Biomedicine and Health: Surgery
Biomedicine and Health: Surgery
Surgery seems such an obvious way to treat some diseases it is hard to imagine that it has not always been valued. It is still not highly regarded in many cultures, and in the West was deemed a low-status treatment of last resort until two centuries ago. This is not simply because surgery was often dangerous and painful. Surgery did not become a valuable therapy until people began to think of diseases as being localized to a part of the body.
In Western history until around 1800 most diseases were considered disturbances of the constitution. There is not much point in removing a local condition if the real problem is a general one. Current debates over breast cancer make this point. Is breast cancer the result of a local disease or a systemic disturbance? If it is the latter, mastectomy can be only a temporary solution. Until the nineteenth century surgery was largely confined to wounds, abscesses, toothache, ulcers, and other local conditions. The nature of surgical treatment is indicated by the etymology of the word. Surgery comes from the Greek, kheirourgia, from kheir, “hand,” and erg, “work.”
Historical Background and Scientific Foundations
The earliest known writings about surgery date from ancient Egypt, India, and Mesopotamia. The so-called Edwin Smith papyrus (named after the dealer who bought it in 1862) is the most important source of information about Egyptian surgery. This document, which may have been a manual of military surgery, dates from about 1600 BC and describes 48 cases of injuries, fractures, wounds, dislocations and tumors. It works systematically downward from wounds of the skull before breaking off abruptly. Cases have titles, such as “Instructions Concerning a Dislocation in a Vertebra of (His) Neck.” After the title comes examination, diagnosis, and verdict. In a number of cases the verdict is “An ailment not to be treated.” The last heading is “Treatment Which Mainly Consists of Manipulation, Dressings, and Diet.” The papyrus mentions “cold applications” and a “fire drill,” which may have been some form of cautery using hot metal. There is no evidence that major operations such as amputation were carried out.
The works associated with the Greek physician Hippocrates of Cos (c.460–c.375 BC), which are clearly written by many different authors, although they contain many surgical references, show that surgery was not considered a major resource. Interestingly, Hippocrates himself was both a physician and a surgeon, and surgery was still held in comparatively high regard—it had not yet acquired the low status that it would in medieval Europe.
One Hippocratic text contains the sentence: “I will not use the knife, not even on sufferers from stone, but will withdraw in favor of such men as are engaged in this work.” (This refers to “cutting for the stone” or lithotomy, a surgical procedure to remove bladder stones, a very painful condition. Until the twentieth century these were removed, if at all, only through a very dangerous operation.) This quotation comes from the famous (and misnamed) Hippocratic oath. Many people believe erroneously that all doctors still take the oath, and that it is the basis of modern medical ethics. This is not the case nor has it ever been so.
In fact, the oath is less of an ethical text than an agreement by the followers of one medical teacher to adhere to the precepts of his particular school. It did not originate in a Hippocratic “school” at all, and it may have been produced by healers who were followers of the Greek philosopher Pythagoras (580–500 BC). It was only in Egyptian Alexandria, perhaps 200 years after it was written, that the oath was collected with many other texts, which were then all attributed to Hippocrates.
The promise not to practice surgery is only one example of what is now agreed by scholars—the oath is an unusual document that contains some very strange rules; its prohibition of abortion, for example, is completely at odds with what we know to have been an accepted practice in Greek society, which condoned infanticide, especially for deformed or female infants.
Hippocratic works that describe surgery are devoted to bony injuries and flesh wounds. They give instructions on suturing, setting broken bones, and the reduction (manipulation into place) of dislocated joints, especially the shoulder. The Hippocratic idea of the interior of the body was not “surgical” or anatomical in the modern sense, but based on the so-called humoral theory of blood, phlegm, and black and yellow bile.
The Hellenistic School and Galen
In the Hellenistic period, Alexandria became the great center of ancient scholarship. Here human dissection was carried out by Greek anatomists Herophilus of Chalcedon (c.335–290 BC) and Erasistratus of Ceos (c.310–259 BC). Although their work did not advance medical practice at the time, it supported a claim that made modern surgery possible. Medicine, they said, should be based on knowledge gained by observation of the hidden structure of the human frame. Nothing like this appears in the Hippocratic texts.
Most of what we know of Hellenistic surgery was gathered by the Roman writer, Aulus Cornelius Celsus (first century AD). Besides wound surgery, Celsus describes resection (surgical removal) of the rib, the couching (pushing aside) of cataracts in the eye, tonsillectomy, the management of umbilical and inguinal (groin) hernias and the removal of goiter (a thyroid tumor in the neck). He even discusses suturing the large intestine in abdominal injuries but it is hard to imagine anyone surviving this operation if they were so badly wounded as to require it. Lithotomy is described in some detail.
Galen of Pergamum (AD 129–c.216), was a Greek physician who practiced in Rome. He does not appear to have performed surgery, but he is of crucial importance in its history for three reasons. First, he endorsed the Alexandrian view that anatomy should be the basis of medicine. Second, he makes no distinction between surgery and internal medicine in his theory of disease. Although this unity was later broken, Galen bequeathed a vision of a union that would finally be recovered in the nineteenth century. Third, his writings formed the basis of medical and anatomical study from the late Middle Ages to the end of the seventeenth century. Medicine's debt to Galen was enormous.
The Muslim World
Arabic medicine was to a great extent developed from knowledge derived from translations from the Greek, and Arabic writings formed the basis of Western academic surgery for 300 years. The Iranian physician Avicenna's (980–1037) Canon of Medicine, based on Galen, is probably the most influential medical textbook ever written and was venerated in the late Middle Ages and Renaissance. The Arabs took a great interest in surgery, despite the Muslim prohibition on representing the human form. The Islamic surgeon Abu al-Qasim, known in the West as Albucasis (c.936–c.1013) wrote an extensive treatise on the subject. Albucasis was an advocate of cauterization by red-hot irons or corrosive agents.
The Medieval Divide
The ancient practical art of medicine, which combined both physic (internal medicine) and surgery, was almost completely lost after the fall of the Roman Empire in the fifth century AD. During this time medicine and surgery were either confined to folk practices or were the preserve of monks, the church being the only institution with any sort of connection to ancient learning. The rise of towns and creation of universities around the twelfth century helped divide medicine from surgery.
Medicine, or physic, because of its connections with the philosophy of Aristotle as cemented by Galen and its endorsement by the Arabs, was taught with law and theology as part of the new universities' curricula. Medicine was an academic subject taught by lecture and books. Aspiring physicians learned theory and principles, but not practice. Physicians also learned surgery at universities, but again, only from books as an academic subject.
Physicians emerged as a tiny, elite community in medieval Europe. Because they were university educated and spoke Latin, they claimed they had the power to deduce the internal or hidden causes of disease. University physicians, particularly in Italy and France, sustained and propagated surgery as a learned subject, but it was accessible to only a small number of practitioners.
One of the most famous medieval surgeons was the physician Henri de Mondeville (c.1260–c.1360). De Mondeville had studied surgery in Paris and Montpellier and obtained the degree of Master of Medicine. He taught surgery at the Paris medical faculty and was physician to the king. He left an unfinished and widely copied textbook on surgery (which was a manuscript, printing having not yet been invented). It was written in Latin and was soon translated into French.
Guy de Chauliac (1300–1368) was the most renowned surgeon of the Middle Ages. His Grande Chirugie is a work of immense learning that cites the great ancient and Arab authors and also shows his wide practical experience. The manuscript was frequently copied and, after the invention of printing, often translated and published.
Most practicing surgeons were not university educated. Surgery, especially in northern Europe, was deemed a craft skill, like weaving or brewing. Surgeons, with their tradesmen counterparts, banded together in guilds or colleges. They learned their trade in their native language and by experience through apprenticeship.
Physicians, who considered themselves superior to surgeons, attempted to control and regulate their practice. Surgeons, said physicians, dealt with external diseases: those conditions accessible to the senses—mainly sight and touch. Their practice was properly limited to disorders treatable by handicraft, not drugs, knowledge of which required book learning, established principles, and reason. The hierarchical distinction between head (reason) and hand (action), exemplified by physic and surgery, runs deep in Western culture (think of hierarchical distinction implied in the terms “factory hand” and “head of a business”). The distinction is as old as the works of ancient Greek philosopher Plato (428–348 BC).
The hands-on world was the surgeon's domain, and its place in the medieval order is illustrated by the fact that most surgical guilds were allied with barbers and sometimes wigmakers. The surgeon (usually a man but occasionally a woman) treated wounds and ulcers and other such ailments. A few extremely skilled surgeons would cut for bladder stones, trepan (bore) the skull after a fracture, amputate limbs, treat hernias, ligate (tie off) or cauterize hemorrhoids, and perform mastectomies to treat breast cancer. The dangers of sepsis and the absence of anesthesia made these operations painful and dangerous rarities. Despite physicians' disdain, many elite surgeons cultivated learning, and many guilds or colleges had fine libraries.
The struggle between the physicians and surgeons over their designated realms is well illustrated by the history of syphilis. A new disease in the fifteenth century, commonly known as the pox, syphilis produced terribleulcers, pain, and fever. Treating it could be lucrative, however, and mercury was found to be effective to some extent (although with dreadful side effects). After mercury's value was discovered, medical battles ensued. Physicians claimed that, because they gave mercury internally, the disease fell in their domain; surgeons said it fell in theirs because they applied mercury compounds to the skin. As these disputes continued, they became more pronounced, and appeared in many other areas as surgeons increasingly displayed confidence in their knowledge of internal disorders. Until the nineteenth century physicians often had recourse to the law (albeit ineffectually) to limit the surgeon's territory.
Beginning in the medieval period, surgeons tried to improve their position in the medical hierarchy and become the social and intellectual equals or even superiors of physicians. Two arenas in particular allowed them to advance their cause: the battleground and the palace. Although surgeons were deemed menial workers, some situations required their skill to relieve unbearable pain or save a life when physic could not (e.g., tooth-drawing, stopping bleeding, and removing bladder stones). Although disdained by physicians, small numbers of highly-skilled surgeons were valued by rulers for service in their armies and as personal attendants in their courts.
Anatomy and War
The study of anatomy in the Middle Ages and Renaissance grew amazingly quickly as ancient texts were rediscovered and human dissection was undertaken. The latter was primarily cultivated in the universities, most famously by Andreas Vesalius (1514–1564), a surgeon and teacher at Padua. At first sight the growth of anatomy at this time seems to suggest an urge to create a sound basis for surgery. In fact, anatomical knowledge in this period was largely paraded by physicians as a demonstration of their great learning. It did little to change their practice or, indeed, that of surgeons.
Far more important than anatomy was war. Ancient wound surgery had been developed by surgeons familiar with the relatively well-defined injuries produced by swords and spears. Gunpowder, invented by the Chinese (who did not have guns) and first used in European battles in the fourteenth century, forced surgeons to rethink their technique. By the sixteenth century the balls fired from muskets and cannons produced macerated injuries often filled with metal shards. Many surgeons considered these poisoned and used cautery by hot irons or boiling elder oil in their treatment.
French physician Ambroise Paré (1510–1590) was a typical surgeon in one sense; he was trained by apprenticeship and wrote in his native French. He was an army surgeon in the 1530s when he campaigned with French troops in northern Italy. Having exhausted his supplies of elder oil, he applied dressings of egg white, rose oil, and turpentine to gunshot wounds with great success. Paré rose to become one of the most distinguished surgeons in France. Often considered the father of modern surgery, he stressed that surgeons should be familiar with anatomy, consider regimen (mainly diet) in healing, and pay attention to their patients' internal condition. His work on gunshot wounds revived the ancient doctrine that the surgeon's work should be aimed at assisting nature, rather than supplanting it.
Surgical Guilds and Colleges
As surgeons began their upward social climb during the seventeenth century, dissection was performed in their increasingly powerful guilds and colleges. By 1700 something like a modern knowledge of the visible body had been established. The guilds began to acquire libraries and a small number of surgeons practiced at courts and had an aristocratic clientele. Most surgeons remained humble practitioners, but a few, although trained by apprenticeship and with no university education, began to present themselves as wealthy, learned gentlemen.
This was especially true of the so-called English school at the Barber-Surgeons Company in London. Here the military surgeon William Clowes (1544–1604) and Scottish-born Alexander Read lectured (c.1575–1641) on anatomy. Read had an MD degree from Oxford and his career exemplifies the sort of medical and surgical marriage that was beginning to occur between what were once separate spheres (at least in England). Another significant indicator of change was the work of John Woodall (1556–1643) whose book The Surgeon's Mate was published in 1617. Woodall was an East India Company surgeon and his text was intended for ships' surgeons, who needed to be highly skilled in wound dressing and rapid amputation. Cannon fire at sea could have spectacularly grotesque and disastrous results. A ball could smash a ship's timbers to pieces and disperse a thousand wooden splinters across the deck.
The most famous English surgeon of the time, the royalist Richard Wiseman (c.1621–1676), began his career as a ship's surgeon. His life illustrates the intertwining of the sea, war, and court—each central to surgical change at this time. Trained by apprenticeship, he joined the Dutch navy, in which he served for 20 years. In the English Civil War he was personal surgeon to the Prince of Wales, and later to Charles II. Like Clowes before him, and following Paré, he advocated the gentlest of treatments for gunshot wounds. Gradually, as navies expanded, ships' surgeons formed a new, but lowly, occupational class. By the end of the eighteenth century, especially on the massive ships of the British royal navy, these men assumed increasing responsibility for the health and discipline of the men aboard the vessels (an unhealthy ship was an unhappy and ineffective one). Naval and military surgeons' increasing power was to be one of the main forces in the transformation of the profession's social status.
In the eighteenth-century the trends already identified only intensified: the stress on anatomy, the emphasis on experience, the endeavor to improve surgical learning and, with it, social status. Two new features, however, characterized Enlightenment surgery.
First the public began to share the surgeon's perceptions that empirical knowledge was at least as valuable as the rational enquiry praised by the physicians. This had been an outcome of the Scientific Revolution in which authors such as Francis Bacon (1561–1625) denounced rationalism and praised the knowledge possessed by craftsmen. The attitude is seen in the great French publishing venture that embodied the Enlightenment's practical, optimistic attitudes. French philosopher Denis Diderot's (1713–1784) 32-volume Encyclopédie (1751–1777) extolled the virtues of surgery over physic because of its tangible benefit to humankind.
The second change reflects this approval of craft and empirical knowledge. Surgeons liberated themselves from antiquity and began to proclaim that they could practice the art of healing better than ancient authorities; as a result, Greek texts were no longer translated as sources of surgical wisdom but as historical documents of antiquarian interest. Enlightenment surgeons repeatedly stressed the improvements they had made to the art, not, as earlier practitioners had done, their recovery of it.
Eighteenth-century surgeons in socially fluid big cities became as rich, famous, and as acceptable as physicians. In London, surgeon William Cheselden (1688–1752), who was trained by apprenticeship, taught anatomy and published widely.
In the same city Percival Pott (1714–1788) was equally celebrated. He included among his friends David Garrick (1717–1779), the great Shakespearean actor, Samuel Johnson (1709–1784), famed essayist and lexicographer, and Thomas Gainsborough (1727–1788), one of the most renowned landscape and portrait painters of the day. Cheselden, Pott, and others valued learning and used it to advance surgery. Cheselden was made a fellow of the Royal Society, the foremost scientific institution in Britain.
Pott was classically learned, although he had little time for ancient authorities as a guide to surgery. Like Francis Bacon, he advanced the view that surgery was to be improved by detailed observation. He published on ruptures, hydrocoele (a collection of fluid in a testicle), anal fistula, wounds of the head, cancer of the scrotum, and lachrymal fistula. Pott is the eponym for two conditions. He observed a relation between a type of spinal curvature (now considered due to tuberculous) and lower-limb paralysis: “Pott's disease.” He also described a distinct fracture dislocation of the ankle: “Pott's fracture.”
In spite of these advances, surgery remained confined to external diseases and was considered an empirical craft. The body's interior remained the seat of constitutional disorders that were thought to be ruled by an overall balance of the fluids and solids. Surgery had no fundamental theory or principles like physic. At the end of the eighteenth century, however, two things happened that were to change surgery in a way that can only be described as revolutionary.
First, surgical principles were established. Unlike those of physic, however, they were not based on reason, conjecture, and inference at the bedside; they were grounded in animal (and sometimes human) experiments and post-mortems. Second, these principles were extended to the interior of the body, banishing the old humoral theories and reuniting the body as a single sphere of investigation and therapy. These new surgical principles were based on the study of the processes fundamental to disease states: inflammation, pus production, scar formation, tissue death, over- and under-development of body parts, fluid exudation, cancer growth and spread, and so on. These were the days before modern cell theory (established in the 1840s) but these processes could be described in the gross tissues and could be provoked and changed in living animals and their effects observed in the dead.
Paradoxically, the surgical revolution is principally associated with two men, a Scotsman and a Frenchman, neither of whom was an urbane, learned operator. In Britain, the revolution is associated with John Hunter (1728–1793) who was born on a small farm near Glasgow and began his career by teaching in London at the private anatomy school of his older brother, William (1718–1783). William had made a fortune as a male midwife (eventually called an obstetrician)—surgeons were beginning to colonize childbirth as part of their territory.
Although the Hunter brothers came from a modest background, anatomy teaching and midwifery allowed William to accumulate great wealth and be acknowledged as a gentleman. His obstetric patients included many members of the aristocracy. He lived in style in London and moved easily among the greatest in the land. He accumulated a huge private art museum open only to wealthy connoisseurs (art-collecting was a form of display—an art collection would include coins, books, antiquities and so forth). But it was the untutored and rather coarse John Hunter who helped transform surgery, by turning himself into a comparative anatomist, specimen collector, experimentalist, and teacher of the principles and practice of surgical operations. The generation of surgeons he taught performed operations on bones and soft tissues of such technicality (still without anesthesia) that they would have been unimaginable a century earlier.
In France, Hunter's contemporary reformer was Marie-François-Xavier Bichat (1771–1802), who came from rural France and studied in Paris when it was the center of the surgical world. Bichat is usually thought of as the founder of tissue theory (although he used the word “membranes” and did not employ a microscope). While it was obvious that the body was made of different sorts of matter: bones, blood, nerves etc., medical theory taught they could all be broken down to inert fibers that were always the same, simply matted together in different ways. Bichat claimed each and every tissue was alive and different from every other. Moreover, he held that each tissue always reacted in the same way wherever it was in the body. Inflammation of the lining of the lung, for instance, was just like inflammation of lining tissue anywhere else. This was the basis of a new surgical pathology. Indeed it was the basis of what is known as Paris medicine.
IN CONTEXT: PARIS MEDICINE
Paris medicine or hospital medicine is the name given to the profound transformation in medical education and concepts of disease that were wrought during the French Revolution of 1789 and the 30 years thereafter. Medically, Paris was unique. It had a large number of huge, overcrowded hospitals filled with the sick and the poor. Surgeons dominated the hospitals and made them the center of European anatomy teaching. During the Revolution all the elite medical colleges and societies in France were abolished. A new medical school was established that made no distinction between medicine and surgery. As in modern universities, all students began with the same courses and specialized in their later studies. Teaching was predominantly at the bedside or in the post-mortem room. The old humoral theories were abandoned in favor of the idea that diseases were local tissue changes. This was the surgical view of external disease carried into the body's interior.
The symbol of the new medicine was the stethoscope, invented by René-Théophile-Hyacinthe Laennec (1781–1826) in 1816. Listening through the stethoscope, doctors could form a picture of a disease in three dimensions. The new medicine was shaped by many forces, one of which was the Napoleonic Wars. The need for good, quickly trained military surgeons shaped a medical profession with ideas of disease oriented to the masses, not the upper classes. A similar transformation of medicine was occurring in the massive British royal navy, soon to be the backbone of a global empire.
In 1814, in his Traité des Maladies Chirurgicales, et des Opérations Qui Leur Conviennent, (Surgical Diseases and Their Appropriate Operations) Baron Alexis de Boyer (1757–1833) wrote: “Surgery has made the greatest progress in our time and seems to have reached, or almost reached, the highest degree of perfection which it seems able to obtain.” For the first 50 years of the nineteenth century, surgery in Europe was almost unrecognizable when compared to its medieval practice, and surgeons, as the quotation suggests, realized this.
French surgery dominated the Western World. At the beginning of the eighteenth century, for life-threatening conditions or severe disabilities, surgery was the treatment of last resort. A gangrenous limb would only be amputated when all else failed. By 1840 in many disorders of bones, joints, and soft tissues, surgery had become the treatment of first choice. Surgeons began to call the new surgery “conservative,” meaning preservative—proclaiming that an early surgical intervention might prevent more drastic treatment later. It cannot be stressed too much that this transformation had occurred before anesthesia had been introduced or surgical antisepsis conceived. Surgeons still had to be fast as lightening at the operating table, but what they could do there amounted to technical wizardry.
Anesthesia and antisepsis, now regarded as great landmarks, have erased the names of the French surgeons of this era from anything but scholarly memory. At war, Dominique-Jean Larrey (1766–1842), was a Napoleonic surgeon who performed 2,000 amputations in 24 hours at the battle of Borodino and invented mobile ambulances. The greatest surgeon of the day was Guillaume, Baron Dupuytren (1777–1835). (Physicians today still diagnose “Dupuytren's contracture”—a shortening of the tendons in the palm of the hand.)
French surgeons devised a whole series of operations for reconstructing body parts maimed by disease, notably rhinoplasty—rebuilding of the nose. They were not afraid to enter the body's interior: They sutured intestines, removed the cervix, and in one instance operated on a brain tumor. But it was in orthopedics that they excelled, notably in the resection of bones and joints.
Before the French school, surgeons and physicians would try to cure bone and joint diseases (which were very common and often caused by tuberculosis, which led to purulent sores) by internal medicines and superficial applications. If the patient were in imminent danger of dying, amputation would be performed. French surgeons perfected techniques for early operations to remove lengths of bone and whole joints, leaving patients with usable, if deformed, limbs. They removed knees, wrists, and jaw bones. They could remove whole legs by disarticulating limbs at the hip. (In one recorded English case, a young girl with a knee amputation that left her in unbearable pain chose this operation. (This was before the days of ether, so confident was she and her surgeons of success—and it worked!). The dark side of French surgery is that it was perfected on the thousands of impotent poor who filled Paris hospitals. American students writing home were shocked by the brutality they saw.
Aside from pain relief, an obvious reason for the introduction of anesthesia was the greater time it gave surgeons to exercise their new skills. But more subtle causes were at work. The Victorians found the sight of pain increasingly distasteful. This was one of the sources for nineteenth-century movements to prevent cruelty to animals and children, both of which became more prevalent around the time of experimentation with surgical anesthesia.
Surgeons began to experiment with anesthesia in the early nineteenth century, after the isolation of a range of gases during what is sometimes called the chemical revolution, 1770–1820. Nitrous oxide (laughing gas) and ether (a volatile liquid) were very popular at parties called “ether frolics.” The first successful anesthetic, however, was hypnotism, then called mesmerism, which was used to good effect in the 1840s by a Scottish doctor, James Braid (1795–1860). Ether anesthesia was first used successfully by an American dentist, William Morton (1819–1868), who was seeking to make his work pain-free to gain a competitive advantage over his rivals. On October 16, 1846, at Massachusetts General Hospital, surgeon John Collins Warren (1778–1856) successfully removed a tumor from the neck of a man who was given ether by Morton. The following year the Scottish doctor James Young Simpson (1811–1870) discovered the anesthetic properties of chloroform and began to use it during childbirth.
Surgeons like to tell the history of their subject in terms of dramatic breakthroughs, and the history of anesthesia has been shaped to fit this model. Many surgeons continued to operate without anesthesia and so the benefits to patients were nowhere near as quick as is sometimes suggested. Anesthesia in its early days was unpredictable and dangerous. In the world of obstetrics there were some objections to the use of chloroform on religious grounds. Opponents apparently used the text from Genesis 3:16 “in sorrow thou shalt bring forth children,” but when Queen Victoria (1819–1901) used chloroform for the birth of Prince Leopold in 1853 these objections evaporated. Anesthesia did indeed help transform surgery, but it was over decades not overnight.
Hospitals and Antisepsis
During the nineteenth century medicine moved into the hospital. These huge cathedrals of “cure” (the word must be treated with caution) were built in all the major European and American cities. The concentration of surgical patients, however, was associated with a terrifying phenomenon known as hospital gangrene or “hospitalism,” in which wounds became septic, limbs became gangrenous, and patients died from raging fevers. Often every single patient in the ward would develop the condition. Many public health reformers, notably Florence Nightingale (1820–1910), saw hospitalism as analogous to the febrile diseases of the city slums produced by overcrowding and filth. The cause of the disease, they said, lay in environmental pollution: they believed miasmas generated in a rotting wound created hospitalism just as sewage and putrefying matter in the streets produced typhoid. Their proposed solution was to tear down the hospitals and rebuild them as spacious, airy “pavilions” in the countryside.
Most surgeons, on the other hand, thought the answer to hospitalism lay in management of the wound rather than the general environment. Some tried simple dressings on the grounds that most minor injuries in everyday life healed without sepsis. The most important and controversial reformer who saw the answer to surgical sepsis in wound management was Joseph Lister (1827–1912).
Lister began practice as a house surgeon at the Royal Infirmary of Edinburgh. In 1860 he was made professor of surgery at the University of Glasgow. He knew of French chemist Louis Pasteur's (1822–1895) work on fermentation and by analogy proposed that the cause of sepsis in wounds was dead tissue harboring microorganisms that caused it to putrefy and produce poisons. Lister was aware that carbolic acid had been used to disinfect sewage and therefore probably had the capacity to prevent putrefaction. He began a method of treatment in which wounds were disinfected with carbolic and then covered with many layers of dressing drenched in the substance. In 1867 he published the results of his work, claiming great success. At this point in history, modern germ theory did not exist. Lister's “germs” were not bacteria, but some sort of fungal-like agent whose properties were shaped by the environment. His theory was one of putrefaction not infection.
Lister's antiseptic treatment of wounds with carbolic acid caused a furor. Many surgeons claimed equally good results using simple techniques, and believed that carbolic was a terrible irritant that delayed healing. Only after 1880 did Lister adopt modern germ theory, by which time surgeons were turning to aseptic methods, that is, heat sterilization of the whole surgical environment: clothes, instruments etc., rather than chemical sterilization of the wound alone. Lister's antiseptic revolution is something of a myth (a good myth for surgeons though). The aseptic approach was developed in Germany and based on modern bacteriology. Surgical mortality did decline in the 1870 and 1880s, but it is very difficult to determine the causes, since hospitals were becoming cleaner and more sanitary, nurses were better trained, and patients' diets were improving.
Exploring the Interior
Anesthesia, antisepsis, and asepsis made it possible for surgeons to venture where, with only a few exceptions, they previously had feared to go: the abdomen, thorax, and cranium. For a while, Germany and Austria became the centers of the surgical and scientific world. This was far more than simply technical: the Germans made it into a modern profession. Societies and specialized journals were founded and annual congresses held. Textbooks poured from presses. University surgical clinics were established with hierarchical structures, strict discipline, and imperious chiefs.
The man most widely admired in this period was Viennese surgeon Theodor Billroth (1829–1894), professor of surgery at Zurich and Vienna. His reputation was built on his surgery of the intestinal tract. He removed cancer from and anastomosed (rejoined) the gut, and resected the stomach for ulcer and cancer. Gallstones, hernias, and hemorrhoids all came under his knife. Surgeons, indulging in their new power, found in the abdomen the origins of all sorts of diseases: the colon was removed as a source of autointoxication, and the spleen as the cause of pernicious anemia. It was in this context appendicitis was described by an American pathologist, Reginald Heber Fitz (1843–1913).
It is sometimes said that the quality of medical teaching can be measured by the number of foreign students visiting a city or country. In the eighteenth century students flocked to Edinburgh, in the early nineteenth to Paris, in the late-nineteenth to Germany, and in the early twentieth to America. More specifically, they went to Johns Hopkins Hospital and its medical school in Baltimore. Hopkins was modeled on German universities, where most of Hopkins's teachers had studied. Germany's scientific reputation was based on its laboratory teaching.
Americans sought to bring the laboratory to the surgical patient in every possible way. They carried out clinical research and operations on animals to perfect new procedures. Patients were carefully investigated before operations and monitored after them. Using this scientific approach, Hopkins's operators brought previously unknown refinement to surgical technique.
Under surgical professor William Halsted (1852–1922), delicate vascular surgery was developed for conditions such as aneurysm (potentially fatal ballooning of the arteries). Halsted also devised a radical mastectomy for breast cancer, which became most surgeons' operation of choice for almost a century. Hopkins's most famous alumnus was not Halsted but the neurosurgeon Harvey Cushing (1869–1939).
Cushing left Hopkins in 1912 to become professor of surgery at Harvard and surgeon at the Peter Bent Brigham Hospital in Boston, where he spent the rest of his working life. He is regarded as the founder of the first surgical specialty, neurosurgery. Besides operating on relatively common brain tumors, notably menigiomas (tumors of the brain covering), Cushing was virtually the single-handed creator of surgery of the pituitary body. More than this, however, his scientific approach to surgery made him one of the great investigators of pituitary endocrine function in health and disease.
The Early Twentieth Century
Surgery expanded spectacularly in twentieth century, both in terms of range and the number of operations done, but all the foundations for these developments had been laid in the previous 100 years. Until this time, little of surgery could be considered anything more than an elaboration of nineteenth-century procedures. World War I (1914–1918) saw the final end to Listerian antiseptic methods, which were still being used by British surgeons, who slowly learned that carbolic acid could not reach the bacteria in deep wounds filled with Flanders mud. They turned instead to irrigation with Carrel-Dakin solution, a fluid devised by Alexis Carrel (1873–1944), a French-born surgeon who practiced in the United States, and Henry Dakin (1880–1952), an English chemist.
Plastic surgery, an ancient art, was developed as a modern discipline in the war by Harold Gillies (1882–1960), a New Zealand-born otolaryngologist, working at a new hospital in Sidcup, Kent, England, devoted to facial injury. Opened in 1917 with more than 1,000 beds, the hospital performed over 11,000 operations on more than 5,000 men. Many techniques of modern plastic surgery were developed there.
The years between the wars were relatively quiet, surgically speaking, with nothing like the changes that took place before 1914 and after 1945. During the 1920s and 1930s surgeons consolidated their powerful place in the medical hierarchy. Specialization accelerated and accreditation became important. Surgery began the last phase of its move from the patient's home to the hospital.
World War II and Its Aftermath
World War II (1939–1945) saw little in the way of innovation at the operating table. The principal change from the World War I was organizational: Surgical teams in 1914–1918 were immobile, stuck behind the trenches. In World War II surgery was organized in small units that followed moving fronts. Aircraft made the rapid movement of patients to larger hospitals possible. But if anything sticks in the surgical memory of the war it is the introduction of penicillin in 1944. There was hardly any operation carried out in that year that could not have been done 30 years earlier, but penicillin drastically reduced postoperative mortality, particularly after cranial surgery.
IN CONTEXT: THE SURGEON AS HERO
In the Middle Ages and beyond it was common to associate the surgeon with the butcher and the hangman. They were regarded as coarse men engaged in brutal work. Surgery established itself as a respectable profession only in the age of Victorian individualism. Nineteenth-century heroes were men of action: pioneers, explorers, mountaineers, soldiers, engineers, and the like. The image of the robust, muscular, daring, individual surgeon was easily included in this group. Manliness and its associated qualities were defining features of these heroes.
American surgeons, in particular, thought of their discipline driven by these characteristics. In 1904, Frederick Dennis, professor of clinical surgery at Cornell University observed: “The undaunted bravery which enabled the people of the Mayflower and others of kindred heart and mind to cross the great unknown ocean, and to settle in the primeval forest for the sake of liberty, has infused itself into the American spirit and has qualified Americans to attempt and to perform daring deeds in surgery.” There was, he went on, “no science that calls for greater fearlessness, courage, and the nerve than that of surgery, none that demands more of self-reliance, principle, independence and determination in the man.”
When Lord Joseph Lister (1827–1912) died, his funeral filled Westminster Abbey, appropriately also the place where David Livingstone (1813–1873), the African explorer, was buried. When Frederick Treves (1853–1923), of “Elephant Man” fame, left for the Boer War, crowds of medical students flocked to Waterloo Station. Using an appropriate sporting metaphor, the (London) Times correspondent said that the cheering reminded him of a try being scored on the rugby (football) field. This heroic image has persisted to the present day, given a glamorous and romantic sheen by Hollywood. The television series M*A*S*H (in spite of its ironic and cynical plot) testifies to the enduring appeal of the heroic surgeon.
Penicillin symbolized the buoyant optimism of medicine in the postwar world. Surgery was a particular beneficiary of this mood. Surgeons and the public were ready for new explorations. Heart and transplant surgery captured the popular and the surgical imagination. In 1896, the English surgeon Stephen Paget (1855–1926) thought that successful heart surgery was impossible, observing that the “surgery of the heart has probably reached the limit set by nature to all surgery.” Indeed, for 50 years after this, surgeons only rarely entered the thorax and then only for relatively minor lung operations.
Surgeons who had removed shrapnel from the heart in the war, however, came back home determined to operate on the sacred organ. One such was Dwight Emary Harken (1910–1993), a Harvard graduate who had worked at the U.S. military Hospital in Cirencester, England. With the end of the war, Harken turned his attention to mitral stenosis, a narrowing of a heart valve that was often a result of rheumatic fever, then a common condition.
Harken reported a successful mitral valvotomy (opening or widening) in 1948. Other surgeons quickly followed suit, including Denton Cooley (1920–) who epitomized the glamorous surgeon: technically brilliant, elegant, and highly successful. His practice was run from the Texas Heart Institute, founded in 1962, where he built a heart surgery production line, carrying out thousands of operations a year. In partnership with manufacturers, he marketed products and promoted himself. Heart surgery boomed everywhere. By the year 2000, 200,000 heart operations per year were performed in the United States.
A technology crucial to the boom in heart surgery was the heart-lung bypass machine, invented by American surgeon John Heysham Gibbon (1903–1973) and first used in the 1950s. This device takes over the heart's action during an operation. It was crucial to the first heart transplant, performed by Christiaan Barnard (1922–2001) in Cape Town, South Africa, in 1967. The patient lived 18 days after the operation. Although technically easier than other heart operations, transplantation had to overcome the emotional obstacle of public suspicion (which it did quite quickly) and the physiological problems of immunological rejection (which have by no means been fully surmounted).
Since the eighteenth century surgeons have claimed their art was a discipline dependent on science. At times this claim has been no more than rhetorical attention seeking. Arguably, however, never have science and surgery been so closely tied as in transplantation. Autografts (transplantations from one part of the body of a patient to another part) have been used successfully in plastic surgery for hundreds of years. Experiments in transplantation from a donor animal to another of the same species—allotransplants—were long known to result in rejection. In the 1940s the immunological mechanisms of rejection were worked out in Britain and Australia by Brazilian-born British zoologist Sir Peter Medawar (1915–1987) and Australian physician Frank Macfarlane Burnet (1899–1985). The first successful kidney transplant was carried out in 1954 on identical twins (and thus involved no rejection problems) by American surgeon Joseph Murray (1919–) at the Peter Bent Brigham Hospital in Boston. All transplantations between immunologically different individuals continued to fail. The isolation in 1971 of cyclosporin from a fungus changed transplant history. It was the first successful immunosuppressive. Although these drugs leave patients vulnerable to infection and some cancers, they have permitted the whole range of modern transplantation surgery: hearts, kidneys, livers, the pancreas, and more.
Modern Cultural Connections
There are long-term continuities in the history of surgery, not least in the fundamental tasks of removing, dividing, joining, and transplanting body parts. In this respect surgeons today have things in common with the operators of the Edwin Smith papyrus. Twenty-first century surgery is very like its nineteenth-century predecessor in many ways, but in others it shares the changes found in twentieth-century culture. Around 1900 surgeons were like aviators. They were heroic individuals who flew by the seat of their pants. Today, flying an airplane, although directed through the pilot, is a massive technology-based activity involving the teamwork of those in the cockpit and many more behind the scenes. Surgery is much the same.
One aspect of surgical experience is being changed today. In the past, surgeons got to know the body through their hands. Nowadays minimally invasive procedures are distancing surgeons from their patients. Through scopes of sorts and by viewing the interior of the body on a screen, surgeons can operate through “keyholes.” Aspiring surgeons can now learn these techniques on computer-generated virtual bodies. Interestingly, these training systems were modeled on flight simulators.
At the end of the eighteenth century, surgeons captured the future. They defined internal diseases as local and thus as surgical diseases. There has, until recently, been a sense of the inevitable march of surgery into the body as the best or only cure of many conditions. There are straws in the wind, however, that suggest surgical conditions can be reconceptualized. The most obvious example is peptic ulcer. These erosions of the gastric surface have been treated by radical surgery since the late-nineteenth century. Doctors now know that many of these ulcers are the result of bacterial infection by Helicobacter pylori and can be treated with a course of antibiotics. Stem-cell research holds the promise of making transplantation seem like a crude procedure. Modern medicine is learning something long known to historians and anthropologists: Surgical disease is not universal, but very culturally bound.
See Also Biomedicine and Health: Antibiotics and Antiseptics; Biomedicine and Health: Bacteriology; Biomedicine and Health: Dissection and Vivisection; Biomedicine and Health: Galen and Humoral Theory; Biomedicine and Health: Human Gross Anatomy; Biomedicine and Health: The Germ Theory of Disease.
Breasted, James Henry, trans. The Edwin Smith Surgical Papyrus. Vol. 1. Chicago: Chicago University Press, 1930.
Haeger, Knut. The Illustrated History of Surgery. London: Harold Starke; Chicago, Fitzroy Dearborn Publishers, 2000.
Lawrence, Christopher, ed. Medical Theory, Surgical Practice: Studies in the History of Surgery. London and New York: Routledge, 1992.
Moulin, Daniel de. A History of Surgery: With Emphasis on the Netherlands. Dordrecht and Boston: Nijhoff, 1988.
Wangensteen, Owen H., and Sarah D. Wangen-steen. The Rise of Surgery: From Empiric Craft to Scientific Discipline. Folkestone, Kent: Dawson, 1978.
Prentice, Rachel. “The Anatomy of a Surgical Simulation: The Mutual Articulation of Bodies in and through the Machine.” Social Studies of Science 35, no. 6 (2005): 837–866.
Nobel Foundation. “Peter Medawar—Nobel Lecture.” http://nobelprize.org/medicine/laureates/1960/medawar-lecture.html (accessed on February 11, 2008).
YourSurgery.com. “Your Surgery.” http://www.yoursurgery.com/index.cfm (accessed on February 11, 2008).