Modern Surgery Developed

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Modern Surgery Developed

Overview

Surgery is an ancient branch of medicine, but it was not until the nineteenth century that doctors learned to apply practical and effective measures for controlling pain and preventing surgical infection. New techniques for anesthesia and antisepsis were key elements of the transformation of the ancient art of surgery into one of the most respected and powerful areas of medical specialization. With dependable methods for the control of pain, infection, and bleeding, surgeons were able to go beyond the treatment of wounds, fractures, dislocations and carry out new and daring operations on the interior of the body.

Background

The transformation of surgery seems to have occurred with remarkable speed in the nineteenth century when surgeons were given the tools to overcome two of the great obstacles to major operative procedures: pain during surgery and the life-threatening infections that often followed surgery. These obstacles were largely overcome in the nineteenth century with the introduction of anesthesia (methods of controlling pain) in the 1840s and antisepsis (methods of fighting infection) in the 1860s.

A closer examination of the evolution of surgery, however, suggests a more complex explanation for the remarkable progress that seemed so revolutionary. Traumatic injuries, wounds, ulcers, skin diseases, fractures, dislocations, bladder stones, urinary disorders, and venereal diseases had been treated by surgeons, with some success, for hundreds of years. Nevertheless, the status of the surgeon was traditionally lower than that of the physician. Medicine was regarded as a learned profession, while surgery was a mere technique that required training and experience rather than learning. During the eighteenth century, however, progress in anatomical investigation, and the acceptance of a new approach to pathology, provided an intellectual framework for advances in surgery. The transformation of surgery in the nineteenth century closed the gap between medicine and surgery and established the basis for the modernization of a powerful and unified medical profession.

Although various narcotics have been used in religious and healing rituals for thousands of years, Dr. Oliver Wendell Holmes (1809-1894) reflected conventional medical wisdom when he said that nature offered only three natural anesthetics: sleep, fainting, and death. The preparations used to induce ceremonial intoxication would not satisfy the criteria for anesthetic agents that were established in the nineteenth century: relief of pain must be inevitable, complete, and safe. Impure mixtures of drugs were acceptable for ceremonial purposes, but they could cause unpredictable and dangerous effects in a person undergoing surgery. Ancient methods were too unpredictable to fit the criteria for modern surgical anesthesia, but the world of drug lore provided examples of potentially useful anesthetic agents. Ancient soporific and narcotic potions contained opium, mandrake, henbane, wine, marijuana, hellebore, belladonna, henbane, jimsonweed, hemlock, and other dangerous drugs. Curare, an arrow poison used by South American Indians, does not relieve pain, but it is useful in modern surgery because it causes muscle relaxation.

In the eighteenth century, the chemical revolution provided a new series of agents that could be used as painkillers. Joseph Priestly (1733-1804), the discoverer of oxygen, also discovered nitrous oxide, or "laughing gas." Humphry Davy (1778-1829) inhaled nitrous oxide while suffering from toothache in 1795 and noted that the pain caused almost disappeared. He suggested that nitrous oxide might be useful during surgical operations. Davy's associate Michael Faraday (1791-1867) discovered the soporific effect of ether vapor during experiments on various gases.

Impact

Many individuals were involved in the discovery of inhalation anesthesia in the nineteenth century and several of them became embroiled in bitter priority battles. Horace Wells (1815-1848) and William Thomas Green Morton (1819-1868) were dentists who shared a successful partnership. Wells recognized the anesthetic properties of nitrous oxide, but his public attempt to demonstrate the effectiveness of his method was unsuccessful. Morton decided to search for another anesthetic agent and in 1846 successfully demonstrated the value of ethyl ether for inhalation anesthesia. Charles T. Jackson (1805-1880), chemist and physician, later claimed that he had discovered ether anesthesia and had instructed Morton in its use. While this priority battle raged in New England, Georgia physician Crawford Williamson Long (1815-1878) announced that he had operated under ether anesthesia before Morton.

After confirming the benefits of ether anesthesia, James Young Simpson (1811-1870), one of Scotland's leading surgeons and obstetricians, discovered that inhaling chloroform produced a sense of euphoria as well as loss of consciousness. Chloroform was easier to administer than ether, but was also more dangerous. Within two years of Morton's first public demonstration, ether, nitrous oxide, chloroform, and other anesthetics were widely used in dentistry, obstetrics, and surgery. Most doctors cautiously accepted anesthesia as a "mixed blessing" which had to be used cautiously and even selectively.

The safety of anesthesia was not the only point of contention. The attack on the use of anesthetics in childbirth was particularly virulent. Clergymen denounced the use of obstetrical anesthesia and advised women to endure the pains of childbirth with patience and fortitude, because the Bible said that Eve was condemned to bring forth children in sorrow. Some obstetricians argued that labor contractions were identical to labor pains; therefore, without pain normal births would be impossible. Simpson was able to address his critics with both theological and scientific rebuttals. The curse in Genesis, he argued, had been revoked in Deuteronomy: "The Lord will bless the fruit of the womb and the land." Moreover, the word translated as "sorrow" in the case of Eve's punishment was really the word for "labor," either in farming or childbirth. Furthermore, he continued, God had established the principle of anesthesia when he caused a deep sleep to fall upon Adam before operating on his rib. When John Snow (1813-1858) successfully administered chloroform to Queen Victoria in 1853 during the birth of her eighth child, the issue of whether a proper lady would accept anesthesia was quickly settled.

With proper management, inhalation anesthesia was generally safe, complete, and inevitable. However, general anesthesia is not suitable for all operations. Fortunately, chemical agents suitable for use as local anesthetics and instruments for their delivery were available by the time the concept of surgical anesthesia had been accepted. Friedrich Wilhelm Sertürner (1783-1841) had turned crude opium into crystals of morphine and Charles Gabriel Pravaz and Alexander Wood (1725-1884) had invented the modern hypodermic syringe. Cocaine had been used by the ancient Incas of Peru for surgical operations, including trepanation. Coca leaves were also used to fight pain, hunger, nausea, and fatigue. Although Europeans quickly took up the Native American custom of smoking tobacco, they ignored coca until the nineteenth century. By the time Carl Koller (1857-1944) and Sigmund Freud (1856-1939) began their experiments on cocaine, chemists had isolated various alkaloids from coca leaves. Koller used cocaine for the relief of eye diseases such as trachoma and iritis. After learning about Koller's experiments, William Stewart Halsted (1852-1922), one of New York's leading surgeons, developed sophisticated techniques for achieving local anesthesia by injecting cocaine solutions into the appropriate nerves.

The specific effect of anesthesia on the frequency of operations has been a matter of debate, but the evidence suggests that anesthesia did expand the amount of surgery performed. In part, the rise in surgical cases was an outgrowth of urbanization, industrialization, and concomitant changes in the role of the hospital. The increase in gynecological surgery, especially ovariotomy, was especially problematic; gynecological surgeons claimed that these operations could cure insanity and various nonspecific "female problems." Some critics were convinced that surgeons who operated in teaching hospitals performed operations not because they expected to save patients, but because impoverished hospital patients were viewed as "teaching material."

As surgical operations became more sophisticated, post-surgical infections assumed epidemic proportions throughout the hospitals of Europe. Some scholars believe that the notorious rise in post-surgical infections was more closely associated with industrialization and urban poverty than anesthesia. Indeed, veterinary surgery was relatively free of the problem of wound infection, although such operations were generally carried out under primitive conditions. Although the cause of wound infection was not clearly understood until the developments of scientific germ theory, "uncleanliness" had been a major suspect since the time of Hippocrates (460?-377? b.c.). However, wound infection was such a common occurrence that many surgeons considered it essentially a normal part of wound healing.

The evolution of the hospital into a center for medical education and research may have been a major factor in the appalling mortality rates of nineteenth-century hospitals. Descriptions of major hospitals invariably refer to the overcrowding, stench, and filth of the wards. The introduction of the "antiseptic system" by Joseph Lister (1827-1912) can be regarded as a major factor in breaking the link between hospital surgery and post-surgical infections. Lister was an experimental scientist, as well as a talented surgeon, who appreciated the insights of Louis Pasteur (1822-1895) concerning the relationship between germs and disease and applied this theory to the problem of wound infection. Lister chose compound fractures for his experiments, because life-threatening infections were frequent complications of open or compound fractures. The prognosis for compound fractures was so poor that amputation was considered a reasonable course of treatment. Lister tested the effects of carbolic acid, which had been used as a disinfectant for sewers and garbage dumps. In 1865 he successfully treated an eleven-year-old boy with a compound fracture of the leg. Further refinements of the antiseptic system led to effective treatments for a variety of life-threatening conditions. Although few Americans today are familiar with the work of Lister, some vague memory of "Lister the germ-killer" survives in advertisements for "Listerine." In 1879 this "germ-fighter" was sold to doctors and dentists as a general antiseptic. By 1879, Pasteur and Charles Chamberland (1851-1908) had demonstrated that heat sterilization was superior to chemical disinfection of surgical instruments. Chamberland's autoclave, a device for sterilization by moist heat under pressure, was in general use in bacteriology laboratories by 1883.

As surgeons mastered the use of anesthesia and antisepsis, operations that had once been impossible became routine. Christian Albert Theodor Billroth (1829-1894) is considered the founder of modern abdominal surgery, as well as the founder of the Vienna School of Surgery. Among his pioneering operations were the resection of the esophagus in 1872 and the complete removal of a cancerous larynx in 1873. He spent ten years developing methods for removing parts of the intestine and sewing the cut ends together (intestinal suture). In 1881 he performed a very dangerous operation to remove a cancerous pylorus (part of the stomach). The patient survived the operation, but died of cancer four months later because the cancer had spread to the liver.

After the basic concept of antisepsis had been accepted, additional safety measures, such as surgical gloves, gowns, caps, and masks were added to the full "aseptic ritual" and spectators were banished from the operating room.

LOIS N. MAGNER