History of surgery

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The Extraction of the Stone of Madness (The Cure of Folly) by Hieronymus Bosch.

Surgery is the branch of medicine that deals with the physical manipulation of a bodily structure in order to diagnosis, prevent or cure an ailment. Ambroise Paré, a 16th century French surgeon stated that there were five reasons to perform surgery: "To eliminate that which is superfluous, restore that which has been dislocated, separate that which has been united, join that which has been divided and repair the defects of nature." Since man first learned to make and handle tools, they have employed their talents to develop surgical techniques, each time more sophisticated than the last; however, up until the industrial revolution, surgeons were incapable of overcoming the three principal obstacles which had plagued the medical profession from its infancy, namely bleeding, pain and infection. Advances in these fields have transformed surgery from a risky "art" into a scientific discipline capable of the most amazing results.

[edit] Generalities

The surgical profession has suffered numerous breakthroughs and setbacks throughout history. In general, the surgeon has been considered the technician while the doctor (more historically related to the priest and shaman) was the true healer. During the development of modern medicine, both disciplines were taught together and one could obtain the qualifications to practice medicine and surgery. A good bit of history, in any case, is intimately related with the history of general medicine. New archaeological technologies confirm that the origin of medicine coincides with the appearance of modern man.

[edit] The origins of surgery

The first surgical techniques were developed to treat the injuries and traumas that man encountered in the course of his everyday life. A combination of archaeological and anthropological studies offer insight into man's early techniques for suturing lacerations, amputating insalvageable limbs, and draining and cauterizating open wounds. Many examples exist: some Asian tribes used a mix of saltpeter and sulfur was poured placed on wounds and lit on fire in order to cauterize wounds; the Dakota Indians used the quill of a feather attached to an animal bladder to suck out purulent material; the discovery of needles from the stone age seem to suggest they were used to in suturing cuts (the Maasai used needles of acacia for the same purpose); and tribes in India and South America developed an ingenious method of sealing minor injuries by applying termites or scarabs who ate around the edges of the wound and then twisted the insects neck leaving their heads rigidly attached like staples.^[1]

[edit] Trepanation

1525 engraving of trepanation.

The oldest surgery for which we have evidence is trepanation ^[2] (also known as trepanning, trephination, trephining or burr hole), in which a hole is drilled or scraped into the skull, thus exposing the dura mater in order to treat health problems related to intracranial pressure and other diseases. Evidence has been found in prehistoric human remains from Neolithic times, in cave paintings, and the procedure continued in use well into recorded history (being described by ancient Greek writers such as Hippocrates among others). Out of 120 prehistoric skulls found at one burial site in France dated to 6500 BC, 40 had trepanation holes.^[3] Folke Henschen, a Swedish doctor and historian, asserts that Soviet excavations of the banks of the Dnieper River in the 1970s show the existence of trepanation in Mesolithic times dated to approximately 12000 BC.^[4] The remains suggest a belief that trepanning could cure epileptic seizures, migraines, and mental disorders.^[5]

Surprisingly, many prehistoric and premodern patients had signs of their skull structure healing; suggesting that many of those that proceeded with the surgery survived their operation. Indeed, in some studies the rate of survival surpassed 50%.^[6]

[edit] Setting bones

Among some treatments used by the Aztecs, according to Spanish texts during the conquest of Mexico, was the setting of broken bones: "...the broken bone had to be splinted, extended and adjusted, and if this was not sufficient an incision was made at the end of the bone, and a branch of fir was inserted into the cavity of the medula..."^[7] Modern medicine developed a technique similar to this in the 20th century know as medullary fixation.

[edit] Anesthesia

Evidence shows that one surgical technique that has existed for thousands of years it anesthesia. Alcohol (Arabic: الكحول‎) is possible one of the oldest forms of anesthesia, and it has been for thousands of years before our time.^[8] Along with alcohol, opium is known to have been used for millenia, both for recreation and as an anesthetic. Some Babylonian cylinders and Mesopotamian bas-reliefs show heads of poppy.^[9] Other substances used from antiguity for anesthetic purposes are the extract of Cannabis sativa, juniper, Aconitum, Erythroxylum coca and mandrake.

[edit] Bloodletting

Hirudo medicinalis. Leeches for bloodletting

Bloodletting is one of the oldest medical practices, having been practiced among diverse ancient peoples, including the Mesopotamians, the Egyptians, the Greeks, the Mayans, and the Aztecs. In Greece, bloodletting was in use around the time of Hippocrates, who mentions bloodletting but in general relied on dietary techniques. Erasistratus, however, theorized that many diseases were caused by plethoras, or overabundances, in the blood, and advised that these plethoras be treated, initially, by exercise, sweating, reduced food intake, and vomiting. Herophilus advocated bloodletting. Archagathus, one of the first Greek physicians to practice in Rome, practiced bloodletting extensively and gained a most sanguinary reputation. The art of bloodletting became very popular in the West, and during the Renaissance one could find bloodletting calendars that recommended appropriate times to bloodlet during the year and books that claimed bloodletting would cure inflammation, infections, strokes, manic psychosis and more.^[10]

[edit] The ancient world

[edit] Mesopotamia

Hammurabi's Code itself contains specific legislation regulating surgeons and medical compensation as well as malpractice and victim's compensation.

Berossus, a 3rd century BC Chaldean philosopher wrote considerably about the traditional Babylonian medical techniques (principally in the archives of Borsippa) and went on to assert that the god Oannes taught the Sumerian people all that was to be known about civilization and that nothing new had been invented. This assertion seemed hyperbolic until analysis of Sumerian tablets showed that the Mesopotamian civilization had developed or invented numerous medical techniques thousands of years before they were re-developed or re-invented by the Europeans.

Some 4000 BC the Sumerian civilization was a established in Mesopotamia between the Tigris and Euphrates rivers, creating the oldest form of writing, cuneiform. Of the 30,000 or so cuneiform tablets that have been discovered, about 800 of them deal with medical themes (one of these being the first prescription known to have been written). The name of the first surgeon is Urlugaledin, from the 4000 BC, whose personal seal depicts two knives encircled by medicinal plants. This seal is now housed in the Louvre.

The Sumerians saw sickness as a divine punishment imposed by different demons when an individual broke a rule. For this reason, in order to be a physician, one had to learn to identify approximately 6,000 possible demons that might cause health problems. To do this, the Sumerians employed divining techniques based on the flight of birds, position of the stars and the livers of certain animals. In this way, medicine was intimately linked to priests, relegating surgery to a second-class medical specialty.^[11]

Nevertheless, the Sumerians developed several important medical techniques: in Ninevah archaeologists have discovered bronze instruments with sharpened obsidian resembling modern day scalpels, knives, trephines, etc. Hammurabi's Code itself contains specific legislation regulating surgeons and medical compensation as well as malpractice and victim's compensation:^[12]

215. If a physician make a large incision with an operating knife and cure it, or if he open a tumor (over the eye) with an operating knife, and saves the eye, he shall receive ten shekels in money.
216. If the patient be a freed man, he receives five shekels.
217. If he be the slave of some one, his owner shall give the physician two shekels.
218. If a physician make a large incision with the operating knife, and kill him, or open a tumor with the operating knife, and cut
out the eye, his hands shall be cut off.
219. If a physician make a large incision in the slave of a freed man, and kill him, he shall replace the slave with another slave.
220. If he had opened a tumor with the operating knife, and put out his eye, he shall pay half his value.

[edit] Ancient Egypt

Pictures of surgery tools at Kom Ombo, Egypt

Around 3100 BC Egyptian civilization began to flourish when Narmer, the first Pharaoh of Egypt, established the capital of Memphis. Just as cuneiform tablets preserved the knowledge of the ancient Sumerians, hieroglyphics preserved the Egyptian's.

In the first monarchic age (2700 BC) the first treaty on surgery was written by Imhotep, the vizier of Pharaoh Djoser, priest, astronomer, physician and first notable architect. So much was he famed for his medical skill that he was deified, becoming the Egyptian god of medicine.^[13] Other famous physicians from the Ancient Empire (from 2500 to 2100 BC) were Sachmet, the physician of Pharaoh Sahure and Nesmenau, whose office resembled that of a medical director.

On one of the doorjambs of the entrance to the Temple of Memphis there is the oldest recorded engraving of a medical procedure: circumcision and engravings in Kom Ombo, Egypt depict surgical tools. Still of all the discoveries made in ancient Egypt, the most important discovery relating to ancient Egyptian knowledge of medicine is the Ebers Papyrus, named after its discoverer Georg Ebers.

[edit] Ebers Papyrus

Main article: Ebers Papyrus

The Ebers Papyrus, conserved at the University of Leipzig, is considered one of the oldest treaties on medicine and the most important medical papyri. The text is dated to about 1550 BC and measures 20 meters in length. The text includes recipes, a pharmacopoeia and descriptions of numerous diseases as well as cosmetic treatments. It mentions how to surgically treat crocodile bites and serious burns, recommending the drainage of pus-filled inflammation but warns against certain diseased skin.

[edit] Edwin Smith Papyrus

Main article: Edwin Smith Papyrus

The Edwin Smith Papyrus is a lesser known papyrus dating from the 1600 BC and only 5 meters in length. It is a manual for performing traumatic surgery and gives surprisingly accurate advice given the time. For example, it gives instructions for dealing with dislocated vertabra:

Thou shouldst bind it with fresh meat the first day. Thou shouldst loose his bandages and apply grease to his head as far as his neck, (and) thou shouldst bind it with ymrw . Thou shouldst treat it afterwards with honey every day, (and) his relief is sitting until he recovers.

[edit] Ancient India

Archaeologists made the discovery that the people of Indus Valley Civilization, even from the early Harappan periods (c. 3300 BC), had knowledge of medicine and dentistry. The physical anthropologist that carried out the examinations, Professor Andrea Cucina from the University of Missouri-Columbia, made the discovery when he was cleaning the teeth from one of the men. Later research in the same area found evidence of teeth having been drilled, dating back 9,000 years to 7000 BC.[1]

Indian physician Sushruta (c. 600 BC) taught and practiced surgery on the banks of the Ganges in the area that corresponds to the present day city of Benares in Northern India. Much of what is known about Sushruta is contained in a series of volumes he authored, which are collectively known as the Susrutha Samhita. It is the oldest known surgical text and it describes in exquisite detail the examination, diagnosis, treatment, and prognosis of numerous ailments, as well as procedures on performing various forms of plastic surgery, such as cosmetic surgery and rhinoplasty.^[14]

In the Sushruta school, the first person to expound Āyurvedic knowledge was Dhanvantari who then taught it to Divodasa who, in turn, taught it to Sushruta, Aupadhenava, Aurabhra, Paushakalāvata, Gopurarakshita, and Bhoja.

Because of his seminal and numerous contributions to the science and art of surgery, Sushruta is also known by the title "Father of Surgery". The Samhita has some writings that date as late as the 1st century, and some scholars believe that there were contributions and additions to his teachings from generations of his students and disciples. Susrutha is also the father of Plastic Surgery and Cosmetic Surgery since his technique of forehead flap rhinoplasty (repairing the disfigured nose with a flap of skin from the forehead),that he used to reconstruct noses that were amputated as a punishment for crimes, is practiced almost unchanged in technique to this day. This knowledge of plastic surgery existed in India up to the late 18th century as can be seen from the reports published in Gentleman's Magazine (October 1794).

The Susrutha Samhita contains the first known description of several operations, including the uniting of bowel, the removal of the prostate gland, the removal of cataract lenses and the draining of abscesses. Susrutha was also the first surgeon to advocate the practice of operations on inanimate objects such as watermelons, clay plots and reeds; thus predating the modern practice of the surgical workshop by half a millennium.

[edit] Ancient Greece

While surgeons are now considered to be specialized physicians, the profession of surgeon and that of physician had different historical roots. For example, Greek tradition was against opening the body, and the Hippocratic Oath warns physicians against the practice of surgery. Specifically, cutting persons laboring under the stone (i.e. lithotomy, an operation to relieve kidney stones) was to be left to such persons as practice [it]. Of course, most knowledge of surgery comes from dissecting bodies, a science which was repulsive to many healers.^{[citation needed]}

[edit] Ancient China

Hua Tuo was a famous Chinese physician during the Eastern Han and Three Kingdoms era. He was the first person to perform surgery with the aid of anesthesia, some 1600 years before the practice was adopted by Europeans.^[15] Bian Que (Pien Ch'iao) was a "miracle doctor" described by the Chinese historian Qima Nan in Shi Ji who was credited with many skills. Another book, Liezi (Lieh Tzu) describes that Bian Que conducted a two way exchanged of hearts between people.^[16] This account also credited Bian Que with using general anaesthesia which would place it far before Hua Tuo, but the source in Liezi is questioned and the author may have been compiling stories from other works.^[17] Nonetheless, it establishes the concept of heart transplantation back to around 300 AD.

[edit] The medieval world

[edit] Islamic world

Abulcasis (Abu al-Qasim Khalaf ibn al-Abbas Al-Zahrawi) was an Andalusian-Arab physician and scientist who practised in the Zahra suburb of Cordoba. He is considered a great medieval surgeon, whose comprehensive medical texts, combining Islamic medicine with Greco-Roman and Indian teachings, shaped European surgical procedures up until the Renaissance. He is often regarded as the Father Of Surgery.^[18] Patients and students from all parts of Europe came to him for treatment and advice. According to Will Durant, Cordova was in this period the favourite resort of Europeans for surgical operations.

Surgery in Holland (ca. 1690)

[edit] Western Europe

By the thirteenth century, many European towns were demanding that physicians have several years of study or training before they could practice. Montpellier, Padua and Bologna Universities were particularly interested in the academic side to Surgery, and by the fifteenth century at the latest, Surgery was a separate university subject to Physics. Surgery had a lower status than pure medicine, beginning as a craft tradition until Rogerius Salernitanus composed his Chirurgia, which laid the foundation for the species of the occidental surgical manuals, influencing them up to modern times.

Ambroise Paré pioneered the treatment of gunshot wounds. Among the first modern surgeons were battlefield doctors in the Napoleonic Wars who were primarily concerned with amputation. Naval surgeons were often barber surgeons, who combined surgery with their main jobs as barbers.

In London, an operating theatre or operating room from the days before modern anaesthesia or antiseptic surgery still exists, and is open to the public. It is found in the roof space of St Thomas Church, Southwark, London and is called the Old Operating Theatre.

[edit] Foundations of modern surgery

To make its transition to the modern era, the art of surgery had to solve three major problems that effectively prevented surgery from progressing into modern science. These were:

[edit] Bleeding

Before modern surgical developments, there was a very real threat that a patient would bleed to death on the table during an operation or while being attended after an accident or wound. The first real progress in combating bleeding had come when early cultures realized they could close wounds using extremes of heat, a procedure called cauterizing. The early cauterization was successful, but only usable in a limited fashion, highly destructive, and painful, with very poor long term outcomes.^{[verification needed]}

The next real breakthrough to come was the invention of ligatures, widely believed to have originated with Abulcasis^[19] in the 10th century and improved by Ambroise Paré in the 16th century. A ligature is a piece of material used to tie closed the end of a severed blood vessel to prevent further bleeding. Ligatures form the basis of modern bleeding control, but at the time, they were more of a hazard than a help because the surgeons using them had no concept of infection control.

A final barrier to be overcome was the problem of replacing blood lost. Limiting bleeding is important, but ultimately, a surgeon is fighting a losing battle if blood cannot be replaced, and this final barrier was only conquered when early 20th century research into blood groups allowed the first effective blood transfusions.

[edit] Infection

The first progress in combating infection was made in 1847 by the Hungarian doctor Ignaz Semmelweis who noticed that medical students fresh from the dissecting room were causing excess maternal death compared to midwives. Semmelweis, despite ridicule and opposition, introduced compulsory handwashing for everyone entering the maternal wards and was rewarded with a plunge in maternal and fetal deaths. However the Royal Society in the UK still dismissed his advice.

The next true progress came when, after reading a paper by Louis Pasteur, the British surgeon Joseph Lister began experimenting with using phenol during surgery to prevent infections. Lister was able to quickly reduce infection rates, a reduction that was further helped by his subsequent introduction of techniques to sterilize equipment, have rigorous hand washing and a later implementation of rubber gloves. Lister published his work as a series of articles in The Lancet (March 1867) under the title Antiseptic Principle of the Practice of Surgery. The work was groundbreaking and laid the foundations for a rapid advance in infection control that saw modern aseptic operating theatres widely used within 50 years (Lister himself went on to make further strides in antisepsis and asepsis throughout his lifetime). The gradual development of germ theory has allowed the final step to be taken to create the highest quality of aseptic conditions in modern hospitals, allowing modern surgeons to perform nearly infection-free surgery.

[edit] Pain

Anesthesia was discovered by two American dentists, Horace Wells (1815-1848) and William Morton. Before the advent of anesthesia, surgery was a traumatically painful procedure and surgeons were encouraged to be as swift as possible to minimize patient suffering. This also meant that operations were largely restricted to amputations and external growth removals.

Beginning in the 1840s, surgery began to change dramatically in character with the discovery of effective and practical anaesthetic chemicals such as ether and chloroform. In Britain, John Snow pioneered the use of these two anaesthetics. In addition to relieving patient suffering, anaesthesia allowed more intricate operations in the internal regions of the human body. The further discovery of muscle relaxants such as curare also facilitated safer applications.

[edit] Modern surgery

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See Surgery#Overview of modern surgery.

[edit] Timeline of surgical procedures