LECTURE 1: History of Surgery

Dr. Abcde Dr. Paul Vincent B. Labajosa | 09 August 2019

of cutting off a person’s nose or ears for certain

OUTLINE:
criminal offenses
I. SURGERY
II. ANCIENT TIMES  Using skin flaps from the forehead, Hindu surgeons
A. Egyptian Surgery shaped new noses and ears for the punished
B. Indian Surgery criminals
C. Greek & Roman Surgery
D. Arab-Islamic Surgery Shushruta Samahita
III. REFERENCES
o One of the first to study the human anatomy
o Forte was rhinoplasty (plastic surgery/ “nose-
SURGERY lift”) and ophthalmology (ejection of
cataracts)
 From the word “chirurgiae” which means Hand
Work Greek & Roman Surgery
 Medical specialty that uses operative manual and
instrumental technique to investigate and treat  Earliest surviving Greek medical writings date form
pathological conditions to help improve bodily about 420 BCE
functions  Word ‘surgery’ comes from the Latin chirurgia
which, in turn, derives from the Greek cheiros
(hand) and ergon (work); surgery was handiwork
ANCIENT TIMES

 First surgical procedures were performed in the Aulus Cornelius Celsus (25 BCE-CE 50)
Neolithic Age (about 10000-6000 BC)
 Roman encyclopaedist who’s not a professional
 TREPANNING: a procedure in which a hole is drilled surgeon but a wealthy estate owner
in the skull to relieve pressure on the brain, may
 Compiled a medical corpus known as De Medicina
have been performed as early as 8000 BC
which consisted of 8 books, one of which was
devoted to surgery
Egyptian Surgery
 De Medicina became one of the earliest medical
works to appear in print (1478)
 IMHOTEP: oldest known physician, lived around
 Much of its content was based on the Greek
2725 BC
Hippocratic corpus but Celsus added new
 Carvings dating to 2500 BC describe surgical techniques for treating fractures, dislocations,
circumcision which is the removal of foreskin from hernias, and glaucosis (cataract)
the penis and the clitoris from female genitalia  “Couching” for cataract involved using a bronze
 Operations which are also believed to have been needle to push the clouded lens to the bottom of the
performed by the Egyptians: castration, lithotomy, eyeball out of the line of sight
amputation o One of the principle of cataract extraction, still
 Ancient Egyptian medical texts provide instructions being practice nowadays
for many surgical procedures including repairing a  Four Cardinal Signs of Inflammation:
broken bone and mending a serious wound o Calor (heat)
 Surgical tools included knives, drills, saws, hooks, o Rubor (redness)
forceps and pinchers, scales, spoons, and a vase o Dolor (pain)
with burning incense o Tumor (swelling)
Ancient Indian Surgery
Claudius Galen (CE 129-c. 200/216)
 Practice of surgery has been recorded around 800
BC  Better known as Galen of Pergamum
 Surgery (Shastrakarma) is one of the eight  Prominent Greek physician and philosopher and
branches of Ayurverda (the science of life and probably the most accomplished medical researcher
longevity), the ancient Indian system of medicine of the Roman period
 Hindus surgically treated bone fractures and remove  Dominated and influenced Western medical science
bladder stones, tumors, and infected tonsils for well over a millennium
 Also credited with having developed plastic surgery  Account of medical anatomy was based on monkeys
as early as 2000 BC in response to the punishment as human dissection was not permitted in his time

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 LECTURE 1: History of Surgery
Dr. Abcde Dr. Paul Vincent B. Labajosa | 09 August 2019

 Wrote about surgery in his book, Methodus  Fellowship of Surgeons in London was united with
Medendi the Barber-Surgeons’ Company Act of Parliament
 System of medicine, based on humoralism (the (1540)
balance of humours in the body)  Barber-surgeons considerably outnumbered
 Advocated bloodletting, to correct humoral physicians and had an important role in what would
imbalance which became an important therapy now be regarded as primary care, or general
 Practical procedure and, therefore, performed by practice
surgeons rather than physicians o During the world war, people were injured and
 It became a staple part of surgical practice thus seek help from them
 They also removed fetuses which had died in the
Arab-Islamic Surgery womb, amputated limbs and dealt with congenital
defects such as tongue-tie and imperforate anus
 Derived from long-standing practices and also  Venereal diseases were officially the province of the
incorporated that of Greece and Rome surgeon
 Made an important contribution to the science of o Syphilis, possibly carried from the Americans by
optics and the understanding of eye diseases Columbus’ (1451-1506) sailors, raged through 16th
(ophthalmology) century Europe
 Salernitan surgeons- ascribed surgery’s decline to  Surgeons also had the monopoly of embalming the
its separation with medicine and neglect of anatomy dead
 Surgeons were not supposed to prescribe internal
SURGERY IN MEDIEVAL TIMES (5TH CENTURY to remedies, officially the province of the physician.
14TH CENTURY AD)  1604, surgery was seen as skilled craft but learned
surgeons generally believed that they had much
Barber Surgeons theoretical knowledge in common with physicians,
and that these 2 professions should be united
 Performed surgeries to people during this era; they  English surgeon, John Halle (1529-1568),
have the materials to do the procedures described a competent surgeon as one “who had the
Surgeons Physicians heart of the lion, the eyes of the hawk, and the
Barber-surgeon guild Physician guilds hands of a woman”
Often illiterate More intellectual
Apprenticeship Attended University SURGERY AND ANATOMY
Mister Doctor
Tool central Eschewed use of tools  Early 1540s, an increasing number of anatomical
works were being published, but the most important
Lucas van Leydan was De humani corporis fabrica (On the fabric of
the human body), by Andreas Vesalius (1514-
 The Surgeon and the Peasant 1564)
 1524
 Depicts barber surgeon
Andreas Vesalius (1514-1564)

Barber Surgeons …  Brussels-born

 Professor of anatomy and surgery in Padua, Italy
 12th-15th centuries, there was an increased output of  Taught that human anatomy could be learned only
surgical literature, both in Latin and the vernacular through the study of structures revealed by human
 First recorded public dissection of a human body dissection
(executed criminal) since the days of Herophilus  De Humani Corporis Fabrica Libri Septem (1543)
(c.330-260 BCE) and Erasistus (c. 330-255 BCE) in provided fuller and more detailed descriptions of
Alexandria, took place at Bologna in about 1315 human anatomy than any of his illustratious
 During the 13th century, there were new and predecessors did
improved surgical instruments such as scissors,  Most importantly, he corrected errors in traditional
trocars (used for piercing body cavities and anatomic teachings propagated 13 centuries earlier
withdrawing fluid), syringes, lithotrites (used to crush by Greek and Roman authorities, whose findings
bladder stones), and sutures made from animal gut were based on animal rather than human dissection
(*now called “chromic)

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 LECTURE 1: History of Surgery
Dr. Abcde Dr. Paul Vincent B. Labajosa | 09 August 2019

… Surgery and Anatomy …  This encouraged the growth of new blood vessels
(collateral circulation), and often prevented the
 Asserted that anatomic dissection must be amputation of a limb
completed by physicians/surgeons themselves- a
direct renunciation of the long-standing doctrine that
dissection was a grisly and loathsome task to be Percivall Pott (1714-1788)
performed by diener-like individual
 This principle of hands-on education would remain  Contributed to the argument for conservative
Vesalius’ most important and long-lasting treatment of compound fractures rather than
contribution to the teaching of anatomy immediate amputation
 He was also the 1st to describe cancer of the
scrotum in chimney sweeps
Ambroise Parế (1510-1590) of France

 Son of a barber Claudius Amyand (c. 1681-1740)

 Most celebrated barber-surgeon in Western
medicine  Performed the 1st successful appendectomy at
 Played the major role in reinvigorating and updating St. George’s Hospital in 1735
Renaissance surgery and represents severing of the o Patient was a 11-year-old boy named Hanvil
final link between surgical thought and techniques of Anderson whose appendix had been perforated
the ancients and the push toward more modern eras with a pin
 From 1536 until just before his death, Paré was o Amyand Hernia: rare form of inguinal hernia in
either engaged as an army surgeon, during which he which the appendix is located within the hernia
accompanied different French armies on their sac
military expeditions, or performing surgery in civilian
practice in Paris
… Surgery and Anatomy …
 His use of a less irritating emollient of egg yolk,
rose oil, turpentine brought him lasting fame and  By the end of the century, the career structure of
glory surgeons was more closely tied to hospitals than
 Described in his Dix Livres de la Chirurgie avec le that of physicians
Magasin des Instruments Necessaires á lcelle  1745: Barber-Surgeon Company dissolved
(1564), the free or cut end of a blood vessel was  1800: George III chartered the Royal College of
doubly ligated and the ligature was allowed to Surgeons of London
remain undisturbed in situ until, as a result of local  1843: Queen Victoria Royal College of Surgeons of
suppuration, it was cast off England
 His experience with amputation enabled him to
develop a great variety of artificial limbs MODERN ERA
 He humbly attributed his success with patients to
God, as noted in his famous motto, “Je le pansay.  First modern surgeons: Battlefield Doctors in the
Dieu le guérit,” that is, “I treated him. God cured Napoleonic Wars who were concerned with
him.” amputation
 Naval surgeons: Barber surgeons
… Surgery and Anatomy … EARLY 19TH CENTURY SURGERY
 Grave-robbing for purposes of dissection was well
 Surgery was dreaded
established by the 17th century
o Patients avoided surgery due to pain
 The earliest body snatchers (also called
 Mortality was high
‘resurrectionists’) were probably surgeons,
o 19% deaths from amputations prior to 185p
anatomists, or their apprentices
 Primarily wound treatment with those who have:
o Lancing boils
John Hunter (1728-1793) of Scotland o Draining abscess
o Suturing injuries
 Surgeon at St. George’s Hospital; developed the
technique of ligating blood vessels in cases of
Tools of the Trade
aneurysm (abnormal dilatation of vessels)
 1846 scarifier
 1863 cupping set

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 LECTURE 1: History of Surgery
Dr. Abcde Dr. Paul Vincent B. Labajosa | 09 August 2019

Infection  Reported use of Nitrous Oxide in 1844

 Post-surgical infection so common that pus felt to be
the sign of healing William E. Clarke
 “Laudable Pus” –pus that develops during healing;
sign of infection  Used Ether
 Gangrene common
 Stench
Crawford Long MD
 Made surgery more difficult
 Delayed treatment  Georgia surgeon
o Patients allowed wounds and tumors to grow  Used ether for the first time in 1842
and fester
 Notion of consent was different
 Drugs like opium, hemp, hashnish, whiskey William Thomas Green Morton (WT Morton)
o Uunpredictable, unsafe
 Speed essential  Dentist
 October 16, 1846
 “In case of amputation, it was the custom to bring  First public demonstration of ether
the patient into the operating room and place him  At the operating theatre of Massachusetts General
upon the table. [The surgeon] would stand with his Hospital (MGH)
hands behind his back and would say to the patient,  Not the 1st surgical use of ether
“Will you have your leg off, or will you not have it
off?” If the patient lost courage and said, “No,” he
had decided not to have the leg amputated, he was James Young Simpson
at once carried back to his bed in the ward.
 1847
If, however, he said, “Yes,” he was immediately
 First to demonstrate the anesthetic properties of
taken firmly in hand by a number of strong
chloroform
assistants and the operation went on regardless of
whatever he might say thereafter.
If his courage failed him after this crucial moment, it Effect of Anesthesia on Surgery
was too late and no attention was paid to his cries of
protest. It was found to be the only practicable  Number of operation increased
method by which an operation could be performed  Mortality increased
under the gruesome conditions which prevailed  Risk associated with anesthetics
before the advent of anesthesia.” o Explosion
 Underanesthesized and overanesthesized
 Decreased patient fear
Surgery and Speed
 Surgery lasted longer
 Surgeon was a “clock-driven gladiator”  Not adopted immediately or universally
o Minimize shock and pain  Restricted in Military
o Speed at the price of tissue damage  Too expensive for charity patients
 Questioned on moral grounds
19TH CENTURY SURGERY  Obstetrical anesthesia
 Socio-economic and racial disparities
 Street clothes worn when doing a procedure
 Bare hands
 Unclean and reused instruments Impact of Civil War
 Assistants were medical students and junior doctors  Amputation (1863)
 Often performed at home  Important training ground
 High chance of morbidity and mortality  Exposure to injuries and infections
ANESTHESIA  Value of hospitals

Horace Wells Rise of Hospitals

 Dentist  During 19th century most surgeries performed in the
 Pioneered the use of anesthesia in dentistry home

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 LECTURE 1: History of Surgery
Dr. Abcde Dr. Paul Vincent B. Labajosa | 09 August 2019

o Mortality 3-5x higher in hospitals von Mikulicz-Radecki

o Hospitals for charity cases
o Social stigma  Proved that speaking during operations encouraged
 1800: 2 hospitals droplet infection (a term coined by him)
o Pennsylvania Hospital
o New York Hospital
William Stewart Halsted (1852-1922)
 1821: Mass General Hospital #3
 1873: 178 hospitals  Introduced rubber gloves for scrub nurse
 1909: 4359 hospitals  Father of Modern Surgery
 Introduction of antibiotics was a major step in the
treatment of infections and the widespread use of
Forces Contributing to Rise of Hospitals antibiotics has even led to the emergence of strains
of antibiotic resistant bacteria
 Professional
o Nurses/ anesthetists/ orderlies available
o Location for teaching/ learning John Lister
 Immigration
 Urbanization  British surgeon
 Lack of extended families  Influence: Pasteur
 Poverty/ expense of health care o Pus/infection caused by microbes in air
 Technology and surgical equipment available  (1867) introduced Antisepsis
o Carbolic acid
Infection o Rinse hands and instruments

 Post-surgical infection rises in 19th century Antisepsis

o Crowded hospitals
o Infection in hospitals  Coincides with heightened public interest in
o Increase in traumatic injuries cleanliness and hygiene
 Hospitalism  Erratically adopted, especially in America
o Gangrene, erysipelas, pyema o Solution caustic
o Associated with large, old buildings o Many physicians opposed germ theory
o Led to new hospital design w/ ventilation and  By 1880s, generally though not uniformly adopted
more space o Lister didn’t wash his hands and operated in
 Bellevue (1860) – unsanitary hospital street clothes
 Pennsylvania Hospital (1911) – sanitary hospital

ANTISEPSIS, ASEPSIS, & UNDERSTANDING THE Robert Koch (1843-1910)

NATURE OF INFECTION  German
 1876: discovered anthrax
Infection Control
 1882: Mycobacterium tuberculosis
 Demonstrated that bacteria have specific etiological
Ignaz Semmelweis
relationship to disease
 1847  Made bacteriology clinically applicable
 Experiments with washing hands & instruments in o Refined culture and dye techniques
chlorine to prevent childbed fever  Koch’s Postulates
 Published in 1860 o Experimental processes showing organism A
 Impact ignored causes disease B

Koch’s Postulates (1882)

Louis Pasteur
 Organism must be present in all cases of diseased
 French chemist condition but not in healthy animals
 1857 and 1860  Organism must be isolated and grown in pure
 Demonstrated that fermentation is caused by a culture
living organism (not a chemical reaction)  Culture must induce disease experimentally
 Refuted spontaneous generation  Organism can be reisolated from experimental
infection

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 LECTURE 1: History of Surgery
Dr. Abcde Dr. Paul Vincent B. Labajosa | 09 August 2019

Impact of Germ Theory Increased in Operations

 Idea of disease specificity  MGH

 Allowed possibility of equating disease with an o 1841-1845: 37 operations/ year
organism o 1847-1851: 98 operations/ year
 Reclassification of disease o 1898: 3700 operations
 Dynamic conception of disease  Surgery in 1900
 Belief that medicine could fight disease, improve o Safer
public health o Less painful
o Provided scientific rationale for public o More invasive
health/hygiene efforts o Less infection risk
 Shifted attention from internal organs to external
invaders “The Century of the Surgeon”
o Ironically reinforced prejudices about “outsiders”
 1870-1970
 Provided theoretical foundation for diagnosis and
 Explosion in surgical techniques
therapy
 New areas of the body accessible
 Specific therapy for infectious disease
 Search for vaccines, antitoxins, “magic bullets”  Attention to detail and tissue

Theodore Bilroth
Magic bullet
 Viennese surgeon
 The perfect drug to cure a disease with no side  1870s: attempted laryngectomies (removal of the
effects larynx) and esophageal resection in cancer
 Term used by German scientist Paul Ehrlich to patients
describe antibody and, later, the drug salvarsan that  1881: performed the first successful gastrectomy
he created to treat syphilis. (removal of the stomach) for cancer

Asepsis
William Macewen of Glasgow
 Introduced by Ernst von Bergmann in 1877
 Recognition that hands, body, instruments were  1879: 1st to remove brain tumor
more likely source of infection than air  By 1893, he had operated 24 cases of cerebral
 Led to sterilization, cleaning patient, abscess with 23 recoveries
handwashing, eventually gloves and masks
o By 1890s, most hospitals used autoclaves Carl Langenbach of Berlin
o However, many surgeries still performed in
homes  1882: removed the gall bladder
(cholecystectomy) of a 42-year-old man with
Sterilization gallstones

 From the 1870s, as sterilization techniques were

adopted, all-metal instruments became popular Robert Lawson Tait
because they were easier to clean
 Scottish surgeon
 1883: Operated on a woman whose fallopian tube
Blossoming of Surgery
had erupted due to ectopic pregnancy
 By 1870s and 1880s surgeons can operate on head,
chest, and abdomen
o 1886: 1st successful appendectomy Abraham Groves
o 1886: MGH abdominal surgery ward  1883: Performed the 1st appendectomy in North
o Abdomen now available to surgeons America
 1880s and 90s: Physiological Surgery
o Conserved tissues, preserved anatomy, careful
dissection Emil Theodor Kocher
o Compare to slash and speed model
 1883: Discovered myxedema because he had
removed too much thyroid gland in his patients with

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 LECTURE 1: History of Surgery
Dr. Abcde Dr. Paul Vincent B. Labajosa | 09 August 2019

over-secretion (toxic goiter). The science of Transplantations

endocrinology was born out of this error.
Frank Macfarlane Burnet and Peter Medawar

Victor Horsley  1940s: the body’s immune system was implicated in

the rejection process
 1887: 1st to remove a spinal tumor, assisted by
Charles Balance
Joseph Murray

Charles Balance  1954: 1st human kidney transplant with long-term

success was performed in Boston
 1895: removed the ruptured spleen of a 10-yr old
boy
 The 1st splenectomy was done in Germany 2 Christiaan Barnard
years previously
 1967: performed the 1st heart transplant in Cape
Town, South Africa
Wilhelm Roentgen  He transplanted the heart of a young woman
killed in a car crash into Louis Washkansky, a
 1895: discovered x-rays 55-year-old grocer. Washkansky died of
pneumonia 1 8 days later. Barnard' s second
patient was Philip Blaiberg who lived for 563
Karl Landsteiner days following his operation in January 1 968.
 1900: introduced the concept of blood grouping Barnard's longest surviving patient, Dirk van Zyl,
and identified the major A, B, and O groups died in 1996, 23 years after surgery.

Transfusion Edward Donnall Thomas (b. 1920)

 Levine and Stetson  American Physician
o Recognized the Rh group in 1939
 1970: 1st successful bone marrow transplant in
 The introduction of preservative solutions in non-twins
1937, such as acid-citrate-dextrose (ACD), citrate-
phosphate-dextrose (CPD), and citrate-phosphate-
double dextrose-adenine (CP2D-A), have extended
the shelf life of blood up to 6 weeks END OF TRANSCRIPTION
 The most recent advance has been the development REFERENCES
of hemoglobin substitute to provide oxygen-carrying Dr. Labajosa’s ppt & recording
capacity

Charles McBurney

 Treatment of appendicitis
 1889: published his landmark paper in the New York
Medical Journal describing the indications for early
laparotomy for the treatment of appendicitis
 McBurney’s point

Alexander Fleming

 Continued work on the natural antibacterial action

of the blood and antiseptics after serving in the
British Army Medical Corps during World War 1
 1928: while studying influenza virus, he noted a
zone of inhibition around a mold colony (Penicillium
notatum) grew on a plate of Staphylococcus, and he
named the active substance penicillin

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