Transcript Timeline of Surgery

Timeline of Surgery
December 22, 2010
Minoans practice
trephination
c. 2500

This skull, excavated at
Jericho in 1958 (tomb
88), shows 4 trephination
holes at different stages
of healing. One hole is
almost completely
healed.
Galen learns surgery by repairing gladiators'
wounds - c.157

In CE 157, the Greek physician,
Galen (CE 129-c. 200/216), was
appointed doctor to the
gladiators owned by the High
Priest of Pergamum, his native
city. He gained much valuable
experience of the damage
inflicted by wounds. Intestines
often rolled out of stabbed
abdomens and were replaced as
quickly as possible, although
survival was rare if the bowels
themselves were penetrated.

Galen claimed an almost total success
in his post as doctor to the gladiators
since there were only 2 deaths under 5
High Priests compared with his
predecessor's 60, none the result of
wounds received in the arena.
Galen learns surgery by repairing gladiators'
wounds - c.157

Galen successfully sewed back
an omentum (layer of peritoneal
tissue) into the abdominal cavity,
and removed a diseased
breastbone from the slave of a
comic playwright. Galen wrote
about surgery in his book,
Methodus Medendi. He closed
wounds with bandages, sutures
or the fibula, and ligated blood
vessels with yarn or silk. He
advocated dissection and
vivisection (his were on animals)
in order to learn how the body
worked and avoid mistakes in
surgery.

Galen claimed an almost total success
in his post as doctor to the gladiators
since there were only 2 deaths under 5
High Priests compared with his
predecessor's 60, none the result of
wounds received in the arena.
Surgical instruments

Roman armies had their own
cutlers, armourers, and
blacksmiths who were trained
to produce surgical
instruments as needed.
Nevertheless, the complexity
of some precision instruments 
suggests that the makers may
have devoted themselves
largely or wholly to this
activity. Instrument makers
produced needles, hooks,
arrow extractors, scalpels,
probes, scoops, catheters,
dilators, bone chisels,
cauteries, and forceps.
Most were made of copper, bronze or
brass, a few from iron. Iron was used for
scalpel blades while the handles were
bronze. Blunt blades could be removed
and replaced by a cutler, instrument
maker or blacksmith. Roman
blacksmiths understood the process of
adding carbon to iron to produce steel
although, according to Galen, the best
quality surgical steel came from natural
ores in northern Europe.
The Christian world divides

In CE 312, the Roman emperor,
Constantine (d. CE 337), was converted to
Christianity and the following year this was
recognised as the official religion of the
Roman Empire. His capital,
Constantinople (formerly Byzantium),
became the centre of the eastern Church
although the bishop of Rome remained the
most important figure in the West.
Nevertheless, the two halves of the
Empire gradually drew apart.
The Christian world divides

In the East, surgery was performed in
some of the first Christian hospitals such
as St Sampson's in Constantinople which
had surgical patients by CE 650. In the
West, Greek texts of Hippocrates and
Galen were translated into Latin and
studied in the monasteries of Europe.
However, apart from brief tracts on
phlebotomy (blood-letting) and cautery,
there is little mention of surgery in the
western medical literature of the 6th-11th
centuries.
Arab-Islamic surgery


Medicine practised in the Arab-Islamic world
derived from long-standing practices and also
incorporated that of Greece and Rome. Many
Greek texts were translated into Arabic. Arabic
authors played an important role in preserving
and adding to classical teaching. Those writing
on surgery included the Persian physicians,
Rhazes (d. 925), Haly Abbas (930-994), and
Avicenna (980-1037).
Avicenna's Canon of medicine was enormously
influential in the West throughout the Middle
Ages and provided a largely Galenic system of
medicine.
Arab-Islamic surgery


The Spanish physician, Albucasis (936-1013),
wrote 30 surgical texts published in Latin
translation as Liber Alzaharavii de Chirugia (12th
century). The texts included operations for
bladder stone and eye diseases, wound
cauterisation, sutures, treatment of fractures and
dislocations. There were, in addition, nearly 200
illustrations of surgical instruments, many of
which he designed himself.
In Arab-Islamic medicine, the knife took second
place to therapies such as pharmacy,
bloodletting, and cupping.

Nevertheless, by the 13th
century, there were new
and improved surgical
instruments such as
scissors, trocars (used for
piercing body cavities and
withdrawing fluid),
syringes, lithotrites (used
to crush bladder stones),
and sutures made from
animal gut.
Cauterisation with a hot iron
(cautery) was an important
surgical technique. It was
used to open abscesses
and boils, arrest bleeding,
burn skin tumours and
haemorrhoids, treat
epilepsy, stroke and
melancholy. In patients
who suffered recurrent
dislocations, the cautery
was used to produce scar
tissue which permanently
immobilised the joints.
The surgeons of southern Europe



In the western world, from the 12th-15th centuries, there
was an increased output of surgical literature, both in Latin
and the vernacular. The University of Salerno in southern
Italy, founded in the mid-10th century, was an important
centre for medical education which included theoretical (but
not practical) surgery.
During the 13th century, the focus for medical studies
moved to the universities of northern Italy at Bologna
(founded 1113), Padua (1222), and Verona.
The first recorded public dissection of a human body
(executed criminal) since the days of Herophilus (c. 330260 BCE) and Erasistratus (c. 330-255 BCE) in Alexandria,
took place at Bologna in about 1315. Dissection was
acceptable to the church authorities provided that the body
was of an executed criminal and that, following dissection, it
was given a proper Christian burial.
Public dissection was spectacle, instruction, and edification all in one. It was sometimes
staged in a church or municipal building, and usually in winter since cold slowed
putrefaction. The abdominal cavity was the first to be exposed because it decayed the
fastest. This was followed by the thorax (chest) and brain. Often, a robed physician sat
on a dais reading from an anatomical text by Galen (although he never dissected
humans), while a surgeon performed the dissection and a teaching assistant pointed out
notable features.

Guy de Chauliac (1298-1368) was both physician (to the Pope in
Avignon) and a surgeon. He was educated at Montpellier and
Bologna. His Chirugia magna was translated many times and
quoted in European surgical literature until the 18th century. These
university-trained doctors, with their intellectual roots planted in the
medical theory of ancient Greece, were almost certainly not typical
of the surgeons operating in the everyday medieval world. Bruno
Longoburgo, an Italian academic writer, considered that the
practitioners in day-to-day contact with patients were 'for the most
part ignorant and stupid peasants'. No doubt, there was a wide
range of skills and intellect. In a male-dominated profession, there
were at least 23 women surgeons licensed in the Kingdom of
Naples between 1273-1410, 11 of whom had no restrictions on the
sex of their patients.

By the end of the 15th century, there were
growing numbers of practitioners who rejected
scholastic theory in favour of an emphasis on
learning through practice. One of these was the
Italian surgeon, Leonardo di Bertipaglia (c.
1380-1465), who made an important contribution
to surgical technique by introducing the sutureligature to tie off bleeding blood vessels. He thus
spared many patients the red-hot cautery or
burning oil.
Itinerant practitioners and
barber-surgeons

From the Renaissance to the 18th century,
surgery and medicine were practiced in most of
western Europe by separate groups of
practitioners. However, surgery was rarely
included in the university curriculum outside
Italy. From the 12th century, physicians were
licensed by universities. Surgeons were
regulated by trade guilds and their closest
occupational links were with barbers. Guilds of
barber-surgeons were established in Europe
from the 13th century.

The barber-surgeon was an artisan who
practised both trades. Hair-cutting and shaving
provided a regular day-to-day income and he
trained through an apprenticeship. More often
than not, he was illiterate. In France, by the mid14th century, the physicians, surgeons, and
barber-surgeons were organised into separate
companies and had clearly defined roles.
Dissections were under the direction of a
physician but the knife-work was performed by a
surgeon. In smaller towns, there was a more
amicable association between the groups.

In this German miniature, a
woman is seated on a bench,
holding a bowl into which her
blood spurts from an incision at
the elbow. She is probably
rhythmically squeezing a
wooden stick in order to hasten
the flow of blood. The surgeon,
wearing a typical surgeon's hat
of the period, holds her round
the shoulder with his left hand
whilst checking her pulse with
his right. If the pulse
weakened, bleeding was
stopped. The elderly man at
left is either washing his arm
before blood-letting or holding
it in warm water to enhance
the blood flow.
Eye surgery and couching for
cataract

Although most university educated doctors dissociated
themselves from the bloody craft of surgery, an exception was
made for eye operations. Eye surgery, being relatively
bloodless, was performed by university graduates as well as
itinerants. The Hebrew physician, Benvenutus Grassus (c.
1150), was educated at Salerno but settled in Montpellier after
acquiring a wide reputation as a skilful operator on cataracts.
The Greek term hypochysis, used to describe the cloudy film
seen through the pupil, was translated by the Arabs as 'flowing
down of water'. This was translated into Latin as 'cataract' by
the Carthaginian monk, Constantine the African (c. 1020-1087).
Cataract was believed to be the result of coagulated humours
within the eyeball falling down in front of the lens.

Grassus used a gold or silver needle to
dislodge the humour since these metals
were soft and less likely to damage the
eye than iron or steel. His technique was
to push the humour well down in front of
the pupil and hold it there until he had said
'four pater nosters'.

The Book of Tobit in The Apocrypha
describes how Tobit, a Hebrew exiled
in Ninevah (Mesopotamia), became
gradually blind with a whiteness' in his
eyes which he attributed to sparrow
droppings while he slept by his
courtyard wall. Local doctors were
unable to help. Meanwhile, he sent his
son, Tobias, on a journey to Rhages
(now Rai, near Tehran) to redeem a
fortune in silver from a cousin. During
the journey, Tobias caught a large fish
in the River

Tigris, and was advised to preserve
the heart, liver and gall against evil
spirits. When he eventually returned
home, Tobias threw the fish gall into
his father's eyes with the words, Be of
good hope, my father'. The severe
smarting caused Tobit to rub his eyes
during which the whiteness' peeled
away and he could see. The vigorous
rubbing rather than the fish gall may
have loosened Tobit's opaque lens
from its supporting tissues, a not
uncommon occurrence in mature
cataracts. An early 20th century
version of fish gall was sugar,
described in the memoirs of a Jewish
immigrant from Russia whose mother
blew it into the eyes of his
grandmother. She was never again
troubled with cataract'.
The surgeon defined



In England, surgery was a Craft Guild until 1540 when the
small Fellowship of Surgeons in London was united with
the Barber-Surgeons' Company by Act of Parliament. The
first master of the Company was Thomas Vicary (c. 14901561), surgeon to Henry VIII (reigned 1509-1547).
Henry granted the Company the annual right to dissect
the bodies of 4 hanged criminals. This was increased to 6
by Charles II (reigned 1660-1685).
Barber-surgeons considerably outnumbered physicians
and had an important role in what would now be regarded
as primary care or general practice. They were less
expensive to consult than physicians and, therefore, used
by a wider section of the population. They set fractures,
treated cuts and burns, knife wounds, tumours and
swellings, ulcers and skin complaints. They also removed
foetuses which had died in the womb, amputated limbs,
and dealt with congenital defects such as tongue-tie and
imperforate anus.
As well as being first master of the
Company of Surgeons, Vicary was also
appointed governor of St Bartholomew's
Hospital, London, in 1548 and a ward
was named after him. His code of
practice for surgeons included keeping
their patients' secrets, helping the poor
as well as rich, not coveting any woman
in a patient's house, not being a
drunkard or so desirous of money to take
in hande those cures that be
uncurable...' However, he required
patients to obey his orders however
unpleasant, for he can not be called a
pacient, unlesse he be a sufferer'.

Venereal diseases were officially the province of
the surgeon. Syphilis, possibly carried from the
Americas by Christopher Colombus's (14511506) sailors, raged through 16th century
Europe. Surgeons also had the monopoly of
embalming the dead. Some surgeons were
licensed by the Barber-Surgeons' Company only
for certain procedures such as bone-setting
whilst others had wider practice rights. Surgeons
who operated outside of their licence were
punished as were those who failed to consult
senior surgeons of the Company when faced
with a difficult case. In 1605, Pascall Lane, was
fined 40 shillings and sent to prison following the
death of a child which he had 'ignorantly' and
'negligently' cut for bladder stone. Surgeons
were not supposed to prescribe internal
remedies, officially the province of the physician.
The reduction of fractures
and dislocations were a
case in point. In his
surgical textbook, the
Dutch surgeon, Paul
Barbette (d. before 1675),
did not trouble to describe
the technique since it is
better learnt by the
frequent view of Practice
than by Reading'.
Surgery and anatomy

In the Italian universities of the early 16th century,
surgery and anatomy were often taught together.
Anatomical dissection was sanctioned by ecclesiastical
and civil authorities because the corpses were criminals
who were both executed and anatomised in public.
Anatomy was given a fillip in 1531 when *Galen's On
anatomical procedures was translated into Latin as part
of a general revival in the medicine of ancient Greece.
The book set out the order in which a dissection should
be carried out. By the early 1540s, an increasing number
of anatomical works were being published, but the most
important was De humani corporis fabrica (On the fabric
of the human body), by the Belgian anatomist, Andreas
*Vesalius (1514-1564). Vesalius had been a dissector
since his student days in Paris during the 1530s, robbing
wayside gibbets and cemeteries for material.
Surgery and anatomy

In 1537, Vesalius was appointed lecturer in surgery and
anatomy at Padua, an appointment which raised the
status of both disciplines since he was a university
educated physician. Numerous students went to Padua
to learn anatomy, and for those who could not get there,
Vesalius' book, De humani corporis fabricus, was a pathbreaking account of human anatomy. As such, it
contradicted Galen since he had only dissected animals.
Vesalius believed that physicians should use their hands
although many anatomical dissections continued to be
made by 'demonstrators' while the students watched.
After Vesalius, anatomy was progressively incorporated
into university medicine. From 1546, the English
physician, John Caius (1510-1573), who had shared
lodgings for a time with Vesalius, gave anatomy lectures
in English both to the College of Physicians in London
and apprentices of the London Barber-Surgeons
Company.


Vesalius' figures are shown, not in
the aspect of death but as
animated manikins against a
backdrop of Italian countryside.
The fact that Vesalius' illustrations
were widely and unashamedly
plagiarised is ample proof that
they were recognised as being far
in advance of anything published
up to that time. Nevertheless, later
anatomists corrected Vesalius as
he had corrected Galen.

Anatomists often had a hard time
convincing people (including
doctors) that dissection was a
worthwhile procedure. Some, like
the Italian artist, Michelangelo
(1475-1564), were physically
repulsed by the business of
disembowelling; others believed
that merely touching a dead
body would pollute the living.
Both Catholic and Protestant
anatomists argued that
contemplation of the body could
lead to a knowledge of God's
handiwork and hence of his
nature and existence. The
creation of university anatomy
theatres helped establish
dissection as a progressive
subject. In the wake of Vesalius,
young anatomists sought to
establish priority in discovering
new bodily structures.
Military and naval surgeons

Many surgeons drew on experience in military and naval surgery.
After the introduction of gunpowder into warfare during the 15th
century, the number and variety of injuries increased substantially.
Practising military surgeons wrote some of the first surgical
handbooks in the vernacular. The Buch der Wund-Artzney (Book of
wound dressing, 1497) by Strasburg surgeon, Hieronymus
Brunschwig (1450-1533), was the first printed book on surgery to
appear in English translation (1525). It also contained the earliest
printed illustrations of surgical instruments. Brunschwig endorsed
the popular belief that gunshot wounds were poisoned by
gunpowder and so required cauterisation, usually with a red-hot iron
or boiling oil of elders mixed with theriac.

In this illustration from his Book of wound
dressing, Hieronymus Brunschwig treats
a man with a chest wound. He is
accompanied by 2 assistants or relatives
of the patient. Growing use of
gunpowder-fired artillery often worsened
the injuries confronting field surgeons
because canonballs and lead shot
destroyed more tissue than arrows or
swords and left gaping wounds which
were susceptible to putrefaction. A British
surgeon, Alexander Read, wrote that
Man in every age doth devise new
instruments of death ... we have in our
age, Gun-shot, the imitation of God his
thunder; but the example is more fierce,
and sendeth more souls to the devil, than
the pattern'.
Ambroise Paré

The most celebrated barber-surgeon in western medicine
was Ambroise Paré (1510-1590) of France, the son of a
barber. He was appointed (c. 1533) aide-chirurgien at the
Hôtel-Dieu, the only public hospital in Paris. In 1537, he
became a military surgeon and for the next 30 years
divided his time between following the French army and
tending the sick in Paris. In Italy, on his first campaign
(1537), he ran out of the boiling oil used to treat gunshot
wounds and compromised with a salve of egg-white, roseoil and turpentine. That night he slept badly, believing that
the men whose wounds he had failed to burn would be
dead by morning. In fact, they were in a much better state
than those who had received the oil. Paré resolved never
again to burn people who had been shot. In 1552, Paré
entered the service of *Henri II but failed to save his life
after he was wounded during a jousting tournament in
1559.


Paré (like the Roman author, Celsus)
believed that the attributes of a surgeon
were a strong, stable, and intrepid hand; a
resolute and merciless mind; and an
insensitivity to the 'common people' who
spoke ill of surgeons because of their
ignorance.
The most gruesome operation performed
by Paré and his contemporaries was
undoubtedly amputation of a limb.
Surgeons were advised to take up their
knives with a steddy hand and good speed'.
It was no less a dreaded experience for the
patient. Fabricius (c. 1533-1619), an Italian
contemporary of Paré, told it how it was for
many 16th century surgeons: I was about
to cut off the thigh of a man of 40 years of
age, and ready to use the saw, and
Cauteries. For the sick man no sooner
began to roare out, but all ranne away,
except only my eldest Sonne, who was
then but little, and to whom I had committed
the holding of his thigh ... and but that my
wife then great with child, came running out
of the next chamber, and clapt hold of the
Patient's Thorax, both he and myselfe had
been in extreme danger'.
Surgeons and the law

In 13th century Spain and Italy, surgeons were called
upon to give evidence as expert witnesses in suspicious
or violent deaths. In cases of wounding, they were
obliged to report to the authorities all cases of wounds
which appeared to have been caused by violence or to
certify if a wound would have, or had, caused death. In
1533, the Holy Roman Emperor, *Charles V (reigned
1519-1555) enacted a legal code (known as the
Carolina) which stated that in all cases of suspected
murder, surgeons had to be consulted. France passed a
similar law (the edict of Valence) in 1536. The French
barber-surgeon, Ambroise *Paré (1510-1590), produced
a Treatise on reports (1575) in which he advised
surgeons how to write legal reports on wounds,
infanticide, death by lightning, and the signs of
wounding, hanging, or suffocation. In England, surgeons
appear not to have given evidence in murder trials until
the 17th century.
Antisepsis and asepsis

Joseph Lister's (1827-1912) practice of 'antisepsis'
whereby germs were destroyed or excluded from wounds
through the application of antiseptic solutions, was
gradually reconciled with 'asepsis'. This practice aimed to
create an environment which was free from the presence
of germs. Asepsis appealed to Victorian notions of
cleanliness in both medical and moral matters. Cleanliness
and hygiene were fundamental to the public health
movement which aimed to sanitise environments and the
people within them. Enthusiasm for asepsis led to
improvements in hospital cleanliness, design, and
ventilation, as well as the ritual of sterilising gowns, masks
and gloves. In the late 1870s, the German bacteriologist,
Robert *Koch (1843-1910) showed that Louis *Pasteur's
(1822-1895) germ theory was essentially correct. He
cultured and identified bacteria which caused specific
infections.
Antisepsis and asepsis
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
In 1874, Pasteur suggested that surgical instruments could be
sterilised in boiling water and then passed through a flame. This was
an alternative to chemical antiseptics such as the carbolic used by
Lister. Pasteur and Koch built the earliest steam sterilisers.
Pressure steam sterilisation was introduced by the Swiss surgeon, T
Kocher (1841-1917), and his colleague, E Tavel (1858-1912), a
bacteriologist.
During the 1880s, the German surgeons, Ernst von Bergmann
(1836-1907), and Johannes von Mikulicz-Radecki (1850-1905),
established bacteriological laboratories within their hospital clinics.
By testing for the presence of bacteria on individuals and even entire
hospitals, bacteriologists could audit the efficacy of aseptic or
antiseptic measures. In this way, von Mikulicz-Radecki proved that
speaking during operations encouraged droplet infection (a term
coined by him).
1890, the American surgeon,
William S Halsted (1852-1922),
introduced rubber gloves


This could be minimised by wearing face masks (except
when the surgeon was bearded).
However, in 1890, the American surgeon, William S
Halsted (1852-1922), introduced rubber gloves. These
were initially worn by his operating room nurse, Caroline
Hampton, (who was also his fiancée) because she
developed eczema of the hands from the carbolic acid
and bichloride of mercury solutions used as antiseptics.
Halstead asked the Goodrich Rubber Company to make
special surgical gloves. The first batch reached the
elbow. By the final years of the century, aseptic and
antiseptic techniques were adopted in one combination
or another by all surgeons.
Surgeons adopt aseptic techniques
c. 1875

In this photograph, the surgeon, Sir
Victor Horsley (1857-1916), is
standing on the left wearing a face
mask and rubber gloves although he
is the only person in the operating
theatre to do so. The others are
wearing outdoor clothes under
gowns or white coats while the
nurses wear standard ward
uniforms. In addition, Horsley's
abdomen was encased in antiseptic
dressings in preparation for the
removal of his appendix the
following day!
Breakthrough dates in XX century
1954-Joseph Murray performs
first kidney transplant
 1962 Charnley pioneers joint replacement
 1964 Coronary bypass surgery
 1967 First heart transplant
 1990 Development of day-case surgery

Anaesthesiology - from curare to pain
clinics

In 1926, the American anaesthetist, John Lundy (1894-1973), first used the
term 'balanced anaesthesia' to describe a combination of several agents to
produce optimum anaesthesia and analgesia. During the early 1930s, he
and other researchers in Germany investigated a number of narcotic
compounds which led to the development of intravenous and intramuscular
anaesthesia. These could be used for short procedures as well as for premedication. They were improved during the 1960s with the introduction of
the barbiturate-free benzodiazepines such as diazepam. Intra-operative
muscle relaxation made abdominal surgery easier. Curare, the South
American arrow poison, was given in 1942 to a patient undergoing
appendectomy. The anaesthetist, Harold Griffith (1894-1985) of Montreal,
administered the anaesthetic gas through an endotracheal tube as the
patient's abdominal and thoracic muscles were completely paralysed.

Curare-like substances were further developed by 1948.
Anaesthesiology increasingly aimed to individualise
anaesthetics for each patient, taking into account the
type of procedure, age, body weight, any underlying
condition (eg. diabetes, high blood pressure, kidney
failure), as well as the physiological effects of perioperative stress. The risk of thrombosis and embolism in
high risk patients was markedly diminished from the
early 1970s by prophylactic anticoagulants such as
heparin, purified in 1929 by Charles Best (1899-1978) of
Toronto who had assisted Frederick Banting (1891-1941)
in the discovery of insulin. Heparin was first used in
Sweden and the USA. The development of artificial
hypothermia, controlled lowering of blood pressure to
diminish blood loss, and extracorporeal circulation via
the heart-lung machine, enabled increasingly complex
surgical procedures to be performed.

Spinal, epidural, and nerve block analgesia
became increasingly effective so as to replace
gas-induced anaesthesia in operations such as
caesarian section and prostatectomy. Advances
in analgesia techniques helped develop daycase surgery whereby minor procedures were
performed on an out-patient basis.
Anaesthestists, like surgeons, began to
specialise in particular areas such as paediatrics,
transplantation, heart surgery, intensive care,
and pain management. Pain clinics were
established in hospitals during the 1980s for
assessing and treating patients with chronic or
intractable pain.