Advances in Surgical Techniques

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Advances in Surgical Techniques

Overview

Surgeons of the twentieth century inherited many ideas and techniques from earlier physicians, which they continued to investigate and improve. Three age-old problems that plagued surgeons—pain, infection, and shock—were beginning to be conquered. Surgeons also ventured into areas of the body, like the heart, that had previously been off-limits and developed unique approaches for their particular specialty.

During the first half of the twentieth century, many doctors played critical roles in developing surgical techniques. At the beginning of the century, Alexis Carrel (1873-1944), practicing on paper with fine needles and silk thread, introduced a method for linking blood vessels. Harvey Cushing (1869-1939) was a pioneer in neurosurgery. Ernst Sauerbruch (1875-1951) and Louis Rehn (1849-1930) first worked with the chest and esophageal surgery, with Rehn performing the first pericardectomy. Evarts Graham (1883-1957) and Jacob Singer (1885-1954) specialized in lung surgery.

Many unnamed surgeons worked to perfect anesthesia, asepsis against infection, pain management, as well as sophisticated blood transfusions. By mid-century, medicine was at a high peak with hope for many additional breakthroughs.

Background

Though surgeons have become highly respected members of the medical community, many doctors were involved in conquering the great enemy of invasive surgery—infection. Joseph Lister (1827-1912) had found that antisepsis, using carbolic acid or phenol, sterilized wounds and equipment. Instruments were put into the solution, and the surgeon may also don a gown soaked in the chemical then wrung out. In a Berlin clinic in 1886 Ernst von Bergmann (1836-1907) introduced the steam sterilizer. The idea that everything that comes into contact with the wound must be sterilized was being developed. Hermann Kummell of Hamburg invented the process of scrubbing up while William Stewart Halstead (1852-1922) of Johns Hopkins ordered special rubber gloves just for operating. In 1896 the gauze mask was used.

At the end of the nineteenth century the master surgeon often performed in an arena. Students sat in rows and observed as he operated on the patient—explaining exactly what he was doing as he proceeded.

Theodor Billroth (1829-1894), the great nineteenth-century surgeon, laid the foundation for many improvements. He developed the concept of experimental surgery by taking problems to the laboratory before going to the operating theater. He developed procedures for recording and reporting the operative procedure, studying complications and mortality, and conducting five-year follow-ups. As a great teacher, he influenced a large number of German and Austrian surgeons. However, the aseptic tradition caught on slowly.

Impact

In 1894, in Lyons, France, Alexis Carrel witnessed the stabbing of the French president, who subsequently bled to death because there were no procedures to repair blood vessels. The son of a silk merchant, Carrel practiced sewing on paper with a fine needle and silk thread until he had perfected the technique to repair blood vessels. In 1906 Carrel moved to New York to the Rockefeller Institute, where he worked to perfect his blood vessel suturing techniques. Carrel's innovative and patient thinking on suturing blood vessels led to a time when blood transfusions and transplants would be a reality. He even did a successful kidney transplant from one dog to another.

Billroth, the famous surgeon of Vienna, influenced many students, including American William Stewart Halstead (1852-1922). Halstead became a top surgeon until he began to experiment with cocaine as an anesthetic and became addicted. However, he had a remarkable career during which he trained surgeons in the philosophy of "safe surgery." His great pupil was neurosurgeon Harvey Cushing.

The science of neurosurgery was revolutionized by the work of Cushing. In 1902 Cushing became a surgeon at Johns Hopkins and began to specialize in neurosurgery. He developed many procedures and techniques basic to brain surgery and greatly reduced mortality connected with such serious treatments.

Cushing probed deeper into the brain. He developed a technique used in the battlefields of World War I in which he applied gentle suction to injured the brain and even developed a magnet to remove bits of metal embedded in the brain. He became an expert on brain tumors and pioneered techniques for their diagnosis and treatment. He was the first to find and understand the role of the pituitary gland, located at the base of the brain. His efforts and numerous writings on surgery won him international recognition in 1912.

The use of anesthesia at the turn of the twentieth century progressed slowly. Since there were no specialists in the field, a surgeon would have to get a nurse, a student, or anyone around to put chloroform over a rag to knock the person out. Chloroform and ether were both popular. Chloroform was easier to administer, although it had a deadly effect on the heart. By 1910 nitrous oxide (laughing gas), combined with ether, was replacing chloroform. With the discovery of other agents, anesthesia came into its own.

The 1920s brought great improvements in anesthesia, which broadened the possibilities of surgery. Ralph Waters of Madison, Wisconsin, introduced the general anesthesia cyclopropane in 1933. John Lundy of the Mayo Clinic, building upon the trials of many others, successfully introduced pentothal or thiopental sodium to put patients peacefully to sleep. Howard Griffith and G. Enid Johnson of Montreal purified curare to inject it into the muscles for a local anesthesia. The development of the specialty of anesthesiology assisted the surgeon, as now he or she could concentrate on operative skills with another specialists taking care of respiration and vital signs.

The progress in anesthesia certainly aided the chest or thoracic surgeon. When the chest cavity was opened, the lung collapses. Tuberculosis, or the White Plague, was the scourge of lungs. Carlo Forlianini (1847-1918) of Pavia, Italy, had attempted the first pneumothorax surgery in 1888. The surgery was unsuccessful because of the collapse of the lungs when the chest was opened. To overcome the problem, the Prussian surgeon Ernst Sauerbruch designed a negative pressure cabinet to control the collapse. His father had died of tuberculosis, and he was determined to conquer the technique.

Experimenting with animals in pressurized cages, he found a way to operate while the animal continued to breathe. Sauerbruch built and demonstrated this cabinet in 1904 at a clinic in Breslau. The devise held patient, table, and a full operating team. By the 1920s he found a new way to establish a temporary collapse by nitrogen displacement or pneumothorax. Although it was a skillful operation, the pneumothorax became obsolete when inhalation under pressure was introduced after World War II.

Thoracic surgery still had many problems to overcome. In San Francisco surgeon Harold Brunn successfully used suction after surgery to keep the lung cavity free of fluid until the remaining lobes could expand.

When Lister first started his operations along with his protegee William Watson Cheyne (1852-1932), about 60% of their practice involved accidents, broken bones, and superficial tumors. They had excellent results, but up until 1893 they tried few intestinal operations. Then Cheyne expanded his practice into a relatively unknown area of abdominal surgery. As a result, the surgeon's status increased.

William Mayo (1861-1939) and Charles Mayo (1865-1939) became masters of abdominal and thyroid surgery, making the Mayos household names and also millionaires. The Mayo Clinic in Rochester, Minnesota, is world renowned.

Shock was one of the most difficult problems to conquer. Understanding of shock is very elusive, but it was known to be caused by a loss of blood. Carrel, with his surgical techniques of sewing blood vessels, enabled transfusions. By developing knowledge of blood typing and blood factors, Karl Landsteiner (1868-1943) added to making successful transfusions.

The heart had been an off-limits area among medical practitioners. Ludwig Rehn of Frankfurt performed the first cardiac surgery in 1896. He showed that wounds of the heart could be treated successfully by draining the infection. In 1912 James Herrick (1861-1954), a Chicago physician, insisted that heart attacks were caused by blood clots and were indeed survivable. In 1913 Rehn and Sauerbruch performed surgery on the pericardium for relief of pericarditis or inflammation. However, these procedures did not gain wide acceptance.

Experimental work on the heart was being done in the first two decades of the twentieth century. Theodore Tuffier operated on the aortic valve and Carrel had worked diligently to perfect the technique. In 1925 Henry Souttar used a finger to dilate a mitral valve, a feat that was 25 years ahead of its time. There was still resistance to heart surgery. It took the experience of World War II, and the remarkable work of Dwight Harden, who removed 134 missiles from the chests of wounded soldiers without losing a single patient. The surgery was performed "blind," as it was not until 1953 that the heart-lung machine, which could stop the heart so the surgeon could see the procedure, was realized. However, the machine had been the dream of John Gibbon Jr. (1903-1973), who began the research on this machine in 1937.

Operations were developed for many forms of cancer. Evarts Graham did a lung resection in 1933. The patient, a doctor, was alive at the time of Graham's death in 1957. He also tackled a lobectomy (removing a lung lobe), a segmental resection (removing only part of a lobe), and a pulmectomy (taking out a whole lung).

The pioneers of surgery during the first half of the twentieth century opened the door for many of the procedures used today.

EVELYN B. KELLY

Further Reading

Klaidman, Stephen. Saving the Heart: The Battle to Conquer Coronary Disease. New York: Oxford Press, 2000.

Wolfe, Richard J., and Leonard F. Menczer, eds. I Awaken to Glory. Boston: Boston Medical Library, 1994.

Zimmerman, Leo, and Ilza Weith. Great Ideas in the History of Surgery. San Francisco: Norman, 1961.


EARLY FEMALE ANESTHESIOLOGISTS IN THE UNITED STATES

Women moved into positions of prominence in anesthesiology in the early twentieth century, just as the specialty began taking shape in the United States. In 1899 Dr. Isabella Herb joined the staff at the Mayo Clinic in Rochester, Minnesota, as the first physician anesthetist at that institution; previously, anesthesia had been administered by nurses or other staff. By 1905 she had moved to Chicago, and four years later became chief anesthetist at Presbyterian Hospital and Rush Medical College, remaining in that position until her retirement in 1941. In addition to holding various other offices, she served in 1922 as the tenth overall and first female president of the American Association of Anesthetists. Another female anesthesiologist in the Chicago area was Dr. Huberta M. Livingstone. After completing medical school and a year of internship, she became Director of the Department of Anesthesiology at the University of Chicago's Pritzker School of Medicine in 1929 and held that position until resigning in 1952.

Dr. Alice McNeal spent the first part of her anesthesiology career in Chicago, working at Presbyterian Hospital from 1925 until 1946. In that year she moved south to Birmingham, Alabama, and became Chief of the Division of Anesthesia in the Surgery Department of the newly created University of Alabama School of Medicine. Two years later she was named Chairman of the new Department of Anesthesiology in the medical school and retained that position until her retirement in 1961. Dr. McNeal's case load at the University Hospital in Birmingham is typical of how busy physician anesthesiologists of this era—both male and female—could be. She was the only full-time faculty member in her department for many years, and had just a few nurses, medical students rotating through the department, and occasional assistance from local private-practice anesthesiologists to help her administer anesthesia for thousands of cases each year.

On the West Coast, Dr. Mary Botsford joined the staff of Children's Hospital in San Francisco in the late 1890s. She later was appointed the first Professor of Anesthesia at the University of California at San Francisco, where she trained more than 40 female anesthesiologists. Dr. Botsford remained in those clinical and academic positions until her retirement in 1920. She also served a term as President of the Associated Anesthetists of the U.S. and Canada, as did one of her trainees, Dr. Eleanor Seymour of Los Angeles.

A. J. WRIGHT


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