IV.

Modern Surgery

In the 19th century, surgeons were emboldened to attempt a wider range of surgical procedures despite the risks of post-operative infection and lack of anaesthesia. The American surgeon Ephraim McDowell, of Kentucky, performed ovariotomies (removal of the ovaries) to treat ovarian disease (1809). Nathan Smith, a doctor in Massachusetts, also performed ovariotomy in 1821, without knowing of McDowell's work. The American surgeon Valentine Mott ligated important blood vessels in the treatment of aneurysm (abnormal expansion of a blood vessel). James Sims, of Alabama and New York, became known as the founder of modern gynaecology. His experimental subjects were black female slaves, who repeatedly underwent excruciating operations as he attempted to repair their vesicovaginal fistulas, and he has been alternately praised and criticized for his innovation and ethics. Samuel Gross of Philadelphia was a great surgeon and teacher. Sir Astley Cooper of England and Sir Charles Bell and James Syme of Scotland were too outstanding surgeons.

The discovery (1842-1847) of inhalation anaesthesia, initially using ether and then chloroform, brought great relief to the patients and allowed surgeons much greater time in which to operate. The muscle rigidity which occurred as the patient was anaesthetized still caused problems and the whole process remained risky until anaesthesiology developed as a separate discipline and employed its own increasingly sophisticated technologies. Hospital gangrene, septicaemia, tetanus, and pyaemia remained as problems. Not until the French chemist Louis Pasteur evolved his germ theory and discovered that fermentation is caused by micro-organisms did surgery reach a new potential. When the British surgeon Sir Joseph Lister applied the discoveries of Pasteur to surgery and formulated his theory concerning sepsis and antisepsis, surgeons were able to counter many of the problems of post-operative mortality. Equipped with anaesthesia and aseptic techniques, surgeons were able to delve more confidently into the body’s cavities, and abdominal, thoracic, and brain surgery followed. Blood loss and its sequelae remained a serious problem until the immunological puzzle of blood groups was unravelled in the early 20th century. George Crile successfully conducted transfusion experiments in 1907, and blood transfusion became widespread after methods of collecting and preserving blood were developed during World War I.

Observations of the effects of surgery on altered physiology led to advances in medical knowledge. In this way, experimental surgery became a research tool, using animal models as well as human subjects. Understanding the function of the thyroid gland and its secretions is a good example.

Surgery in the 20th and into the 21st centuries has been characterized by the greater integration of surgery and medicine, so that practitioners of these two disciplines are most likely to form a team for understanding and treating disease. In general, there is a trend towards conservative surgery, for instance the heroic cancer surgeries of the first half of the 20th century, usually the first therapeutic intervention, have been replaced by a more focused surgical oncology which uses surgery often as a secondary or salvage approach. For instance, in cancers of the larynx, radical radiotherapy (sometimes in conjunction with chemotherapy) will be employed before surgery to try to preserve a patient’s normal speech capability. Surgery has refined its techniques and co-opted technologies, such as improved imaging and micromanipulation to effect treatment while leaving healthy tissues unaffected and intact wherever possible.

Surgery today is practised for the following purposes: diagnosis, such as surgical opening of the body for exploratory purposes, and excision of tissue for examination (although modern diagnostic tools eliminate the need for some of this, and minimal access surgery has reduced the severity of the operation needed in many visualizations, for example, laparoscopy); the correction of deformity or abnormality; the cure of disease; the amelioration of suffering; and the prolongation of life.

A.

Corrective Surgery

At present, corrective surgery is employed for club foot, harelip, cleft palate, bow-legs, deformed spine, congenitally dislocated hip joints, and many heart and blood-vessel diseases. In correcting conditions caused by accident or disease, plastic surgery is used. Some surgeons have entered the field of cosmetic surgery, changing “unattractive” features, as well as treating crumpled ears, malformed noses, and other conditions caused by accident or disease. The use of lasers in ophthalmology has allowed correction of refractive errors by changing the curvature of the cornea. Radial keratotomy is most successful in myopia (shortsightedness).

B.

Curative Surgery

Surgery is employed in the treatment of sarcoma, tuberculosis, and osteomyelitis. In the field of bone diseases, the British surgeon Sir William Arbuthnot Lane originated the procedure known as bone plating; John Murphy of Chicago contributed to the technique of arthroplasty, or plastic surgery of joints; and Fred Albee and other American surgeons have contributed to surgery of the spine by their work on bone transplantation and osteoplasty (plastic surgery on bone).

The brain is subjected to inspection and many kinds of operation, including removal of tumours, evacuation of abscesses, and clearing of blood clots and other obstructions to blood vessels. The spinal cord too is subjected to surgical treatment and is also the site of injection for induction of spinal analgesia. The peripheral nervous system, like the brain and spinal cord, is amenable to surgical treatment in the relief of affections of the nerves themselves, or in the course of the surgical care of other diseases.

The vascular system, including the heart, has been brought within the domain of experimental and practical surgery. Whereas a large proportion of the practical surgical work on the heart formerly dealt with injuries such as stab or gunshot wounds, many current heart operations are performed to correct congenital heart abnormalities and tight or leaky heart valves resulting from diseases such as rheumatic fever. The ligation of arteries for the control of haemorrhage has played an important part in surgical practice since Paré introduced it in the 16th century.

Many blood-vessel diseases that were formerly fatal or crippling are cured surgically today. The surgeon can restore normal blood circulation to vital organs by eliminating obstructions and stopping leaks in arteries. Damaged sections of arteries can be removed and the channel restored by grafting in a segment from a donor or, if the defect is not too extensive, by sewing together the cut ends. Arterial defects can be repaired by: opening the vessel and scraping out the clot; bypassing or replacing the obstructed segment with a natural or synthetic graft; or widening the bore of an artery by inserting material in its wall. Sometimes vessels are cauterized by laser if surgery is too risky.

The history of respiration-system surgery was entirely changed as a result of the invention of means of operating upon the lungs and other thoracic viscera without collapse of the lungs. This is accomplished by various kinds of apparatus designed to maintain the necessary differential air pressure during operation, by the hypoatmospheric and the hyperatmospheric methods. In present-day surgery, one lung or portions of a lung can be removed safely in patients with cancerous conditions or inflammatory infections such as tuberculosis. Laser surgery has also been used in cancer of the lung to remove blocked and obstructed tissue before radiotherapy.

In surgery of the gastrointestinal tract, ulcers and tumours are excised, injuries are repaired, adhesions resulting from inflammatory processes are broken up, and portions of the tract that are distorted as a result of adhesions are restored to normal function. Again, lasers may be used to cauterize lesions, and in cases of oesophageal cancer remove the malignancy, where conventional surgery is inappropriate. Portions of the stomach and intestine are sometimes removed because of an ulcer or cancer. The liver and gallbladder and their appendages also can be operated on successfully. For example, when gallstones are present the gall bladder can be removed.

The genitourinary system, that is, the kidney, bladder, and organs of reproduction, is the site of many operative procedures. Surgery of the female generative organs, such as ovaries, uterus, and Fallopian tubes, is a field in which impressive achievements have been recorded. The present trend in the surgical treatment of these organs is towards conservatism. The use of lasers to excise malignant or re-malignant tissue in cancer of the cervix has been successful, particularly when it is employed as part of a regular screening programme.

A comparatively new phase of surgery is the treatment of conditions resulting from disordered function of the ductless glands and other organs having internal secretion (endocrine glands). The pineal and pituitary glands in the brain, the thyroid, parathyroid, and thymus glands in the neck, the pancreas, the suprarenal capsules, the liver, the spleen, the sexual glands (ovaries and testes), and other structures are currently classed among the organs of internal secretion.

C.

Ameliorative Surgery

Surgery is often employed to ameliorate suffering when a cure is unlikely, especially in the relief of cancer. Suffering may be relieved: by cutting nerves that are pressed on by the tumours; by removing portions of the malignant growth that impinge on other organs, causing pain or impaired function; and by clearing up ulcerating areas and skin grafting. Sometimes very large areas of degeneration may be cleared up, especially with the aid of certain forms of electricity, and the surface covered with other portions of the patient's body. Orthopedic surgeons are now involved in the team care of haemophilic patients as frequent bleeding into joints can cause their destruction.

D.

Continuing Developments

Preoperative care and preparation of patients has made significant advances, and diagnosis of deep-lying conditions has been simplified by a multitude of devices, including CAT (computerized axial tomography) and, increasingly, MRI (magnetic resonance imaging) scanners. The methods of surgical anaesthesia have been greatly improved, including spinal anaesthesia, which has, however, proved inadvisable for patients in a condition of shock. Introduction of antibiotics has eliminated post-operative pneumonia and significantly reduced other infections, although antibiotic resistance is now a problem affecting surgical wards. Haemorrhage and rupture of wounds following surgery are less common because of improved surgical techniques and better suture materials. Embolism, the breaking away of a blood clot that may travel and lodge in a vital organ, is curtailed by the use of anticoagulants and by early ambulation of patients after surgery. Post-operative shock is now controlled by intravenous administration of fluids and by blood transfusion. During the Vietnam War, skilled surgeons using new operating-room techniques and materials were able to reduce the fatality rate among wounded soldiers to less than 2 per cent, compared with 5.5 per cent in World War I and 3.3 per cent in World War II.

The electroencephalograph, a device that records brain waves, has been of great value in diagnosing cerebral conditions, as the electrocaudery has been in brain surgery. Trials of surgically implanted neural pacemakers, which release electrical stimulation into the brain, have been conducted to determine their effect as antidepressants.

Cryosurgery is one of the so-called bloodless techniques available to modern surgeons. It has been used to treat Parkinson's disease and certain eye ailments, brain tumours, and glandular disorders. Another method involves focusing a beam of radioactive particles on the site of a tumour. Irradiation has been effectively employed in treating tumours of lymphoid tissue and tumours of the urinary tract. Early diagnosis and surgical removal or, when inoperable, exposure to radium or X-rays, has significantly reduced mortality and prolonged the life of cancer victims. Surgeons have also used helium ion beams to treat eye cancers and heal lesions in the brain, and have used laser beams to weld back detached retinas.

Surgical ligation has proved valuable in treating some heart defects, including the installation of pacemakers. When hypertension is caused by a diseased kidney, removal of the affected kidney has relieved the condition. High blood pressure as a result of the narrowing of the renal artery can be reduced to normal by several surgical procedures, the most common being bypass grafting and patch grafting. The anticoagulant drug heparin has proved valuable in vascular surgery and cerebral thrombosis.

Removal of the spleen has been successful in treating congestive splenomegaly (enlargement of the spleen) and spherocytic jaundice. A new technique for observing the condition of the stomach wall (gastroscopy) has advanced diagnosis and treatment of gastric disorders, including cancer. Marked advances have been made in surgery of the descending colon and in rectal surgery.

Modern surgical techniques permit operations that only a few years ago might have been considered impossible. An example is the stapes operation, or stapedectomy, in which the tiny bones of the inner ear are exposed in order to correct a hearing disorder known as conduction deafness. The surgery is performed within such a small area that surgeons must view their work on a television screen using a special microscope. The stapes, one of the small bones that transmit sound vibrations in the inner ear, is replaced by a tiny plastic tube or piece of stainless steel wire.

Microsurgery techniques were also used successfully for the first time in rejoining a severed limb in 1962, at Massachusetts General Hospital, in Boston, United States. An arm completely separated from the body at the shoulder was restored to nearly normal use. Today, about two thirds of the attempts to rejoin severed limbs succeed. An operation in which the legs of extremely tall people are shortened by sawing out sections of bone and rejoining the severed parts was first achieved in 1965. Sterilized calf bone was developed in the 1960s as a replacement for human bone. Artificial skin and cloned human skin were both developed in the 1980s.

Plastics, particularly silicone and Teflon, are now commonly used in permanently implanted artificial organ parts, including corneas, heart valves, and Fallopian tubes. Plastics are used in plastic surgery for parts of noses, ears, and chins. Artificial blood vessels and tubes to drain fluids from the brain and chest are made from plastics that do not trigger an immune reaction when implanted and joined with natural tissue. A single-ventricle heart pump can temporarily support the circulation of patients whose hearts are damaged to such an extent that they cannot provide their bodies with adequate circulation. An artificial heart to replace the human heart permanently or for prolonged periods was first used in 1982 and has been used several times since then, but several technical and physiological problems remain to be solved.

One of the most remarkable achievements of modern surgery is the transplanting of vital organs from one human body to another (see Transplantation, Medical). Since the first kidney transplant was accomplished at Peter Bent Brigham Hospital, in Boston, in 1951, many kidney transplants have been performed. Teeth, cornea, liver, heart, pancreas, small bowel, and endocrine-gland transplants have also been successful; the first human heart transplant was performed in 1967 by Christiaan Barnard in Cape Town, South Africa. In all these cases, the technical skills were developed before the immunological hurdles had been overcome.

To combat immune reactions that would result in transplant rejection, recipients are treated with drugs such as cyclosporin. Cyclosporin’s toxicity for the kidney led to the evolution of a multi-drug treatment regime involving small, non-toxic doses of azathioprine, corticosteroids, and cyclosporin. New agents also include FK506 and mycophenolate mofetil, used instead of cyclosporin and azathioprine respectively. Control of rejection has allowed transplant patients to enjoy considerable post-operative periods of longevity. Currently there are people living 30-plus years after renal transplants, 20-plus years after cardiac and liver transplants, and 10-plus years after pancreas and heart and lung transplants. A possible new direction in transplant surgery, which faces a worldwide shortage of donor organs and continues to raise ethical issues, is the use of xenografts from animals. Research using transgenic pigs, which share the same complement-controlling protein, have yielded organs, which are not immediately destroyed by human antibodies, and research continues.

Minimally invasive surgery has come to the fore since the mid-1980s and its impact is tremendous. It was first used to telescopically remove kidney stones using a 1-cm (0.4-in) incision through the skin to reach the kidney. This operation was further refined by extracorporeal shockwave lithotripsy, which used electrical or acoustic waves to break up stones within the body, which are then passed out through the urinary system. With current lithotripters, these machines can be used without anaesthetic, involve no invasion of the body, and allow walk-in-walk-out appointments for what was previously a major operation.

Keyhole surgery has proliferated since the mid-1980s into many branches of surgical medicine. Open-operation hysterectomies can be replaced by diathermy or, if necessary, removal of the uterus can be carried out through the abdominal cavity using a telescope and then extracted from the body via the vagina. Orthopaedic surgery on the knee, now involves telescopic removal or repair of damaged cartilage. Neurosurgeons remove prolapsed intervertebral discs by such minimally invasive means; local rather than a general anaesthetic is used and there is no overnight stay in hospital. Skill in the use of endoscopes and robots are becoming the new benchmarks for surgical success. Patients may expect to receive treatment from a highly trained technician rather than a fully-fledged surgeon. The growth of minimally invasive surgery will reshape use of in-patient hospital accommodation.

See also: Medicine; Medicine, Chinese; Medicine, Early Modern; Medicine, Eighteenth-Century; Medicine, Medieval Islamic; Medicine, Medieval Western; Medicine, Nineteenth-Century; Medicine, Twentieth-Century.