Surgery
Surgery
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 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 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 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 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 (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 Paré (1510–1590).
Trained as a barber-surgeon, Parè’s 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 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. 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 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 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 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 (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. Gray’s 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. Gray’s 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 Schaum’s 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