Perspectives, Surgery

PERSPECTIVES, SURGERY FRANCIS D. MOORE* 1940-1980: Safe Convalescence As originally planned by the editor, this issue ??Perspectives was to be a personal retrospective based on the past quarter century. For many reasons , both personal and biological, I would like to extend my perspective a little earlier than that, to 1938-1942. These were the years of the outbreak of World War II, of the initial work that led to plasma fractionation , the discovery and synthesis of antibiotics, the development of blood banking and blood transfusion, prolonged red cell preservation, routine endotrachial positive pressure anesthesia for open-chest surgery, modern concepts of surgical biology, and, on a personal note, they were the years of my internship and residency. In 1936 the late Frederick C. Irving, William Lambert Richardson Professor of Qbstetrics at the Harvard Medical School, wrote an account of his life's work under the title Safe Deliverance [I]. During his lifetime he had witnessed progress in obstetrics from events of high hazard to both mother and infant (even in well-organized centers, where the hazards sometimes were greater than simple home delivery) through a long development of safer anesthetic procedures for childbirth and for the safety of the infant, to a point where maternal mortality had reached an apparently indivisibly low level. By the middle 1930s, a pregnant mother could indeed look forward to safe deliverance for the first time in history; problems for the infant still remained, as will become clear later in this story. During the past 40 years, and developing a little later than the changes in obstetrics because of the greater uncertainties of surgery in disease (as contrasted with attending to a normal biological event), surgery has finally reached the same point, a point that might be called "safe convalescence ." It is this achievement, of an indivisibly low morbidity and *Moseley Professor of Surgery, emeritus, Harvard Medical School; Surgeon-in-Chief, emeritus, Peter Bent Brigham Hospital; Consultant in Surgical Oncology, emeritus, Sidney Färber Cancer Institute.© 1982 by The University of Chicago. AU rights reserved. 0031-5982/82/2504-03 1 2$0 1 .00 698 I Francis D. Moore · Perspectives, Surgery mortality for most major operations performed for most everyday disease , and in the case of most major traumas, wherein surgery has made its greatest progress in the past 40 years. As we shall see, this remains true even when comparing these advances in basic surgery with the many spectacular new surgical operations that have made headlines during these same years. Underlying safety of the surgical operation, arrived at through application of bioscience to surgery, has provided the infrastructure upon which all the remarkable new operations rest secure . Safe convalescence has come about through three agencies. First has been the extension and stabilization ??surgical education. Undergraduate education in surgery has been improved by a firmer emphasis on the bioscience underlying diagnosis, the operation itself, and the biology of recovery. Postgraduate education in surgery in the United States usually traces its historical roots back to the period of W. S. Halsted at the Hopkins. But similar changes in Great Britain, Scandinavia, and in other universities in this country were based on the realization that the craft of surgery required—for the safety of the patient—a prolonged postgraduate period (the residency). The surgical residency was longer, more complex, and more laden with true responsibility than those in other disciplines such as pediatrics or internal medicine. Now, the fully trained university surgical resident, upon completion of his "white suit" years, is at a peak of technical competence and daily experience that he may not soon exceed while, over the next decade, his judgment will mature as it does for any practicing physician between the ages of35 and 45. A second key factor in the development of safe convalescence has been the development ofsurgical biology. By this we mean an understanding of the basic biology of healing and convalescence, their evolutionary place in species survival, the need for the surgical patient to be left alone to his inbuilt recovery process, the avoidance of meddlesome treatment and "supportive therapy" or drugs, and at the same time, increased ability to intervene effectively and appropriately should assistance become necessary...