Hospital Practice
ISSN: 2154-8331 (Print) 2377-1003 (Online) Journal homepage: http://www.tandfonline.com/loi/ihop20
On Swallowing the Surgeon Harold J. Morowitz To cite this article: Harold J. Morowitz (1978) On Swallowing the Surgeon, Hospital Practice, 13:4, 203-208, DOI: 10.1080/21548331.1978.11707324 To link to this article: http://dx.doi.org/10.1080/21548331.1978.11707324
Published online: 06 Jul 2016.
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Date: 24 August 2017, At: 16:57
Harold J Morowitz------------------.
Downloaded by [University of Saskatchewan Library] at 16:57 24 August 2017
On Swallowing the Surgeon A book or article on an unfamiliar subject often sets the mind off in new and surprising directions. A copy of Symposium of Microsurgery (A. I. Daniller and B. Strauch, Eds., The C. V. Mosby Co., St. Louis, 1976) thus evoked long-resting memories of a 1966 science fiction movie, "Fantastic Voyage." In that saga, a small submarine with a crew of five was miniaturized by some rather mysterious physical process to the size of a bacterium. The surgical team was then injected intravenously and sent on a mission through the bloodsh:eam to remove a lesion from the brain of Dr. Benes, an incomparable scientist from "the other side" with secrets of monumental importance. Of particular fascination to me was the description of the terrors of aortic turbulence when viewed from the inside of an underseas craft a few microns in length. Several years before the fictional account of medical miniaturization, Nobel laureate Richard P. Feynman had raised this very issue from the scientific perspective in an imaginative and entertaining essay entitled "There's Plenty of Room at the Bottom" (reprinted in Miniaturization, H.D. Gilbert, Ed., Reinhold, New York, 1961). He started out by posing the question, "Why cannot we write the entire 24 volumes of Encyclopaedia Britannica on the head of a pin?" The answer, stated with great optimism, is that such a task is theoretically possible and requires only technological ingenuity. At this scale all the extant books in the world could be transcribed into a small pamphlet; librarians take notice. Feynman's analysis of smallness then went on to a discussion of computers and concluded that great reduction was possible. Since the writing of his essay in 1959, there has been a size decrease in this hardware of orders of magnitude, as witnessed by a hand-held calculator sitting in front of me that can far outperform the large desk~top model that I used 20 years ago. The next item was miniaturizing machines, and the author passed on a suggestion of a friend of his, Arthur Hibbs, that very small mechanical devices could be used therapeutically. "He [Hibbs] says that, although it is a very wild idea, it would be interesting in surgery if you could swallow the surgeon. You put the mechanical surgeon inside the blood vessel and it goes into the heart and 'looks' around. (Of course the information has to be fed out.) It finds out which valve is the faulty one and takes a little knife and slices it out." While cardiac surgeons might be amused by this description of valve repair, the general idea is clear: tiny computer-controlled devices could work from inside the body much as the submarine functioned in "Fantastic Voyage." The Symposium of Microsurgery gives us occasion to examine how far we have come in miniaturizing surgical hardware. The discipline is defined in the first article as the art of operating with the aid of a microscope. The technique is used for the union of blood vessels in the size range of 1 mm and in nerve repair. The smallest pieces of equipment reported are suturing needles formed by electroplating the ends of single strands of nylon thread in the size range of 7 to 15 microns diameter (about one hundredth of a millimeter). Needles of 70 microns are generally used along with jewelers' forceps, clamps 8 mm long, and similar microinstruments. At present the instruments are manually controlled under microscopic observation, and the greatest dexterity is required. Moving from human to animal studies we note that for many years protozoologists have been performing microsurgery on single amoebae. One of the most impressive feats is a nuclear transplant in which the nucleus from one protozoan is inserted into (continued on f'dge :zo8)
Dr. Moruwitz is Professor of Molecular Biophysics and Biochemistry, Yale University.
Hospital Practice April 1978
203
Harold J Morowitz------------------,
Downloaded by [University of Saskatchewan Library] at 16:57 24 August 2017
(from page 203)
208
Hospital Practice April 1978
a second cell which had previously undergone a nucleo-ectomy. Such experiments, carried out with micromanipulators, allow for a study of the relative function of nucleus and cytoplasm in large unicellular forms. Another kind of miniaturization was shown to me by an entomology student who makes tuned circuits on very tiny discs that are glued to the backs of bees. Appropriate circuitry allows the experimenter to record the goings and comings of individual insects as their antennae pass his antenna at the entrance to the nest. In Feynman's terms all of these examples are only the beginning of size reduction, and there is still plenty of room at the bottom. However, there are limits to fabricating small machines which relate to two fundamental properties of matter: atomicity and molecular motion. In 1827, the English botanist Robert Brown reported that microscopic pollen grains in aqueous suspension underwent a continuous zigzag motion. He showed that this type of movement is characteristic of all very small suspended particles, both living and nonliving, and the designation "Brownian motion" honors his contribution. The cause of these irregular particle trajectories remained an enigma until near the end of the century. It was then postulated that the phenomenon was due to collision of the particles with fast-moving solvent molecules. Einstein finally worked out a theoretical explanation of Brown's observations, and subsequent experiments confirmed this theory and led to a determination of molecular sizes. Brownian motion is only one example of an intrinsic feature of molecular structures known as random thermal motion. Fluctuations are also seen in electronic circuit noise and light scattering. At the atomic level all particles are ceaselessly moving about and colliding. Temperature is, of course, a measure of this motion. A consequence of this randomness is a limitation on the smallest possible dimensions of working apparatus. Below a certain size the thermal motion makes it impossible for a functioning piece of hardware to carry out a precise job. If we are prevented by a fundamental law of physics from building apparatus below a certain size, we must ask how a living cell manages with much smaller working parts. That question was ~aised by Erwin Schrodinger when he examined biology from a physicist's perspective. He pointed out that most physical laws achieve precision because they are averaged over a large number of molecular events, while cellular processes like gene replication involve only a small number of molecules. Precision in the latter example comes from quantum mechanical transitions of covalently bonded structures; biologically miniaturized machines must thus be single molecules. There are two types of precision: order from disorder in conventional machinery containing a large number of atoms, and order from order in such gadgets as enzymes and membrane-bound energy transducers. We are tempted to ask, can microsurgery be done with molecular machines? The answer is yes, but in raising this question we have subtly moved from surgery to pharmacology. At an abstract degree of miniaturization, this move defines the line between si.ugery and internal medicine. In the former we work with supercellular structures such as tissues to manipulate the system to a healthier state. In the latter case we chemically attack problems at the subcellular domain to improve that state of the patient's health. It is strange that medical specialties divide at such a fundamental level. Will ordinary miniaturization ever get good enough so that we can swallow the surgeon? It is hard to predict what future technological problems might arise. There is certainly a wide-open and exciting field in biomedical instrumentation of extremely small components, and we are very far from any theoretical limits. What we may certainly conclude is that in Feynman's terms we have been swallowing the internist ever since systemic drugs have come into being.
ISSN: 2154-8331 (Print) 2377-1003 (Online) Journal homepage: http://www.tandfonline.com/loi/ihop20
On Swallowing the Surgeon Harold J. Morowitz To cite this article: Harold J. Morowitz (1978) On Swallowing the Surgeon, Hospital Practice, 13:4, 203-208, DOI: 10.1080/21548331.1978.11707324 To link to this article: http://dx.doi.org/10.1080/21548331.1978.11707324
Published online: 06 Jul 2016.
Submit your article to this journal
View related articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ihop20 Download by: [University of Saskatchewan Library]
Date: 24 August 2017, At: 16:57
Harold J Morowitz------------------.
Downloaded by [University of Saskatchewan Library] at 16:57 24 August 2017
On Swallowing the Surgeon A book or article on an unfamiliar subject often sets the mind off in new and surprising directions. A copy of Symposium of Microsurgery (A. I. Daniller and B. Strauch, Eds., The C. V. Mosby Co., St. Louis, 1976) thus evoked long-resting memories of a 1966 science fiction movie, "Fantastic Voyage." In that saga, a small submarine with a crew of five was miniaturized by some rather mysterious physical process to the size of a bacterium. The surgical team was then injected intravenously and sent on a mission through the bloodsh:eam to remove a lesion from the brain of Dr. Benes, an incomparable scientist from "the other side" with secrets of monumental importance. Of particular fascination to me was the description of the terrors of aortic turbulence when viewed from the inside of an underseas craft a few microns in length. Several years before the fictional account of medical miniaturization, Nobel laureate Richard P. Feynman had raised this very issue from the scientific perspective in an imaginative and entertaining essay entitled "There's Plenty of Room at the Bottom" (reprinted in Miniaturization, H.D. Gilbert, Ed., Reinhold, New York, 1961). He started out by posing the question, "Why cannot we write the entire 24 volumes of Encyclopaedia Britannica on the head of a pin?" The answer, stated with great optimism, is that such a task is theoretically possible and requires only technological ingenuity. At this scale all the extant books in the world could be transcribed into a small pamphlet; librarians take notice. Feynman's analysis of smallness then went on to a discussion of computers and concluded that great reduction was possible. Since the writing of his essay in 1959, there has been a size decrease in this hardware of orders of magnitude, as witnessed by a hand-held calculator sitting in front of me that can far outperform the large desk~top model that I used 20 years ago. The next item was miniaturizing machines, and the author passed on a suggestion of a friend of his, Arthur Hibbs, that very small mechanical devices could be used therapeutically. "He [Hibbs] says that, although it is a very wild idea, it would be interesting in surgery if you could swallow the surgeon. You put the mechanical surgeon inside the blood vessel and it goes into the heart and 'looks' around. (Of course the information has to be fed out.) It finds out which valve is the faulty one and takes a little knife and slices it out." While cardiac surgeons might be amused by this description of valve repair, the general idea is clear: tiny computer-controlled devices could work from inside the body much as the submarine functioned in "Fantastic Voyage." The Symposium of Microsurgery gives us occasion to examine how far we have come in miniaturizing surgical hardware. The discipline is defined in the first article as the art of operating with the aid of a microscope. The technique is used for the union of blood vessels in the size range of 1 mm and in nerve repair. The smallest pieces of equipment reported are suturing needles formed by electroplating the ends of single strands of nylon thread in the size range of 7 to 15 microns diameter (about one hundredth of a millimeter). Needles of 70 microns are generally used along with jewelers' forceps, clamps 8 mm long, and similar microinstruments. At present the instruments are manually controlled under microscopic observation, and the greatest dexterity is required. Moving from human to animal studies we note that for many years protozoologists have been performing microsurgery on single amoebae. One of the most impressive feats is a nuclear transplant in which the nucleus from one protozoan is inserted into (continued on f'dge :zo8)
Dr. Moruwitz is Professor of Molecular Biophysics and Biochemistry, Yale University.
Hospital Practice April 1978
203
Harold J Morowitz------------------,
Downloaded by [University of Saskatchewan Library] at 16:57 24 August 2017
(from page 203)
208
Hospital Practice April 1978
a second cell which had previously undergone a nucleo-ectomy. Such experiments, carried out with micromanipulators, allow for a study of the relative function of nucleus and cytoplasm in large unicellular forms. Another kind of miniaturization was shown to me by an entomology student who makes tuned circuits on very tiny discs that are glued to the backs of bees. Appropriate circuitry allows the experimenter to record the goings and comings of individual insects as their antennae pass his antenna at the entrance to the nest. In Feynman's terms all of these examples are only the beginning of size reduction, and there is still plenty of room at the bottom. However, there are limits to fabricating small machines which relate to two fundamental properties of matter: atomicity and molecular motion. In 1827, the English botanist Robert Brown reported that microscopic pollen grains in aqueous suspension underwent a continuous zigzag motion. He showed that this type of movement is characteristic of all very small suspended particles, both living and nonliving, and the designation "Brownian motion" honors his contribution. The cause of these irregular particle trajectories remained an enigma until near the end of the century. It was then postulated that the phenomenon was due to collision of the particles with fast-moving solvent molecules. Einstein finally worked out a theoretical explanation of Brown's observations, and subsequent experiments confirmed this theory and led to a determination of molecular sizes. Brownian motion is only one example of an intrinsic feature of molecular structures known as random thermal motion. Fluctuations are also seen in electronic circuit noise and light scattering. At the atomic level all particles are ceaselessly moving about and colliding. Temperature is, of course, a measure of this motion. A consequence of this randomness is a limitation on the smallest possible dimensions of working apparatus. Below a certain size the thermal motion makes it impossible for a functioning piece of hardware to carry out a precise job. If we are prevented by a fundamental law of physics from building apparatus below a certain size, we must ask how a living cell manages with much smaller working parts. That question was ~aised by Erwin Schrodinger when he examined biology from a physicist's perspective. He pointed out that most physical laws achieve precision because they are averaged over a large number of molecular events, while cellular processes like gene replication involve only a small number of molecules. Precision in the latter example comes from quantum mechanical transitions of covalently bonded structures; biologically miniaturized machines must thus be single molecules. There are two types of precision: order from disorder in conventional machinery containing a large number of atoms, and order from order in such gadgets as enzymes and membrane-bound energy transducers. We are tempted to ask, can microsurgery be done with molecular machines? The answer is yes, but in raising this question we have subtly moved from surgery to pharmacology. At an abstract degree of miniaturization, this move defines the line between si.ugery and internal medicine. In the former we work with supercellular structures such as tissues to manipulate the system to a healthier state. In the latter case we chemically attack problems at the subcellular domain to improve that state of the patient's health. It is strange that medical specialties divide at such a fundamental level. Will ordinary miniaturization ever get good enough so that we can swallow the surgeon? It is hard to predict what future technological problems might arise. There is certainly a wide-open and exciting field in biomedical instrumentation of extremely small components, and we are very far from any theoretical limits. What we may certainly conclude is that in Feynman's terms we have been swallowing the internist ever since systemic drugs have come into being.
