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Gastro Enterology => Ulcer => Surgery
Surgery
INTRODUCTION
Surgery, treatment of disease and correction of deformity or defect by manual and operative procedures, with or without the use of drugs. This branch of medicine is subdivided according to the nature of the procedure employed, including: general surgery, which deals with all manner of cases; orthopaedic surgery, which pertains to the correction of deformity; and plastic surgery, which involves the building up of tissues and the restoration of lost parts, principally by the transfer of tissue. Surgery is also subdivided according to the region involved, as: intracranial (brain) surgery; aural (ear) surgery; cardiovascular (heart and blood-vessel) surgery; and abdominal surgery. Many elements have contributed to the development of surgery, such as the gradual accumulation of knowledge concerning anatomy and physiology, the discovery of the circulation of the blood, the perfection of the microscope, the discovery of X-rays, and the invention of better instruments and apparatus, including laser and ultrasonic devices. The discovery of anaesthesia and antisepsis has broadened the scope of surgery so that patients formerly treated with plasters and medicines are now subjected to surgical intervention. For further information, see separate articles on most of the doctors and organs and diseases mentioned in this article.
EARLY HISTORY
Elementary general surgical procedures were known in many diverse societies since ancient times, but more scientific surgical techniques were not practised until the 3rd century BC.
° Ancient
The ancient Egyptians are said to have performed operations such as castration, lithotomy (removal of stones from the bladder), amputations, and various eye operations. In India, the Hindus were familiar with surgical practices such as the treatment of fractures and the removal of bladder stones, and they are credited with having originated plastic surgery. The surgery of the early Greeks, largely practised on the battlefield, seems to have been derived from that of the ancient Egyptians, as was their medicine. In Rome, sacerdotal or guild medicine and surgery prevailed until the time of the Greek physician Hippocrates, whose studies, practice, and writings embraced surgery as well as medicine. Little definite progress was marked until the rise of the Alexandrian school (233-230 BC), when surgery was based on diagnostic precision and operative daring through the study of human anatomy. The Greek anatomist and surgeon Herophilus was the founder of this study.
° Medieval Medieval
surgery was practised from the decline of the Alexandrian school to the beginning of the 16th century. The Roman physician Aulus Cornelius Celsus, the Greek physician and philosopher Galen, and Paul of Aegna, a Greek surgeon of the late-7th century, virtually shaped the course of surgery throughout the Middle Ages. Byzantine and Arabian medicine helped to foster surgery, and, during the latter part of this period, European countries, especially Italy, produced many distinguished surgeons. Outside of Italy during this period, medicine and surgery began to be distinctly separate. In France, in about the middle of the 13th century, a new order of surgeons arose, called surgeons of the long robe, as distinguished from the barber surgeons, who were known as surgeons of the short robe. Corporations, or guilds, were formed in several countries. In England, King Edward IV granted (1461) a charter to the Corporation of Barber Surgeons, and the charter of the surgeons of London was confirmed by King Henry VIII.
SIXTEENTH TO NINETEENTH CENTURY
During the 16th, 17th, and 18th centuries, many discoveries in surgical practice were made. Much credit belongs to the French surgeon Ambroise Paré, who was a member of the Corporation of Barber Surgeons. Paré successfully employed the method of ligating arteries in order to control haemorrhage, thus eliminating the old method of cauterizing (searing) the bleeding part with a red-hot iron.
During this period the English physician and anatomist William Harvey discovered the circulation of the blood. Anton van Leeuwenhoek, the Dutch lensmaker and naturalist, contributed to the evolution of the microscope. This made possible the discovery by the English physicist Sir Robert Hooke of the cellular structure of plants and the discovery by the Italian anatomist Marcello Malpighi of the cellular composition of the blood and of other details, thus paving the way for discoveries in such fields as bacteriology and pathology.
Many able surgeons contributed to the development of surgery during the latter part of this period. In France, the surgeons Jean Petit and Pierre Desault were outstanding. In Great Britain, the Scottish anatomist Alexander Monro and his son and grandson of the same name; the surgeon Sir Percivall Pott; and William Hunter, an anatomist and physiologist, and his brother John Hunter, an anatomist and surgeon, made important contributions to surgery.
MODERN SURGERY
The era of modern surgery probably began with the notable event of the performance (1809) of ovariotomy (removal of the ovaries) in the treatment of ovarian disease by the American surgeon Ephraim McDowell of Kentucky. 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; 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 outstanding surgeons.
With the discovery (1842-1847) of anaesthesia, that barrier to progress in actual operations was removed. Hospital gangrene, septicaemia, tetanus, and pyaemia remained as problems, however. Not until the French chemist Louis Pasteur evolved his germ theory and discovered that fermentation is caused by micro-organisms did surgery reach its full development. When the British surgeon Sir Joseph Lister applied the discoveries of Pasteur to surgery and formulated his theory concerning sepsis and antisepsis, another major obstacle was removed.
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); the correction of deformity or abnormality; the cure of disease; the amelioration of suffering; and the prolongation of life.
° Corrective Surgery
At present, corrective surgery is employed for clubfoot, harelip, cleft palate, bowlegs, 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.
° 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.
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. 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.
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.
° 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.
° Recent 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) 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. 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 war in Vietnam, 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.
Prefrontal lobotomy, that is, severing of nerves of the four quadrants of the frontal lobes of the brain to relieve the pain and anxiety of involutional depression, obsessive tension states, and schizophrenia, largely has been replaced by the use of such drugs as tranquillizers and psychic energizers. 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.
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 through 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. 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, and endocrine-gland transplants have also been successful; the first human heart transplant was performed in 1967 by Christiaan Barnard in Capetown, South Africa. To combat immune reactions that would result in transplant rejection, recipients are treated with drugs such as cyclosporin.
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