It was a singular privilege to serve as editor-in-chief of the first and subsequent six editions of Principles of Surgery. The invitation from the current editor-in-chief, Dr. F. Charles Brunicardi, who has discharged that responsibility for the ensuing four editions, to participate in the textbook’s 50th anniversary, is gratifying. The readers of the first seven editions often commented on the distinctive yellow cover. On this particular celebration of longevity, the color yellow connotes “gold.”
The past 50 years has witnessed an unimaginable growth in scientific knowledge available to students of surgery. The “science of surgery” has gained dominance over the “art of surgery.” Diverse technologies have been incorporated to expedite diagnosis and improve surgical excision or repair. The establishment of more precise criteria for categorization and analyzing data, coupled with advances in informatics, has allowed for the practice of “evidence-based medicine and surgery.” It is, as if, today’s surgeons have adopted a new language, new rules, new protocols—and anticipate new outcomes. The passage of time has been associated with transformative change, which has been beautifully captured in the 11th edition.
Among the “Basic Considerations” that transcend individual organ systems, change has occurred at an ever-accelerating pace, in multiple arenas, with variable consequences, since the first edition made its debut. Not all changes have been favorable. Increased effectiveness of antibiotics has improved the outcomes of the treatment of sepsis, but has been associated with the appearance of c. difficile colitis and lethal MRSA hospital outbreaks. HIV, AIDS, HPV (human papilloma virus), and hepatitis B and C had not entered the surgical lexicon prior to publication of Principles of Surgery.
Over the course of years, trauma has become an ever-increasing problem. Since publication of the first edition, improved diagnostic techniques have altered the approach to individuals who sustained major trauma. The concept of immediate “damage control to be followed by delayed definitive treatment,” the availability of angioembolization to control bleeding, and inert material to maintain protect the unclosed abdominal abdomen for protected state for a critical, at times prolonged, period of time, during which caloric requirements are satisfied parenterally.
In oncology, a more precise tumor classification based on size, nodal involvement, metastases, chemical and biologic characteristics has been accepted. This, in turn, has allowed for more meaningful assessment of a variety of therapeutic regimens. Chemotherapy has been joined by immunotherapy, and targeted, precision genomic therapy has recently been introduced.
At the time of publication of the first edition of Principles of Surgery, only the kidney was deemed clinically acceptable for homotransplantation and satisfactory immunosuppression had not been developed. Advances in immunosuppression have added the liver, pancreas, small bowel, heart, and lungs to the list of organs transplanted with anticipated success.
Among the 1805 pages of text in the first edition, “facts” and “declarations by experts” have failed to stand the test of time for a variety of reasons. Little effort is required to uncover statements that now would be judged “False!” For example: (1) Cancer of the hypopharynx is three to four times as common as cancer of the larynx (the reverse is true). (2) Effective treatment of a single ventricle in a neonate is not feasible. (3) The distal 1 to 2 cm of the esophageal lumen is normally lined by columnar rather than squamous epithelium (the description of a Barrett’s esophagus). (4) There is but one treatment for acute appendicitis…the only question to be resolved is the timing of surgical intervention. (5) The adenomatous (colonic) polyp is a lesion of negligible malignant potential. (6) The only acceptable treatment for a splenic injury accompanied by any evidence of intraperitoneal bleeding in an adult is splenectomy. (7) Hundred percent of patients with primary hyperaldosteronism have hypokalemia (most have no hypokalemia). More dramatic is the evidence that many of the prevalent surgical procedures that merited detailed illustration, consuming multiple pages in the first edition, are now, rarely if ever, performed.
It must be emphasized that a textbook chronicles a science during the contemporaneous time. The first edition, as is true for each of the 11 editions of Principles of Surgery, is a compendium that pertains, solely, up to the time of publication. Print does not imply permanence. Print often outlasts the fact it promulgates. I congratulate Dr. Brunicardi and the coeditors on a modern and beautifully written 11th edition that carries forward the tradition of the Principles of Surgery into the next 50 years.
Seymour I. Schwartz, MD, FACS
Distinguished Alumni Professor of Surgery
University of Rochester School of
Medicine & Dentistry