchanged. The success of the milder treatment lead to abandonment of the boiling oil dressing.

Pare's books on surgery related everything from effective treatment of gunpowder wounds to methods for removing arrows and treatment of urinary-tract infections. He also discussed the use of ligature to repair damaged blood vessels. Pare and other surgeons enhanced the reputation of the profession. But until the nineteenth century, surgeons and their patients were limited by their inability to fend off infection or control pain. Their failure to do so meant that surgery was generally painful and life-threatening.

The limits of anesthesia in the pre-modern era shaped the way doctors operated on patients. One measure of the need to limit pain was the value placed on speed in surgery. Reportedly, Scottish surgeon Robert Liston could amputate a limb in 29 seconds. Long operations were impossible, because patients died on the operating table due to shock, pain, and heart failure.

Surgeons from ancient times developed anesthetics drawn from plants or plant products, such as opium from the poppy plant and wine drawn from grapes . But all of these substances had flaws, such as dangerous side effects. All were difficult to control for dosage, and none provided surgeons with what they most needed—a patient who would lie still and not feel pain during surgery, then awaken after the procedure was over.

This changed with the development of effective anesthesia in the eighteenth century. There was no single inventor of anesthesia. Indeed, controversy marked the early use of anesthesia, with many different individuals claiming credit. Ether , the first gas to be used widely, was described as early as 1540 as a solvent which could also be used to aid patients with pleurisy and pneumonia . The gas gained new life in the early 1800s, when American and British pleasure-seekers marveled at the changes in behavior and perception induced by inhaling ether or nitrous oxide.

The story of the first public display of anesthesia by dentist William Thomas Green Morton is a story of claims, counterclaims, and frustration. The first to have his claims of innovation overlooked was Crawford Williamson Long, a physician in Jefferson, Georgia. Long reported the safe removal of a tumor in the neck of a patient anesthetized with ether in 1842. His failure to promptly report his use of the substance to medical journals resulted in the eclipse of his achievement by Morton in 1846.

Another dentist, Horace Wells, also was frustrated in his claim to be the first to successfully use a gas anesthetic. Wells used nitrous oxide in 1844 to anesthetize patients while their teeth were being pulled. Wells attempted to perform a dental procedure under anesthesia before a class of Harvard Medical students. The 1845 demonstration was a failure. The patient cried out in pain, and Wells was ridiculed. Eventually he committed suicide, after a bitter campaign to gain credit for his discovery.

Morton did not know about the use of nitrous oxide as an anesthetic until after Wells, a former teacher, traveled to Boston to display the new technology in 1845. Taking a more careful and politic route than Wells, Morton conducted a series of experiments using ether with dogs, goldfish, and other animals. He applied for a patent, and in 1846 performed a successful tooth extraction on a patient who had inhaled ether. He also associated himself with a number of prestigious physicians, then scheduled a public display of ether anesthetic. The 1846 display, during which a prominent surgeon operated on a vascular tumor, was a success.

Though Morton received credit for the first successful use of ether anesthesia, his credit was challenged a second time after the procedure was deemed successful. This time, he was accused by a chemist who had advised him, Charles T. Jackson, who said he was the true inventor.


A sanitary leap forward

The development of anesthesia cleared the way for more ambitious types of surgery and more careful surgical endeavors. Without the need to operate so quickly, surgeons could focus on operating more carefully. Yet surgery still had not entered the modern era, for infection continued to make recovery treacherous.

Patients who survived surgery in the middle nineteenth century continued to face frightening odds of dying from infection. An 1867 report noted that 60% of patients who received a major amputation in a Paris hospital died. Physicians routinely plunged their unwashed hands inside the body and often wore the same outfit for repeated surgical operating, unknowingly passing one patient's germs on to the next.

Ignorance about the nature of germs lead to drastic surgical measures. For example, individuals with compound fractures, in which the bone protruded through the skin, faced serious risk of infection and death in the early nineteenth century. To avoid infection, surgeons often amputated the limb.

Joseph Lister (1827-1912), the British surgeon who is credited with bringing antiseptic surgery to medicine, drew upon the work of his French contemporary, Louis Pasteur (1822-1895). Pasteur observed that germs could be present in the air and on certain surfaces. Lister was the first to apply Pasteur's observation to surgery.

Lister shook the medical world with his use of carbolic acid on compound fracture wounds after surgery. Because surgery for such fractures had a high rate of infection, Lister's report of success with nine out of 11 patients in 1867 was a dramatic finding. Cheered by the success of this effort, Lister continued his drive to remove germs from surgery. His efforts included immersing surgical instruments in a carbolic acid solution , requiring surgical assistants to wash their hands in soap and water, and careful washing of the area to be operated upon.

The success of the sterile surgical technique transformed surgery, over time, from a risky endeavor to one which carried a low risk for most procedures. The new safety of surgery made the practice more familiar, less risky, and far more open to innovation.

A third discovery helped clear the way for the dramatic surgical developments of the twentieth century. This was the finding by immunologist Karl Landsteiner (1868-1943) that blood varied by blood group types. Landsteiner, who received the Nobel Prize in 1930 for his work, described four different blood groups. Knowledge about the compatibility of certain blood types and the incompatibility of others, enabled the development of safe blood transfusions during surgery.


The modern era

By the late nineteenth century, surgery was still performed rarely. For example, in 1867, only 3.2% of the hospital admissions involved surgery at the Charity hospital in New Orleans. By 1939, surgery was involved in about 40% of admissions.

But surgeons of the nineteenth century broke many barriers. As recently as the 1880s, most surgeons would not intentionally operate on the head, the chest, or the abdomen unless an injury already existed. Over the next few years, surgeons mastered numerous abdominal operations, including surgery for appendicitis, new types of hernia operations, and surgery for ovarian disorders.

During the twentieth century, surgeons created successful techniques to operate on the brain and the heart and even techniques for organ transplantation. Surgeons became elite members of the medical establishment, earning more money than general practitioners and gaining celebrity as medical trailblazers.

Once a last resort, surgery is now performed frequently. Each year, a total of 25 million surgical operations calling for anesthesia are conducted in the United States. These operations cost a total of about $125 billion annually.

Heart of hearts

The emergence of heart surgery in the twentieth century defied earlier beliefs that the heart was inviolate and untouchable. Contemporary surgeons replace hearts in heart transplant operations, create new pathways for the blood using tissue from other parts of the body in coronary bypass operations, and clear out the blood vessels of the heart using special tools in coronary angioplasty. But the story of the development of heart surgery makes clear the high cost in human lives of medical advancement in this area.

As early as 1882, the German physician M.H. Block wrote of his successful suturing of rabbit hearts and suggested that human hearts could also be sutured. Surgeons in the early twentieth century who attempted surgery on heart valves found limited success. A 1928 survey of the 12 known cases of surgery on heart valves reported that 83% of those who received the procedure had died.

Due to overwhelming death rates, heart valve surgery waned until the 1940s and 1950s, when the procedure was reintroduced and surgeons could take advantage of several research advances. These included procedures which enabled surgeons to maintain circulation during surgery and to slow the beating of the heart. In 1950, the first electric pacemaker was developed. The race to add new ways to preserve the precious heart intensified.

In 1967, the first successful human heart transplant was performed by South African surgeon Christian Barnard. Although the patient died in 18 days, Barnard was celebrated internationally for his surgical skill. The thrill of transplanting hearts, and the great potential for saving lives, encouraged surgeons around the world to try the operation. The results were disappointing, as patient after patient died in a number of days or, sometimes, months. Most died after their bodies rejected the donated organ. Enthusiasm for the operation faded. While 99 transplants had been conducted in 1968, nine were performed in 1971.

As a small number of surgeons continued performing transplants, success rates for the operation improved. In addition, effective drugs to fight organ rejection were developed. By the early 1980s, heart transplants had regained popularity and in 1984, about 300 heart transplants were performed in the United States. In 1994, a total of 83% of individuals receiving heart transplants were expected to survive one or more years, making the surgery far safer than life with a failing heart.

A more common, and safer, procedure for individuals whose hearts are weak but not in need of complete replacement is the coronary artery bypass, a procedure developed in the late 1960s. The procedure takes tissue from elsewhere in the body to form new, clear pathways for blood to flow through the heart. A total of 309,000 coronary artery bypass grafts were performed in the United States in 1992. The procedure is not without risk, and the death rate linked to bypass surgery is from one to two individuals out of 100. Yet the prospect of a limited life without the surgery makes coronary bypass a common procedure.

One vivid measure of the extent to which surgery has become routine is the high number of babies born using caesarian section, the surgical delivery of a baby. In 1992, a total of 921,000 caesarian sections were performed, making the procedure the most common type of major inpatient surgery. The procedure is used when labor fails to progress, when a child being born is in distress, and in other situations where normal birth is considered unwise or dangerous. The frequency of the procedure is controversial, with many critics saying that cesareans are used too frequently, placing mothers at risk and adding to the high cost of health care.

Many contemporary experts challenge the long-told story that cesarean birth was named after the birth of Roman statesman Julius Caesar. They say that had Caesar been delivered using caesarian section, his mother probably would have died, due to the high risk of infection. Historical evidence suggests that she survived the birth of her son. Cesarean sections were mentioned in ancient Indian medical texts, although the outcomes are unclear. In the modern era, the first cesarean births in which mother and child were expected to survive were performed in the early 1800s. Death due to infection still occurred frequently following the surgery. Cesarean births did not become popular until the late 1920s and they did not approach their current popularity until recently.


A prettier face

Another type of surgery which has recently flourished is plastic surgery. Evidence of the reconstruction of noses, ears, and lips can be found as early as the first century a.d., in ancient Indian medical texts. In the contemporary era, surgery to repair injuries or to treat disease, particularly cancer , continues to be the most common type of plastic surgery.

But cosmetic plastic surgery has also become popular, and procedures to make breasts larger, noses smaller, and buttocks less saggy have gained in popularity. For example, in 1992, a total of 50,175 procedures for nose reshaping were performed, and 32,607 procedures to increase the size of the breast were performed. Nearly nine out of 10 individuals who received plastic surgery in 2002 were women, but men were also recipients of facelifts, buttock lifts and so-called "tummy tucks." The popularity of cosmetic plastic surgery testifies to the public perception of surgery as a safe, predictable activity.

Fetal surgery

Contemporary surgeons have taken the concept of surgery well beyond what their counterparts as little as 100 years ago believed to be their domain. One of the most dramatic types of surgery is fetal therapy on the unborn. The first successful effort to address fetal problems in the womb took place in the early 1960s, with the first prenatal blood transfusion. Effective techniques for human fetal surgical therapy were first performed in the 1980s and are still being developed. Because such surgery presents a risk to the fetus and the mother, surgery on the fetus is performed rarely. Such procedures are only performed if the potential benefit to the fetus is deemed to be great. Successful surgery has been performed on fetuses suffering from certain types of life-threatening hernias and urinary-tract obstructions.

The procedure involves placing the mother under anesthesia and opening the uterus to expose the fetus. Following the surgery, amniotic fluid is replaced with a liquid solution containing antibiotics . The uterus is then stitched closed.


Surgery of the future

Technological advances in robotics and imaging devices suggest dramatic changes in the operating room of the future. Robots have already performed certain procedures in clinical trials. One such trial involves using a robot in surgery to help replace non-functioning hips with a prosthesis. Hip-replacement procedures are commonly performed and have a high rate of success. But surgeons have long been concerned about the procedures that do not succeed due, in part, to the difficulty of creating an exact fit for the prosthesis.

Developers of the robot used in the clinical trials hope the robot will be able to do a better job. The robot is linked to a CT scanner which measures the exact dimensions of the thigh bone. These measurements are used to help the robot hollow out a cavity in the thigh bone which will be an exact fit for the prosthesis. Successful use of such robots could change the role of the surgeon, whose tasks may include robot supervision in the future.

New imaging devices should also help surgeons operate more safely and efficiently in the future. Researchers are currently working on imaging devices that combine powerful computer technology with existing imaging technology to produce images of the body during surgery. Such images could be used for surgeons in training, to see how the body changes during surgery. They may also be used during surgery to limit the amount of potentially harmful cutting that is done. As technology enables surgeons to be more precise about where they cut, surgery could become more effective and less invasive.

One possible result of this could be what has been dubbed "trackless" surgery, procedures performed without cutting the patient. If images of harmful tissue, such as a breast tumor, could be sharpened, surgeons may be able to operate by simply focusing ultrasound waves on the tissue. Mastery of such techniques could make scalpels, sutures, and other conventional surgical tools obsolete.

Surgery of the future may bear little resemblance to the bloody, messy surgery of the present. But certain elements of surgery are unlikely to change. Surgical innovation will continue to require patients willing to take a risk and surgeons willing to challenge convention. Surgical skill will continue to require the traits Hippocrates urged surgeons to honor in ancient Greece: "ability, grace, speed, painlessness, elegance, and readiness." Finally, surgical progress will continue to depend on the ability of skilled surgeons to use their physical ability and their medical knowledge to heal patients.

See also Laser surgery; Neurosurgery; Prenatal surgery; Psychosurgery; Thoracic surgery; Transplant, surgical.

Resources

books

Bollinger, Randal R., and Delford L. Stickel. "Transplantation." Textbook of Surgery. 14th ed. David C. Sabiston. Jr., Philadelphia: W.B. Saunders Co, 1991.

Brieger, Gert H. "The Development of Surgery." In Textbook ofSurgery. 14th ed. ed. David C. Sabiston Jr., Philadelphia: W.B. Saunders Co, 1991.

Gray, Henry, Lawrence H. Bannister, Martin M. Berry, and Peter L. Williams, eds. Gray's Anatomy: The Anatomical Basis of Medicine & Surgery. London: Churchill Livingstone, 1995.

Magner, Lois N. A History of Medicine. New York: Marcel Dekker, Inc., 1992.

Nuland, Sherwin B. Doctors: The Biography of Medicine. New York: Alfred A. Knopf, 1988.


periodicals

Houkin, K. "Digital recording in Microsurgery." Journal ofNeurosurgery 92, no. 1 (2000): 176-180.

Leparc. G.F. "Nucleic Acid Testing for Screening Donor Blood." Infectious Medicine no. 17 (May 2000): 310-333.


other

Current Science and Technology Center. "Robotic Surgery." [cited April 2003]. <http://www.mos.org/cst/article/1623/>.

Kobus, Nancy. 1992 Plastic Surgery Statistics. The American Society for Aesthetic Plastic Surgery, Inc., 1992.


Patricia Braus

KEY TERMS

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Cauterization

—The use of heat, electricity, or other substance to destroy tissue.

Ligature

—Material used to tie a blood vessel or body part.

Prosthesis

—An artificial body part.

Sutures

—Substance used to stitch closed a surgical wound.

Trepanation

—The operation in which a circular area is removed, usually in the skull.

Uterus

—Organ in female mammals in which embryo and fetus grow to maturity.

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