Aninals of Surgery Vol

ANINALS OF SURGERY VOL. 119 MARCH, 1944 No. 3 TRANSACTIONS OF THE SOUTHERN SURGICAL ASSOCIATION MEETING HELD AT NEW ORLEANS, LA. DECEMBER 7-9, 1943 ADDRESS OF THE PRESIDENT PSYCHOSOMATIC SURGERY* BARNEY BROOKS, M.D. NASHVILLE, TENN. FROM THE DEPARTMENT OF SURGERY, VANDERBILT UNIVERSITY SCHOOL OF MEDICINE, NASHVILLE, TENN. "THE OPERATION" is and will no doubt continue to be the dominant feature of surgery. In the anticipation of an operation a patient presumably has fear and dread. An operation often produces such an impression on a patient's memory that he may for the remainder of his life refer to past events as happening before or after "my operation." The surgeon of today, as of yesterday, must of necessity be a man endowed with the sort of mind suitable for making quick decisions and pro- ceeding with a minimum amount of delay in bringing to a conclusion a task with which he is often unexpectedly confronted. Many of his problems are of a nature which does not permit leisurely reflection. If a patient is admitted to the hospital with an acute attack of intra-abdominal disease, a decision must be reached quickly as to whether the patient is to be submitted to operation or not, and often in deciding to delay operation, the surgeon must assume an even greater personal responsibility for the preservation of the life of his patient. In the operating room, whether it be the head, chest or abdomen which is open, the surgeon is confronted with the necessity of bringing the operation to a successful or unsuccessful conclusion in a limited space of time; but no matter how objective the mind of a surgeon, I imagine *Address delivered before the Southern Surgical Association, December 7-9, 1943, New Orleans, La. 289 BARNEY BROOKS AnnalsM1a r ch.of Surgery1 94 4 there is none who has become so calloused that his heart does not beat faster before beginning a formidable surgical operation, or during the course of an operation when it is noted that the patient's breathing becomes shallow, the arteries spurt with less vigor and the veins become distended with dark blood. The well known scene in the operating room has not greatly changed since the last generation. There is much the same operating team, gowned and masked and gloved. There have been no significant changes in the tools which the surgeon employs. There is the same prostrate patient, of whom Doctor Halsted spoke as an individual left with but a single weapon, his spurting artery, to resist the continued application of the therapeutic procedure. I am sure that no surgeon of today privileged to witness the manual dexterity in anatomical dissection of the masters of surgery of past generations would for a moment entertain the idea that this feature of "the operation" has improved. Although the scene in the operating room remains much the same today as it was 25 years ago, new methods to be employed before and after the operation have made it possible not only to perform the surgical operation with far less risk, but have extended the usefulness of operative surgery for the relief of conditions previously unknown or believed to be irremediable. It is the purpose of this paper to inquire into the effect of this advance in knowledge in surgery in the realization of the fundamental purposes of surgery; that is, the prolongation of life, the removal of disabilities and the relief from an unfavorable balance in the pain-pleasure principle in those individuals receiving surgical treatment. In the beginning surgery was objective, anatomical and for the most part destructive. Most of the operations were amputations, ligation of arteries or excision of tumors. Surgeons received their preliminary training in anatomical laboratories. The immediate result of the discovery of methods of anesthesia and asepsis was only to increase the number and scope of operations based on factors almost purely anatomical. I remember less than 25 years ago, after I had completed a gastrojejunostomy, the referring physician remarked that it was indeed a strange sort of an operation because nothing was removed. I can recall, also, when I was given the responsibility of establishing a surgical pathology laboratory for the Washington University Medical School in I9I2, the very large number of normal uteri, small cystic ovaries, acutely inflamed fallopian tubes, kinked appendices and tuberculous lymph nodes brought to me for pathologic examination. The introduction of the use of the roentgen ray served at first almost entirely to enlarge the opportunities for the determination of anatomic abnor- malities. The preponderance of a materialistic philosophy in surgery is illustrated by the frequency with which surgical operations were performed for the replacement of such structures as the stomach and large bowel, which from roentgenologic examination had been presumed to be dislocated. Also, the introduction of the use of the roentgen ray in the treatment of fractures not infrequently led to a state of mind which is well illustrated by a personal 290 Volume 119 PSYCHOSOMATIC SURGERY Number 3 experience. An orthopedic surgeon asked me if I would come to a Roentgeno- logic Department so that I might see the good results he had obtained from a series of fractures of the leg. I am quite sure that he did not understand me when I told him that I would much rather see his patients walk, and it has often occurred to me since to wonder if the treatment of fractures of the leg were not more successful when it was the purpose of surgeons to make the external appearance of the fractured leg correspond as nearly as possible to that of the unfractured leg, than at the present time when surgeons attempt to secure perfect anatomic restoration of the bone fragments by the use of one or more of the several mechanical appliances which sometimes remind me of an exhibit which I once saw of the instruments used for torture at the time of the Spanish Inquisition. During the past 25 years, ana particularly during the past ten years, there has been a tremendous advancement in knowledge applicable to surgery which can perhaps best be said to belong to physiology. It is much- to the credit of surgery that a great deal of this valuable knowledge has been the result of the laboratory experiments of a group of surgeons now arrived at their maturity, and who, I am glad to say, have been more than welcomely received by the older group of surgeons who did not have the good fortune of the opportunity and the stimulus for laboratory investigation. Following the development of knowledge of the physics and the chemistry of respiration, there was almost immediately a tremendous advance in surgery of the chest. I believe I am not making any overstatement when I say that the low operative mortality and the smooth postoperative course of a patient after a pneumonectomy still seems almost miraculous to those of us who began the practice of surgery as long as 25 years ago. Recent developments in the knowledge of the physics and chemistry of the body fluids not only have reduced greatly the risk of old operations, but have made it possible to undertake with safety operations previously considered to be associated with a prohibitive operative risk. The beneficial effects of surgery have thus been extended to a large group of people previously considered inoperable. The significance of this achieverment becomes greater when it is realized that our population is growing older and that individuals are not so frequently "too old" to be operated upon. It is worth while calling attention to the fact that although surgeons have become physiologists as well as anatomists, the essential philosophy of the surgeon is still for the most part materialistic. Water, sugar, sodium chloride, proteins, carbon dioxide and even hydrogen ion concentration are just as real as muscle or tendon or nerve. There is, however, a fundamental difference between the old anatomical surgeon and the modern physiological surgeon, in that the latter has opportunities for being what, for lack of a better term, we might call constructive. An appendix can only be removed. Sodium chloride may be either added or subtracted. I believe that there can exist at the present time no reasonable doubt that the accomplishments of the surgeon have been vastly increased because of this knowledge of conditions in the human body not immediately discernible to any of the special senses. 291 BARNEY BARNEYBROOKS ~~~~~~AnnalsM.1a r c h,of Surgery1 9 4 4 It remains, however, to call attention to the fact that a purely materialistic philosophy in surgery carries with it the necessity of a fundamental conception which I believe is apparent in nearly all of the innovations in surgery, as well as in the evaluation of the results of the numerous well established operative procedures. The surgeon with only a materialistic philosophy must conceive of each human being as compared to a standard human being, a sort of John Doe. During the early anatomical phase of surgery, Mr. X, who differed from John Doe, had only the possibility of surgery making him into a conventional part of John Doe. The addition of the physiologic concept into surgery brought with it the idea that certain departures of a Mr. X from John Doe might be restored or compensated for, in order to improve Mr. X's well being, or, more frequently, to improve Mr. X's chances of survival of some major anatomic alteration. I have had the good fortune to observe a considerable succession of men through periods of five years of postgraduate training in surgery, and I am quite sure that I am correct in stating that almost all the effort of the Resident Surgeon today is directed toward the accumulation of facts concerning abnor- malities of anatomy and physiology of the patients for whom he is trusted to assume great responsibility.

Load more