The Surgeon and Environment

SURGICALLY speaking, we live in exciting times, and unlike Erickson, Moynihan, Murphy, and others in the past, the modern leader of surgical thought wisely refrains from declaring that surgery has achieved its final victories; indeed, rather do we anticipate with confidence further triumphs. On the other hand, as Ogilvie rightly points out, it is not manual dexterity or skill that improves, for who to-day could match in precision and speed Cheseldon in lithotomy for bladder stone, or Liston in amputation through the hip joint; it is the tools that scientific progress puts into our hands that make for this leap forward we are witnessing. Fluid and crystalloid balance, the more accurate matching and safer storage of blood for transfusion, blood substitutes, anticoagulants, intravenous feeding, all these, bringing us ever nearer to the molecular level, have rendered safer all surgical procedures and have made possible the most recent advances in the surgical treatment of diseases of the cesophagus, heart, pancreas, great vessels and of portal hypertension. Newer developments are moving towards a better understanding of the metabolic response of the body to trauma, and from the technical point of view we seem to be in a phase of replacement and substitution surgerythe making of a new cesophagus, or new stomach reservoir, or new bladder, or replacing a length of damaged or diseased artery by a frozen or freeze-dried homograft, or, more recently, by an artificial one of orlon or a mixture of orlon and nylon. Only two months ago my colleague, A. L. d'Abreu, in operating for a mixed salivary tumour of the left bronchus encroaching on the carina, had to remove these parts, and replaced them by tantalum fabric and orlon, and the patient is alive and well: it was also a feat of clever anaesthesia. All this requires skilled assistance, first-class nursing, complicated apparatus, and generous laboratory services, and whatever objections there may be to the Health Service, one cannot deny that, so far as hospitals are concerned, it is easier to get skilled help and material equipment to-day than ever before. The teaching hospitals have special responsibilities, well summed up by Nathaniel Faxon as: