Surgery, New Style

Seven thousand surgeons swarmed last week through Manhattan's Waldorf-Astoria. Gathered for the annual clinical congress of the American College of Surgeons, they packed room after room to hear technical papers read and discussed. They watched dozens of colored movies (Cine Clinics, they called them) of operations ranging from standard procedures through the specialties to the spectacular. They trooped off by bus and motorcade to 61 hospitals in New York City's five boroughs to watch "wet clinics," as they call the real thing.

Though the assembled thousands included many of the deftest-fingered scalpel wielders and gut tiers in the U.S., and such honored elder surgeons as New Orleans' Alton Ochsner and St. Louis' Evarts Graham, there was none among them who towered above his fellows as did Baltimore's William Stewart Halsted half a century ago, or Halsted's pupil, Harvey Gushing, a generation later. The reason lies not in a decline in the caliber of surgeons, but in a change in the nature of surgery itself.

U.S. surgery is no longer symbolized by the old-style autocrats of the operating table, who made a dramatic entrance into the theater, striped pants showing below their white coats, to operate on a patient they had probably never seen. Skill and ingenuity are as important as ever, and some surgeons are famed for developing brilliant procedures--e.g., Boston's Robert (heart valve) Gross, Johns Hopkins' Alfred (blue baby) Blalock.

But such men, for all their spotlighted brilliance, belong to the new school in surgery, in which the operation is no longer the be-all and end-all. Great surgeons now are concerned with the patient as a whole man, from the salt content of the blood circulating through his fingertips "to the vague fears of mutilation that flit through his mind. One of the deepest preoccupations of surgery today is learning more about the chemistry of the patient's body before, during and after operation.

The Team Approach. Unassuming but nonetheless outstanding among the surgeons in Manhattan last week was Harvard's Francis Daniels Moore. Characteristically, he gave no solo performance. His name appeared in the program only twice, and then as one of a team of authors submitting technical papers with forbidding titles.

Scion of a Boston family which had moved to Illinois, Moore naturally went to Harvard (class of '35), where he became president of Hasty Pudding and wrote the score for its 1934 show, Hades the Ladies. He had thought of making music his career, but anthropology under Earnest Hooton led him to medicine. It was not until his fourth year in Harvard Medical School that Moore decided to become a surgeon.

"I liked the idea of doing something active in the treatment of disease," Dr. Moore now says. "And then I came to feel that there was a tremendous place in surgery for understanding the biology of a patient." That idea was relatively new in the late 19305, but it was beginning to inspire research workers in half a dozen medical centers.

Hormones for Healing. The body's chemical processes are not the same in all injured or surgical patients, Dr. Moore points out. But after allowance is made for individual differences, all patients follow certain general rules in their response to an operation (which is itself an injury). "After operation," says Dr. Moore, "the patient responds with hormones to heal his wound, to get new energy from fat, to conserve sodium for maintenance of blood pressure. The surgical patient is a chameleon adapting his responses to his back-ground,whether healthy or malnourished."

Like a chameleon on a piece of Scotch plaid, the patient has a complex pattern of response. Several of the endocrine (ductless) glands go to work. The adrenals pump out both adrenalin and cortisone-like hormones. Both lobes of the pituitary step up their activity. So, probably, does the thyroid. Triggered by these hormonal reactions, about which much is yet to be learned, the body's chemistry changes in a dozen ways.

Women's Curves. When young Dr. Moore began interning at Massachusetts General Hospital in 1939, methods had recently been found for accurate measurement of some of the body's chemicals. But one of the most fundamental of all physiologic facts still could not be measured accurately in a patient: How much of his body is water?

Dr. Moore puzzled over this but, until he got a National Research Council fellowship in 1941, he could do little about it. Then he made good progress. His tools were simple: plain water and heavy water (deuterium oxide). Basically, what Dr. Moore did was to inject 100 cc of heavy water into a volunteer, wait for it to mix thoroughly with the ordinary water in his system, and then take a blood sample. The dilution of heavy water showed the total amount of water in the body. Easy as this sounds, it was not until 1950 that the method was accurate enough to satisfy Dr. Moore. Surprisingly, he found that women are less succulent than men. "It's their curves," he explains. "Fat doesn't contain much water, but muscle is full of it."

To learn more about water, fat and muscle and their importance to surgical patients, Dr. Moore surrounded himself with a team of equally eager young researchers. They worked at Massachusetts General and Peter Bent Brigham hospitals, both connected with Harvard Medical School, where now, at 39, Moore is a full professor. Gradually they chased down other pieces of the patient's jigsaw pattern of progress; so did other teams in other centers. Last week St. Louis' Carl A. Moyer and Manhattan's Henry T. Randall attracted attention with new (and highly technical) reports.

Food & Drink. Now, only a dozen years after the investigation got going in earnest, the new-school surgeons have assembled this much of the pattern:

After a severe injury or operation, the patient first burns up his own fat as a source of energy. (Dr. Moore's team has just reported that as many as 4,000 calories a day may thus be burned.) This goes far to explain what had long been known but little understood: why the patient seems to have no appetite or even need for food soon after an operation. A normally built man has enough fat (about 15% of his body weight) to tide him over most operations; a "soft," curvaceous woman may have up to 25% of her weight as fat, so her body can nourish itself for a longer period.

While the patient is burning fat, the body demands water and stores it up. This phase usually lasts two to three days after a severe operation; it may last five. But before the first week is out, the process normally begins to reverse itself, presumably because the hormone switches have been flicked. The patient than gets hungry. He needs fat and carbohydrates from food to provide calories. He starts to take up nitrogen and rebuild muscle protein at the same prodigious rate as a one-year-old (suggesting that the growth hormone may have been switched on). The need for sodium goes down, while that for potassium goes up. Weeks or months later, the body replaces its store of fat.

Korea & After. In The Metabolic Response to Surgery, Dr. Moore spells out what he and other researchers have learned for the benefit of surgeons across the country, many of whom have to work without the fancy gadgets of a big hospital. Many of these, he says, while essential in research, are completely unnecessary in everyday practice: "Most surgical hospitals in this country are well enough equipped with analytic facilities. What is needed is a framework of concept for interpretation ... so that effective care can be given without doing a research job on each patient."

Unlike the old stereotype of the surgeon whose one aim was to wield the knife, Dr. Moore (who specializes in abdominal surgery) and the dozens of like-minded colleagues who dominated the surgeons' meeting last week will never use it if they think it can be avoided. And, except in emergency, they will never use it without careful consultation with the patient's physician, an interview with the patient himself, and a full-team study of the results of many laboratory tests made on him.

Dr. Moore's missionary zeal has taken him to Edinburgh as a visiting professor and to Korea as consultant on problems which Army surgeons are trying to work out close behind the front. He is already looking eagerly at the next great, unexplored territory: the influence of psychological factors on surgical patients, e.g., what are the differences in response between patients operated on after long illnesses and those who have suffered sudden injury? Wha difference does it make if a soldier is wounded as soon as he goes into combat, or after long months of action and exhaustion?

By learning the answers to these questions, and eventually learning the explanations of the answers, the modern surgeon hopes to give final burial to the old saw: "The operation was a great success, but the patient died."

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