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[DEC. 9, 1950ORIGINAL ARTICLES

THE CHANGING FACE OF SURGERY*

SIR CECIL WAKELEY

K.B.E., C.B., D.Sc., P.R.C.S.SENIOR SURGEON AND DIRECTOR OF SURGICAL STUDIES, KING’S COLLEGE HOSPITAL, LONDON ; SURGEON TO THE ROYAL MASONIC

HOSPITAL AND THE BELGRAVE HOSPITAL FOR CHILDREN;CONSULTING SURGEON TO THE WEST END HOSPITAL FOR

NERVOUS DISEASES AND TO THE ROYAL NAVY

SURGERY as we know it may perhaps be termed a newprofession, when compared with the profession ofmedicine by physicians. In the days of the ancients,operations of various kinds were performed, but in theearly hundreds A.D., barbers, bathkeepers, mountebanks,and sow-gelders were the people to whom the practiceof surgery was entrusted. In their hands the art fellto a low level. In A.D. 529 St. Benedict founded atHonte Cassino a monastery which became famous onceagain in the second world war. Here a rebirth of surgerytook place. But in A.D. 1210 William of Salicet wrote :" A wise surgeon will refrain from stealing while he isactually in attendance on a patient." Even as late asthis the profession of surgery could hardly be called a

i noble one.Although in 1295-Lanfranc held that " no man could

be a good physician who has not acquired a knowledgeof operative surgery, a knowledge of both branches isessential," surgery was retarded by prejudice and

j tradition. Even such men as Galen remarked : "Surgeryis only a mode of treatment." It was Pope Innocent III

who said : "Ecclesia abhorrit a sanguine."In A.D. 1368, by the appointment of master surgeons,

a small guild of surgeons within the City of London wasofficially recognised. This was the earliest recognitionof surgeons becoming distinct from both barbers and1 barbers exercising the faculty of surgery. The firstAct regulating the practice of surgery in England waspassed in A.D. 1441, but the struggle between the barbersand the surgeons went on until 1540 when the two guildsbecame incorporated as the Barber Surgeons.There were really three factors which held back the

progress of surgery.- One was the knowledge of anatomy or the lack of it.

The student of today may well be appalled at the amountof anatomy which he is expected to learn, but the practice

of surgery nowadays is dependent upon a detailed

knowledge of anatomy. For many years any effort toobtain bodies for dissection was frowned upon by theChurch, and as late as the 18th century it was only byillegal means that even the bodies of criminals wereobtained for examination.The second was the incidence of sepsis, which was

always a sequel to surgical intervention, death veryoften following even minor procedures, until theresearches of Lister resulted in antiseptic surgery,which has now been modified to aseptic surgery.The third factor was the lack of adequate anaesthesia.Until Lister with antiseptics and Simpson with

anaesthesia removed the two last obstacles, the operationsby which reputations of great surgeons were made, weremore or less confined to amputations and cutting forstone. Both these operations were performed with greatrapidity, surgeons disarticulating at the hip-joint inunder a minute and removing a stone from the bladderby lateral lithotomy in under thirty seconds.In the latter half of the last century what we now

understand by the art of surgery took shape. Surgeonswere able to open the abdomen. As time went on andanaesthetics developed, the brain was explored, the

chest opened, and the scope of operations increased.

* Opening address delivered at the Westminster HospitalMedical School on Oct. 2.

With the widening field of surgery there has beenassociated a more detailed study of the basic subjects ofanatomy, physiology, and pathology, and in the last

thirty years surgery has undergone changes which arerelated to discoveries and developments in the ancillarysubjects. The discovery of the sulphonamides in 1931was followed by the discovery and clinical use of penicillin,and later of streptomycin and the other antibiotics nowunder clinical trial.The physicists have developed X rays and radium,

and radioactive elements are being used in the investiga-tion and treatment of patients. The biochemists haveplayed their part too. Intravenous therapy with blood,plasma, serum, saline, and glucose-saline is of ever-

increasing importance in extending the ever-growingscope of surgery. The importance of water balance inthe body has now been recognised.

In this country anaesthesia has established itself as

a full specialty, and has been improved to such an extentthat surgery which could not be practised twenty yearsago is now performed as an everyday procedure. Theold arrow poison, curare, which was used by primitivepeople to kill their enemies, is now used by anesthetistswith better motives.With the increasing average age of the population and

the greater longevity of the race, with the help of betteransesthetics, better supportive treatment, and the use ofantibiotics, more old people are now undergoing majoroperations and surviving without becoming a burden tothe rest of the population.

UNDERGRADUATE TEACHING

Before the days of Lister surgical lectures were

practically the only form of instruction for the students.Today set surgical lectures are not popular nor are theynecessary. In their place lecture-demonstrations havecome into vogue. Bedside teaching and outpatientteaching are of the utmost service to the student. It is

only by coming into personal contact with patients thatstudents can acquire a satisfactory knowledge of surgicalconditions. The actual palpation of a lump or tumourwill register far more on the cerebral cortex of the studentthan a well-delivered lecture.

APPRENTICESHIP

In earlier days the student was apprenticed to a

surgeon, and there was a great deal to be said for thisform of learning. There was a personal touch aboutthis way of acquiring clinical knowledge and the addedinterest of seeing patients in their homes and thus

becoming initiated into problems which nowadays areonly met with after qualification. It is to be hopedthat when the new Medical Act comes into force, makinga year’s postgraduate experience compulsory prior toregistration, the qualified student will be able to takepart of his year’s postgraduate training with a generalpractitioner.

Apprenticeship puts the student on his mettle becausehe must rely on his clinical acumen rather than on allthe ancillary aids which are ready at hand in hospitals.There is a tendency today to overlook clinical observationand to rely too much on X rays and pathological orbiochemical tests in making a diagnosis. I very muchdoubt if the clinician today has the clinical acumen ofthe late Victorian physicians, who made their diagnoseswithout the aid of tests and were often amazingly accurate.

PROFESSORIAL UNITS

After the first world war the surgical professorialunits came into being, and their number has been greatlyincreased since the second world war. There is a trend,however, for full-time professorial units to become tooacademic and to lose touch with patients and theirdiseases. There seems to be a tendency for teaching

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and attention to be directed to those whose sole objectis to pick out a small aspect of surgery and beat it until

. it is dead, and to take teaching away from those who arepractising surgery as a full-time occupation, the verypeople who are continually in touch with patients andtheir diseases, and who are therefore perhaps the betterable to teach because their knowledge is more practicaland less academic.Whole-time surgical professors are apt to spend the

greater part of their day attending university meetings,and therefore they have less opportunity for actual

teaching and operating than their part-time colleagues.Part-time professors of surgery have in the past

century been pioneers, for it is from them that advancein the art and practice of surgery has sprung. Suchmen as Lister, Fergusson, Macewen, Stiles, and Watson-Cheyne all held professorial surgical chairs, but they gaveonly half their time to these appointments. They cameinto contact with the practitioner, did consultative

practice, and were in constant contact with their

professional colleagues. To my mind any real advancein surgery will come from the part-time men rather thanthe whole-time surgical professor.

SPECIALISATION

Specialisation in surgery is good up to a point, butthere is a real danger of developing the ultra-specialistwho will only perform one type of operation. Such astate of affairs is bad for teaching and makes for littleprogress. There is a tendency to view a patient withultra-specialist eyes and only see a minute part of theanatomy instead of considering the patient as a whole.How often has a special operative procedure been

performed on a patient in whom a far more seriouscondition has been overlooked because a careful generalexamination has not been carried out.

It is important that surgeons on the staff of teachinghospitals should remain general surgeons, but it does notmatter if they have a hobby-for instance gastric surgery,thyroid surgery, or urological surgery. General surgeonsshould have a sufficient variety of cases to give thestudents a general outlook which is essential. It is, Ithink, agreed that there should be in teaching hospitals5 beds per clinical student in general medicine andgeneral surgery, but I wonder how often this obtains today.

WAR AND SURGERY

There has always been a relationship between warand surgery. Many of the famous surgeons of oldertimes were military surgeons before they became wellknown in civil life.

Progress in surgery occurs during great wars becausethe surgeon has such a wealth of material coming underobservation and review. The lessons learned in warsare often of great value in civilian practice ; this is

especially so with regard to traumatic lesions. In thismechanical age the treatment of injuries to the body is ofthe utmost importance. During wars surgical know-ledge is pooled and made available to vast numbers ofsurgeons. This was especially noticeable in the secondworld war when the War Wounds Committee of theMedical Research Council did a great service to themedical personnel of the fighting forces of Great Britainand America. The use of blood-transfusion, of penicillin,and of early evacuation by air were developments whichwill not be easily forgotten by’ medical men in theServices. Every branch of surgery made progressduring the last war, but perhaps the most outstandingadvances were made in the treatment of nerve injuryand the surgery of the heart and great blood-vessels.

EARLY AMBULATION

Today the patient is no longer allowed to become aninvalid because he or she has had an operation. Earlyambulation has proved its worth both in the young and

old and has lowered considerably the incidence of post-operative thrombosis and embolism. At the commence-ment of the present century elderly patients sufferingfrom fracture of the femoral neck did not die from theinjury but from pneumonia due to enforced rest in bed.Today early operation, early ambulation, and the use ofpenicillin have removed most major complications.

Early ambulation has put a different complexion onthe bad-risk patient, for he benefits not only physicallybut also mentally. The stimulating effect of earlyambulation on an obese female patient following chole-cystectomy has to be seen to be believed. There is lesslikelihood of pulmonary collapse, inertia of the abdominalmuscles, and circulatory failure, and there is in additionthe desire to get well quickly. The old-fashioned

procedure of 14 days in bed after an operation simplyled to atrophy of the muscles, and distension of theintestines, with constipation and depression as a result.Modern physiotherapy goes hand in glove with early

ambulation. Before operation the patient is taught howto breathe properly and how to make use of the abdominalmuscles. This preoperative preparation has a verydefinite beneficial effect on the patient who will co-

operate after the operation and use his abdominalmusculature and so reduce the incidence of complications.

THE PUBLIC AND THE PRESS

Before leaving the subject of postoperative after-treatment it might be well to consider how much apatient should know.

Although the public require to be educated in certainaspects of disease-especially in cancer-yet we mustalways remember that there is a danger of the press andthe public knowing too much. Moderation in all thingsshould be the ideal. Instruction in the early signs ofcancer may be justifiable and important, but it wouldbe a tragedy if we were responsible for creating a nationalcancer phobia among the population.When the mystery goes out of surgery the patient often

loses much of his cooperative power and confidence in hisfull recovery. Human beings are individuals and requiretreating as such. Some will benefit from a descriptionof the operation performed upon them, while such

knowledge will transform others into nervous wrecks ;the surgeon must decide how much knowledge is justifiedin each individual case.

Confidence is the sheet anchor as far as the patient isconcerned ; once confidence is established he will ceaseto worry and the surgeon will have little difficulty ingetting cooperation throughout any form of treatmentthat may be necessary.

SURGERY OF THE FUTURE

To those starting on a surgical career it may seemthat operations go according to plan. Extensive opera-tive procedures are seen to cause a minimum of incon-venience to the patients, owing to blood-transfusion,gastric suction, and the preoperative and postoperativeuse of vitamins and drugs such as vitamin K andheparin ; yet you must remember that these are recentinnovations in surgical treatment and rarely a yearpasses without the introduction of something new.

Surgery has by no means arrived at its zenith andfurther progress is not yet impossible-although it maywell be that future research will eliminate some forms ofsurgical operations and that some diseases now treatedsurgically will be cured by intravenous drugs or otherforms of treatment.

Surgeons of the Westminster Hospital have played animportant part in the world of surgery and have contri-buted their quota to the changing face of the professionof surgery. To mention only a few, Walter Spencer,Rock Carling, Tudor Edwards, and Stanford Cade aremen of whom you should all be proud.