History of Surgery:

An Overview
Prof. Mohey Elbanna
Prof. of Surgery, Ain Shams University
 Definition and Meaning

Surgery comes from the Latin cheirourgia

Cheir = hand + ergon = work

Meaning: Surgery is using the hand to treat

History of Surgery in Ancient
Egypt
Trephination
Drainage of Dental Abscess
Circumcision
Castration
Hernia Surgery
Amputation
Surgical Positions: Lithotomy
Medications: Opiates
Evidence of Ancient Egypt
Surgery
 Civilization and Surgery
Surgery is use of the hand for treatment

And it goes hand in hand with civilization

There were signs of Surgery in Prehistoric

Times

However, the development of Surgery

reflected the degree of human development
 The Oldest Surgery
Evidence of The Oldest Surgery was found
in Caves in France dating back to Prehistoric
times
And the oldest surgery was trepanation
Many prehistoric patients had signs of skull

healing, suggesting survival after surgery

Out of 120 prehistoric skulls found at one

burial site in France dating to 6500 BCE 40

had trepanation holes
 Surgery in Old Egypt
Everything started in Egypt
And, it started with the unification of Egypt
Narmer (Mina), unified Egypt, becoming the
first Pharaoh, paving the way for civilization
in Egypt

In the first monarchic age (2700 BC) the first

text on surgery was written by Imhotep, the
first chancellor of Pharaoh Zoser
 The Evidence
Until the 19th century, the main sources of information
about ancient Egyptian medicine were writings from:
The Greek historianHerodotusvisited Egypt around

440 BC and wrote extensively of his observations of

their medicinal practice
Pliny the Elder, a Roman author, scientist and naval

and army commander wrote favorably of them in

historical review
Hippocrates; the father of medicine; Herophilus and

later Galen studied at the temple of Amenhotep and

acknowledged in their writings the contribution of
ancient Egyptian medicine to Greek medicine
 Monuments and Papyri

On one of the doorjambs of the entrance to

the Temple of Memphis there is the oldest
recorded engraving of a medical procedure:
Circumcision

Engravings in Kom Ombo demonstrate

surgical tools, including scalpel, scissors,
forceps, curette, and dilators
 Kom Ombo Temple, Qar

The scene on the inner face of the rear wall

of the temple is of particular interest, and
"probably represents a set of surgical
instruments

The oldest metal (Bronzeor copper) surgical

tools in the world were discovered in the
tomb ofQar
 The Tomb of Qar
The Tomb of Qar (G 7101) in the Eastern Cemetery At
Giza
Meryrenefer was an official during Egypt's5th Dynasty,
probably during the reign ofPepi II
He was the "Overseer of the Pyramid Towns of Khufu
and Menkaure", the "Inspector of wab-priests of the
Pyramid of Khafre" and "Tenant of the Pyramid of Pepi
I
However, he is better known to us as Qar (or Kar). He
was married to Gefi, who was a "Prophetess of Hathor"
Qar's mastaba tomb (G 7101) is located in the Eastern
Cemetery atGiza
 Rosetta Stone
In 1822, the translation of theRosetta Stone
finally allowed the translation of ancient
Egyptianhieroglyphic inscriptions and
papyri, including many related to medicine
(Egyptian Medical Papyri)
The resultant interest inEgyptology in the

19th century led to the discovery of several

sets of extensive ancient medical
documents
 Papyri

Kahun Gynecological Papyrus (1800 BC)

Edwin Smith Papyrus (1600 BC)
Hearst Papyrus (1600 BC)
Ebers Papyrus (1550 BC)
Brugsch Papyrus (1300 BC)
London Papyrus (1300 BC)
 Ebers Papyrus
The Ebers Papyrus, 20 meters long, 110
pages Scroll, conserved at the Univ. of Leipzig
One of the oldest treaties on medicine (About

1550 BC)
Includes recipes, a pharmacopoeia and

descriptions of numerous diseases and

treatments
It describes surgical treatment of crocodile

bites, burns, and drainage of pus-filled

inflammation
Ebers Papyrus
 The Oldest Texts:
Where and When ?

The Ebers Papyrus probably describes and

collects older texts,
probably dating back to

3400 BC
Edwin Smith Papyrus
 Edwin Smith Papyrus
The Oldest Textbook of Surgery
Dates back to dynasties 16-17, 1600 BC
4.68 m in length, divided into 17 pages.
The front side 377 lines, while the backside is 92 lines
The vast majority of the papyrus is concerned with trauma
and surgery, with short sections on gynecology and cosmetics
on the backside
On the front there are 48 cases of injury, each detailing the
type of the injury, examination of the patient, diagnosis,
prognosis, and treatment
The verso side consists of 8 magic spells and 5 prescriptions
The spells are exceptions to the practical nature of this
medical text and may have been used as a last resort in
terminal cases
 The Author of the Edwin Smith
Papyrus
The text is attributed by some to Imhotep, an architect,
high priest, and physician of the Old Kingdom, 3000-2500
BC
Imhotep was the first Polymath
He is considered the first architect, engineer and physician
in early history, though two other good physicians, Hesy-
Ra and Merit-Ptah lived around the same time.

The full list of his titles is:

Chancellor of the King of Egypt, Doctor, Administrator of
the Great Palace, Hereditary nobleman, High Priest of
Heliopolis, Builder, Chief Carpenter, Chief Sculptor, and
Maker of Vases in Chief
 The oldest metal (Bronze[18]or copper[19][20])
surgical tools[21]in the world were
discovered in the tomb ofQar
Imhotep: God of Medicine
 Imhotep and Zoser

An example of the relation between the first

Surgeon and the Governor

The Role of the Governor in advancing

Medicine and Surgery
 Old Egypt Doctors
The names of 82 physicians and surgeons
could be collected from Monuments

Hesy-Ra may be the first Doctor in history

whose name was recorded (2650 BC)

Peseshet was the first Lady Doctor in

history, 4000 years before Elizabeth
Garrett Anderson, (1836 1917)
Specialization in Old Egypt
Herodotus described the Egyptians as "the
healthiest of all men, next to the Libyans",
due to the dry climate and the notable
public health system that they possessed.

He stated that The practice of medicine is

so specialized among them that each
physician is a healer of one disease and no
more."
 Medical Schools
Since the 1st dynasty (3000 BC), medical institutes
called peri-ankh or houses of life existed
The most reputable ones were that of Imhotep at

Memphis which gained an international reputation

particularly for its library, at Sais where midwives
were trained and afterwards instructing physicians
in the art of obstetrics, and Abydos
At least four other houses of life were attached to

temples at Tel-El Amarna, Bubastis, Edfu, and

Kom-Ombo
In these teaching centers medical books and papyri

were written and preserved in libraries

 Ancient India
Sushruta 600 BC
Sushruta Samhita:
120 Surgical Instruments
300 Surgical procedures
I and D
Cataract surgery
Bowel anastomosis
Rhinoplasty
Tonsillectomy
Prostatectomy
Leeches
Ethical Code
Technical Skills Lab
 Sushruta Samhita
TheSushruta Samhita( ) is an

importantClassical Sanskrittext onsurgery.
It is dated to theGupta period(the 3rd or
4th century AD), although it is traditionally
ascribed to a surgeon and physician of the
6th century BC.
It is one of three foundational texts of
Ayurveda(Indian traditional medicine),
alongside theCharaka Samhitaand the
medical portions of theBower Manuscript.[4]
[5][6]
 Sushruta Samhita
TheSushruta Samhita is 184 chapters and contains descriptions
of 1,120 illnesses, 700 medicinal plants, 64 preparations from
mineral sources and 57 preparations based on animal sources

wastranslated to ArabicasKitab-i-Susrudin the 8th century

discusses surgical techniques of making incisions, probing,

extraction of foreign bodies, alkali and thermal cauterization,
tooth extraction, excisions,
trocars for draining abscess draining hydrocele and ascitic fluid
the removal of the prostate gland, urethral stricture dilatation,
vesiculolithotomy, hernia surgery, caesarian section
management of haemorrhoids, fistulae
 Sushruta Samhita

Describes laparotomy and management of

intestinal obstruction, perforated intestines,
and accidental perforation of the abdomen
with protrusion of omentum

Classification of eye diseases including

cataract surgery
 Sushruta Samhita
Orthopedics:
Principles of fracture management:

traction, manipulation, appositions and

stabilization including some measures of
rehabilitation and fitting of prosthetics
It enumerates six types of dislocations,

twelve varieties of fractures

Classification of the bones and their

reaction to the injuries

 Ancient Greece
Hippocrates 460-370 BC
Disliked Opening the body
Knowledge from the Battle field
3rd century BC :
Herophilus allowed to dissect
Arcagathus famous for use of knife and
cautery
130 AD 200 AD:
Claudius Galen Galdiators Surgeon
advanced practice
 Hippocrates
460 BC-370 BC
Hippocrates Oath
 Ancient China
200 BC:
Hua Tuo Was a

physician and
Surgeon
Was Executed and

Scripts burnt
 Middle Ages

Fifth 14th Century AD

Practice of Surgery Declines

Left to Barbers
 Modern Surgery
There is no more
Science in Surgery
than in Butchering

Lord Thurlow
1730-1806
Lawyer and

Politician
Islamic Era

Islamic
and
Arabic
Surgery
 The Big Four

1. Al-Razi (Rhazes) 865-925

2. Al-Zahrawi (Abuclasis) 936-1013

3. Avicenna (Ibn Sina) 980-1037

4. Ibn-Al Nafis 1236-1288

Abu Bakr Mohammad Bin Yahia
Bin Zakaria Al-Razi
Rhazes , as written in Latin, was a Persian
polymath
Physician, Philosopher, Chemist, educated

in music and mathematics

Probably the greatest and most original of

all the physicians, and one of the most

prolific as an author Edward Browne
 Physician Life
Early proponent of experimental medicine
Described as the father of pediatrics
A pioneer of Ophthalmology
Studied and described several urinary diseases
The first physician to distinguish smallpox from

measles by clinical examination

Became chief physician of Rey and Baghdad

hospitals
As a Professor of medicine, he attracted students

of all disciplines and was devoted to the service

of his patients, whether rich or poor

This monumental medical encyclopedia in
nine volumes known in Europe also as
The Large Comprehensive or Continens
Liber

translated into Latin in 1279 by Faraj ben

Salim, a physician of Sicilian-Jewish origin
employed by Charles, king of Sicily, and had
considerable influence in Europe

To those not attended by a doctor was a
home medical manual for the general public
He dedicated it to the poor, the traveler,

and the ordinary citizen who could consult it

for treatment of common ailments when a
doctor was not available
Of special interest to the history of

pharmacy
 Al-Razis Philosophy
He believed in a doctrine of equal aptitude in all
humans,
granting no special role for unique and divinely

favored prophets
Additionally, it recognizes the possibility of future

progress in the advancement of knowledge

Philosophically, al-Razi was by his own

admission a disciple of Socrates and Plato

Accordingly, he was noted for upholding the

eternity of five primary principles, God, soul,

time, matter and space
 Who owns the truth ?

Al-Razi claimed that he could and had

moved beyond his ancient philosophical
predecessors and that neither the religious
prophets nor the Greek masters (nor even
al-Razi himself) possessed the final word or
ultimate truth
 Al-Razi and
Razi became Diector of the hospital of Rey during the reign
of Mansur ibn Ishaq ibn Ahmad ibn Asad the Governor of Rey
Razi dedicated his al-Tibb al-'Mansuri to Mansur ibn Ishaq
ibn Ahmad
Razi moved from Rey to Baghdad during Caliph Muktafi's
reign where he held position as Chief Director of a hospital
After al-Muktafi's death in 295 AH (907 BC) Razi returned to
Rey where he deidcated himself to teaching medicine until
he died blind
His eye diseases started with cataracts and ended in total
blindness
Some attribute his blindness to a blow to the head
 Avicenna
The Chief Professor

A Persian polymath who wrote almost 450 treatises

on a wide range of subjects, of which around 240
have survived
150 of his surviving treatises concentrate on

philosophy and 40 of them concentrate on medicine

His corpus includes as well writing on astronomy,

alchemy, geology, psychology, Islamic theology,

logic, mathematics, physics, as well as poetry
He is regarded as the most famous and influential

polymath of the Islamic Golden Age


His most famous works are The Book of
Healing, a vast philosophical and scientific
encyclopaedia, and The Canon of Medicine,
which was a standard medical text at many
medieval universities

The Canon of Medicine was a textbook in

the univ. of Montpellier and Leuven till 1650
 Philosophy and Religion
Ibn Sn was a devout Muslim and sought to reconcile
rational philosophy with Islamic theology
He aimed to prove the existence of God and His
creation of the world scientifically and through reason
and logic
He considered the prophets "inspired philosophers",
arguing that prophets are higher than philosophers
He wrote on various scientific and philosophical
interpretations of the Qur'an, such as how Quranic
cosmology corresponds to his philosophical system
Ibn Sn memorized the Qur'an by the age of ten, and
as an adult, he wrote five treatises on Verses from the
Qur'an
Ibn Sina and the Governor
Ib Sina was close to the Emir of Hamadan;
Shams Addoulla, who raised him to a
minister
After his death, the new Emir imprisoned

him
When Isfhan conquered Hamadan, he

reagianed his status

The last ten or twelve years of Ibn Sn's life

were spent in the service of Abu Ja'far 'Ala

Addaula, whom he accompanied as
physician and general literary and scientific
adviser, even in his numerous campaigns
 Hemostasis
Abulcasis 10th century - Sutures
Who is Abulcasis ?
Abulcasis is the father of Modern
Surgery

Abu al-Qasim Khalaf ibn al-Abbas Al-

Zahrawi (936 - 1013), also known in the
West as Abulcasis, was an Andalusian-Arab
physician, surgeon, chemist, cosmetologist,
and scientist
 Al-Zahrawi
Abu al-Qasim Khalaf ibn al-Abbas Al-Zahrawi (936
1013) Abulcasis, was born in Al-Zahra, near Cordoba,
Al-Andalus (now Spain) and lived all his life in Cordoba
He is considered the greatest surgeon of the Islamic
World, and is by many as the father of modern surgery
His greatest contribution to medicine is the Kitab al-
Tasrif, a thirty-volume encyclopedia of medical practices
His pioneering contributions to surgery had an
enormous impact in the East and West well into the
modern period
He was the first physician to describe ectopic pregnancy
in 963, and the first physician to identify the hereditary
nature of haemophilia
 Al-Zahrawi
Ab al-Qsim was a court physician to the Andalusian
caliph Al-Hakam II
He devoted his entire life and genius to the advancement
of medicine as a whole and surgery in particular

Ab al-Qsim specialized in curing disease by

cauterization
He was interested in inspecting body entrances
He invented several instruments for inspection of the
interior of the urethra, applying and removing foreign
bodies from the throat, inspection of the ear, etc
Not only natural orifices, but he was the first to illustrate
the various cannulae
Al-Zahrawi Surgical Instruments
 The Pure Chief Surgeon
Scientist
Al-Zharawi marked the beginning of scientific
surgery

His texts dominated European Surgical practice for

five centuries
In the 14th century, the French surgeon Guy de

Chauliac quoted al-Tasrif over 200 times

Pietro Argallata (d. 1453) described Ab al-Qsim as

"without doubt the chief of all surgeons

Even in the 16th century al-Tasrif was the reference

to texts of the famous French surgeon Jacques

Delechamps (15131588)
 Ibn Al-Nafis
Born in 1213 in Damascus
He attended the Medical College Hospital (Bimaristan
Al-Noori) in Damascus
learned jurisprudence , theology, literature
became an expert on the Shafi'I school of jurisprudence
and an expert physician
In 1236, Al-Nafis moved to Egypt
He worked at the Al-Nassri Hospital, and then Al-
Mansouri Hospital, where he became chief of physicians
and of course the Sultans personal physician
Died in 1288, donating his house, library and clinic to
the Mansuriya Hospital
 Writings
The largest of his books is Al-Shamil fi al-Tibb ,
planned to be an encyclopedia not completed due to his death

The manuscript is available in Damascus

His book on ophthalmology is largely an original contribution

One of his most famous books is The Summary of Law

Another famous book was on the effects of diet on health,

entitled Kitab al-Mukhtar fi al-Aghdhiya

His book translated in the West under the title Theologus

Autodidactus , has been argued to be

both the first theological novel and the first science fiction novel
wrote a number of commentaries on Hippocrates' books, and

several volumes on Avicenna's The Canon of Medicine

Additionally, and a commentary on Hunayn Ibn Ishaq's book
 Pulmonary Circulation
In 1924, an Egyptian physician, Mohey Eldin
Altawi, discovered a script titled,
"Commentary on the Anatomy of Canon of
Avicenna" in the Prussian State Library in
Berlin while studying the history of Arab
Medicine at the medical faculty of Albert
Ludwigs University in Germany
This script written by Ibn Al-Nafis is earliest

anatomical, physiological and pathological

detailed description the pulmonary circulation
Foundation of Modern Surgery
Four Milestones that lead to the
development of Modern Surgery:

1- Anatomy
2- Anesthesia
3- Hemostasis
4- Antisepsis
Hemostasis
16 th century :
sutures over cautery : Ambroise Par

20th century :
ABO system 1901 Karl Lansteiner
Diathermy (Cushing Bovie)
21 st century
Ultrasonic dissector: Harmonic Scalpel
 Infection Control
1847: Hand Washing: Ignaz Semmelweis
(Austerian)
1860: Germ Theory Louis Pasteur
1867: Cleanliness and Gloves Joseph Lister
1928: Penicillin Alexander Fleming
 Anesthesia
200 BC: Hua Tuo
1842: Ether Crawford Long
1844 : Nitrous Oxide Horace Wells
1846: Ether - by William Morton
1847: Ether by John Snow
1596-1942: Curare - by Walter Raleigh ,

Harold Griffith
 Modern Surgery
1316: Guy de Chauliac - Chirurgia Magna
1616: William Harvey An anatomical

Exercise on the motion of the heart and

blood in animals
1651: Richard Wiseman several chirurgial

treatises
1661: Marcello Malpighi describes

capillaries
18th C: John Hunter anatomist and surgeon
1895: Wilhelm Conrad Rntgen
 Advances in Europe
The early Christian Church had an adverse
effect upon medical progress
Disease was regarded as a punishment for sin,
and such chastening demanded only prayer
and repentance
Moreover, the human body was held sacred
and dissection was forbidden
But the infinite care and nursing bestowed
upon the sick under Christian auspices must
outweigh any intolerance shown toward
medicine in the early days
 Church and Medicine
The greatest service rendered to medicine by the
church was the preservation and transcription of
the classical Greek medical manuscripts
These were translated into Latin in many medieval
monasteries, and the Neostorin Christians (an
Eastern church) established a school of translators
to render the Greek texts into Arabic
This famous school, and also a great hospital, were
located at Jundi Shhpr in southwest Persia, where
the chief physician was Jurjs ibn Bukhtsh, the
first of a dynasty of translators and physicians that
lasted for six generations
 Medicine and Miracle
A number of saints were associated with
miraculous cure
Among the earliest of these were twin brothers,
Cosmas and Damian, who suffered martyrdom
who became the patron saints of medicine
Other saints were powerful healers of certain
diseases, such as:
St. Vitus for chorea (or St. Vitus' dance)
St. Anthony for erysipelas (or St. Anthony's fire)
St. Roch for plague during the plague years of
the 14th century
Anothomia and Chirurgia Magna
Monedinnio de Luccio taught at Bologna
Prohibitions against human dissection were slowly

lifting, and Mondino performed his own dissections

rather than following the customary procedure
Although he perpetuated the errors of Galen, his

Anothomia, published in 1316, was the first

practical manual of anatomy
Guy De Chauliac was a physician to three Popes at

Avignon
His Chigurgia magna ("Great Surgery"), based on

observation and experience, had a profound

influence upon the progress of surgery
 The Renaissance
The Renaissance in the 14th, 15th, and 16th
centuries was much more than just a reviving of
interest in Greek and Roman culture
It was rather a change of outlook, an eagerness for

discovery, a desire to escape from the limitations

of tradition and to explore new fields of thought
and action
In medicine, Anatomy and Physiology, the

knowledge of the human body and its workings,

became the first aspects of medical learning to
receive attention from those who realized the need
for reform
 Correcting Galen
It was in 1543 that Andreas Vesalius, a young Belgian
professor of anatomy at the University of Padua, published
De humani corporis fabrica ("On the Structure of the Human
Body)
Based on his own dissections, this seminal work corrected
many of Galen's errors
Vesalius showed that Galen could no longer be regarded as
the final authority
His work was continued by Gabriel Fallopius and
Hieronymus
It was his work on the valves in the veins, De venarum
ostiolis (1603), that suggested to his pupil William Harvey
his revolutionary theory of the circulation of the blood, one
of the great medical discoveries.
 Ambrose Par
Father of modern surgery
Surgery profited from the new outlook in anatomy,
and the great reformer Ambrose Par dominated the
field in the 16th century
Par was surgeon to four kings of France, and he has
deservedly been called the father of modern surgery
In an autobiography, written after he had retired
from 30 years of service as an army surgeon, Par
described how he had abolished the painful practice
of cautery to stop bleeding and used ligatures and
dressings instead
His favourite expression was "I dressed him; God
healed him
 John Hunter
John Hunter FRS (1728 1793) was a
Scottish surgeon regarded as one of the
most distinguished scientists and surgeons
of his day
He was an early advocate of careful

observation and scientific method in

medicine
The Hunterian Society of London was

named in his honour

John Hunter: Father of Scientific
Surgery
John Hunter, the father of scientific
surgery, embodies the transformation of
Surgery from Butchery to Science
He was committed to making surgery a

science based on principles best discovered

by natural history and experiment
Hunter aspired to raise the status of the

surgeon to that of the physician

 John Hunter
He was an excellent anatomist; his knowledge and skill as a
surgeon was based on sound anatomical background Among
his numerous contributions to medical science are:
study of human teeth
extensive study of inflammation, gunshot wounds, and
venereal diseases, including his likely self-experimentation
Understanding of the nature of digestion, and verifying that
fats are absorbed into the lacteals
The first complete study of the development of a child
Proof that the maternal and foetal blood supplies are separate
Discovering one of the major anatomical mysteries of the
time the role of the lymphatic system
 History of Royal Colleges of
Surgeons
The Royal College of London is descended
from the Fellowship of Surgeons, which was
already over a century old when it was
awarded a 'cognizance' (similar to a coat of
arms) in 1492
Under Henry VIII, the Fellowship united with

the Company of Barbers to form the Company

of Barber-Surgeons in 1540
They maintained a somewhat uneasy

partnership in the 16th and 17th centuries

when surgical intervention was limited
 Separation of Surgeons and
Barbers
in 1745, the surgeons broke away from the barbers to form a
separate Company of Surgeons, with its own hall close to the Old
Bailey
In 1797, the surgeons moved away from the City to property
purchased in Lincoln's Inn Fields
This coincided with the government placing into the care of the
College the writings and specimen collection of John Hunter (1728-
1793), a surgeon regarded as one of the most distinguished
scientists of his day
In 1800, the Company of Surgeons was granted a Royal Charter to
become The Royal College of Surgeons in London, later of England.
A new College building was built to provide lecture theatres,
meeting rooms and accommodation for the Hunterian Collection.
Although the buildings have been replaced, the College occupies
the same site today
 Limits of Surgeons
The Twentieth Century witnessed breaching
the Abdomen, the Chest and the Heart
Sir John Erichsen, British Prof. of Surgery

(1818-1896) wrote that

The Abdomen, the chest and the heart will

forever be closed to operations by a wise

and humane surgeon
Billroth : an operation on the heart would be

a prostitution of surgery
19th Century Surgery Revolution
Carl Langenbuch, Berlin, in 1882, did the
first Cholecystectomy
In 1884, J. Knowsley Thornton conquered

the CBD, and did the fist choledchotomy

At the same time Robert Abbe in the US
Discovering that Cholemic bleeding was due

to Vit K defeciency and is preventable by

giving it, earned Henrik Dam (Denmark)
Noble Prize in 1943
 Gastric Surgery
Pan (1879) performed the first gastric resection due to pylorus cancer
with gastroduodenal anastomosis. Pt died after 6 hours

In 1880, Rydygier used the same technique idealized by Pan. Pt died 4

hours later

Billroth (1881), performing the same Pan technique, accomplished the

first survival case of gastrectomy, called Pean-Billroth or Billroth I.

In 1885, Billroth performed a successful (Billroth II)

With the advance of suture techniques, Schlater (1897), performed the

first successful total gastrectomy with survival

Roux (1893), intending to obtain better survival proposed resection in Y,

that is, an end-to-side esophagojejunal anastomosis
 Kocher
Emil Theodor Kocher (25 August 1841 27 July 1917) was a
Swiss physician, medical researcher, and Nobel laureate for his
work in the physiology, pathology and surgery of the thyroid.
Kocher was born in Bern, Switzerland. He studied in Zrich,

Berlin, London and Vienna, and obtained his doctorate in Bern

in 1865.
In 1872, he succeeded Georg Albert Lcke as Ordinary

Professor of Surgery and Director of the University Surgical

Clinic at the Inselspital in Bern.
He published works on a number of subjects other than the

thyroid gland including hemostasis, antiseptic treatments,

surgical infectious diseases, on gunshot wounds, acute
osteomyelitis, the theory of strangulated hernia, and
abdominal surgery.
 Emil Theodor Kocher
His new ideas on the thyroid gland were initially controversial but
his successful treatment of goiter won him recognition
The prize money, from the Nobel prize he received, helped him to
establish the Kocher Institute in Bern
A number of instruments are named after him
Certain surgical techniques (for example, the Kocher manoeuvre,
and kocher incision) are named after him
Kocher-Debre-Semelaigne syndrome
Works
Die antiseptische Wundbehandlung (Antiseptic wound treatment;
1881)
Vorlesungen ber chirurgische Infektionskrankheiten (Lectures on
surgical infections; 1895)
Chiruigische Operationslehre (1894; Eng. trans. as Textbook of
Operative Surgery, 2 vols., 1911)
 History of Antisepsis in
Surgery
Hand Washing

Surgical Gloves

Antiseptic Solutions

Germ Theory

Penicillin
 Hand Washing
Ignaz Semmelweis (1818-1865)
Ignaz Semmelweis was a Hungarian

physician whose work demonstrated that

hand-washing could drastically reduce the
number of women dying after childbirth
This work took place in the 1840s, while he

was Director of the maternity clinic at the

Vienna General Hospital in Austria.
 Washing Hands
We all now know how important it is to wash our hands. In
hospitals, antibiotic-resistant strains ofBacteria are wiped out by
the simple act of hand-washing. Wards are supplied with
antiseptic hand gel which medical staff and visitors use before
they see patients who are vulnerable to infection. The routine of
scrubbing up by surgeons before an operation is, of course, a
well-established practice.
But this was not always the case. Until the late 1800s surgeons
did not scrub up before surgery or even wash their hands
between patients, causing infections to be transferred from one
patient to another. Doctors and medical students routinely
moved fromdissecting corpses to examining new mothers
without first washing their hands, causing death by puerperal or
childbed fever as a consequence. AsDissection became more
important to medical practice in the 1800s, this only increased.
 His Book
In 1861, Semmelweis published Die Aetiologie,
der Begrif und die Prophylaxis des Kindbettfiebers
(Etiology, Concept and Prophylaxis of Childbed
Fever) which stands as one of the epoch-making
books of medical history. (History of Medicine by
Roberto Margotta)
Ignaz Semmelweis died in 1865. He was buried in

Vienna. Very few people attended his funeral. In

1891, his body was transferred to Budapest. A
statue was only erected to him and his
achievements in 1894, nearly thirty years after his
death
 Death at 47
Through vigorous statistical analysis,
Semmelweis figured out where the problem lay
and introduced rigorous hand-washing rules in
the maternity ward. Deaths were drastically
reduced and Semmelweis became known as the
saviour of the mothers.
Sadly, Semmelweiss was committed to an insane

asylum when he started to exhibit what was

possibly the early onset of Alzheimers disease.
While there he was beaten by the staff and died
from his injuries just two weeks after admsission
 Surgical Gloves
Caroline Hampton became Dr. Halsted's
scrub nurse, but she developed a severe
contact dermatitis in 1889, as her sensitive
hands could not tolerate the disinfectants
mercuric chloride and carbolic acid
(phenol).
 Halsteds writings
As Dr. Halsted explained (as quoted by Sherwin Nuland inDoctors: The
Biography of Medicine):
In the winter of 1889 and 1890I cannot recall the monththe nurse in
charge of my operating-room complained that the solutions of mercuric
chloride produced a dermatitis of her arms and hands. As she was an
unusually efficient woman, I gave the matter my consideration and one
day in New York requested the Goodyear Rubber Company to make as
an experiment two pair of thin rubber gloves with gauntlets. On trial
these proved to be so satisfactory that additional gloves were ordered.
In the autumn, on my return to town, an assistant who passed the
instruments and threaded the needles was also provided with rubber
gloves to wear at the operations. At first the operator wore them only
when exploratory incisions into joints were made. After a time the
assistants became so accustomed to working in gloves that they also
wore them as operators and would remark that they seemed to be less
expert with the bare hands than with the gloved hands.
 From Operating Room to
Bedroom
This has been called the most famous
paragraph ever printed in the surgical
literature, not only for its description of the
introduction of rubber operating gloves
But also because it represents the beginning of
a love affair being recorded in the medical
literature
In the words of one of Halsted's assistants,
Venus came to the aid of Aesculapius.
Halsted and Caroline married in June 1890. Dr.
William Welch was the best man
 Louis Pasteur
Louis Pasteur (December 27, 1822 September
28, 1895) was aFrench Chemist and Microbiologist
renowned for his discoveries of the principles
ofvaccination, fermentation and pasteurization
He is remembered for his remarkable

breakthroughs in the causes and preventions

ofdiseases
He reduced mortality frompuerperal fever and

created the first vaccines forrabies and anthrax

His medical discoveries provided direct support for

thegerm theory of disease

 Pasteurization
He is best known to the general public for his invention of
the technique of treatingmilk and wine to stop bacterial
contamination, a process now called pasteurization
He is regarded as one of the three main founders

ofbacteriology together withFerdinand Cohn andRobert

Koch and is popularly known as the "father of microbiology"
Pasteur performed experiments that showed that without

contamination, microorganisms could not develop. Under

the auspices of theFrench Academy of Sciences, he
demonstrated that in sterilized and sealed flasks nothing
ever developed, and in sterilized but open flasks
microorganisms could grow. This experiment won him the
Alhumbert Prize of the academy
 Discoveries in Chemistry
Although Pasteur was not the first to propose thegerm
theory, he developed it and conducted experiments that
clearly indicated its correctness and managed to convince
most of Europe that it was true. (He was preceded
byGirolamo Fracastoro, Agostino Bassi and others, with the
significant experimental demonstration byFrancesco Redi
in the 17th century.)
Pasteur also made significantdiscoveries in chemistry,

most notably understanding of a fundamental principal in

the structure of organic compounds.
He was the director of thePasteur Institute, established in

1887, till his death, and his body lies beneath the institute
in a vault covered in depictions of his accomplishments
inByzantine mosaics
 Joseph Lister
Joseph Lister (5 April 1827 10 February 1912),
known between 1883 and 1897 asSir Joseph Lister,
Bt., was aBritish Surgeon and a pioneer ofantiseptic
surgery
By applyingLouis Pasteurs advances inmicrobiology,
he promoted the idea ofsterile portable ports while
working at theGlasgow Royal Infirmary
Lister successfully introduced carbolic acid (now known
asPhenol) tosterilize surgical instruments and to
cleanwounds, which led to a reduction in post-operative
infections and made surgery safer for patients,
distinguishing himself as the "father of modern surgery"
 Penicillin
Sir Alexander Fleming(6 August 1881 11 March 1955)
was a Scottishbiologist and microbiologist
His best-known discoveries are the enzyme lysozyme in 1923
and the world's firstantibiotic substance benzylpenicillin
(Penicillin G) from the mouldPenicillium notatum in 1928, for
which he shared theNoble Prize in Physiology or Medicine in
1945 withHoward Florey andErnst Boris
He wrote many articles on bacteriology, immunology, and
chemotherapy
Fleming wasknighted for his scientific achievements in 1944
Named inTimemagazine's list of the100 most important
people of the 20th century, and in 2002 he was named among
the BBC's list of the100 greatest Britons
 Cushing
Harvey Williams Cushing, M.D. (April 8,
1869 - October 7, 1939), was an American
neurosurgeon and a pioneer of brain
surgery, and the first to describe
Cushing's syndrome

He is often called the "father of modern

neurosurgery"
 Cushings Contribution
Cushing was born in Cleveland, Ohio, the son of a
physician whose family came to
Hingham, Massachusetts, as Puritans in the 17th
century.
He graduated with A.B. Degree in 1891 from

Yale University
He studied medicine at Harvard Medical School and

earned his medical degree in 1895.

Cushing completed his internship at

Massachusetts General Hospital and then did a

residency in surgery under the guidance of a famous
surgeon, William Stewart Halsted, at the
Johns Hopkins Hospital, in Baltimore.
Cushing and Brain Surgery
After doing exceptional cerebral surgery abroad under
Kocher at Bern and Sherrington at Liverpool, he began
private practice in Baltimore.
At the age of 32, he was made associate professor of
surgery at Johns Hopkins Hospital, and at the hospital
was placed in full charge of cases of surgery of the
central nervous system.
Yet he found time to write numerous monographs on
surgery of the brain and spinal column and to make
important contributions to bacteriology.
He made (with Kocher) a study of intracerebral pressure
and (with Sherrington) contributed much to the
localization of the cerebral centers.
 Cushings Achievements
In Baltimore, he developed the method of
operating with local anaesthesia
His paper on its use in hernia gave him a

European reputation
He made important contributions to the

study of blood pressure in surgery

 Cushings Achievments
In 1911, he was appointed surgeon-in-chief
at the Peter Bent Brigham Hospital in
Boston
He became a professor of surgery at the

Harvard Medical School starting in 1912

In 1913, received honorary F.R.C.S. (London)
He was elected a Fellow of the

American Academy of Arts and Sciences in

1914
In 1915, he showed the possibility of

influencing stature by operating on the

pituitary gland
Retiring
From 1933 to 1937, when he retired, he
worked at Yale University School of Medicine
Cushing died on October 7, 1939 from a

myocardial infarction
He was interred at Lake View Cemetery in

Cleveland
Autopsy revealed he had a colloid cyst of

the third ventricle

 Surgeons Life

What is the Life Cycle of the Surgeon ?

Surgeons Career and Life
Stages:
Learning
Building Experience
Starting Practice
Establishing Practice
Positioning in the Community
Teaching
Mentoring
Retiring
 20th Century
1953 : John Gibbon Heart/Lung Bypass
Machine that allowed Open Heart Surgery

Transplantation

Laparoscopic Surgery
 Transplantation
1905: Cornea (Eduard Zim)
1954: Kidney (Joseph Murray)
1959: Azathioprine
1963: Lung (James Hardy)
1964 : Heart in Chimpanzee (James Hardy)
1966: Pancreas (Richard Lillihei and William Kelly
1967: Heart (Christiaan Bernard South Africa)
1967: Liver (Thomas Starzel)
1968 : Heart and Lung failed (Denton Cooley)
1970: Cyclosporine
1981: Heart and Lung successful (Bruce Reitz)
1978: Lung (Joel Cooper)
1998: Hand (Jean Michel Dubernard)
2005: Face (Bernard Devauchelle)
2006: Penis (Hu Weilie)
 Laparoscopy
1901: Kelling cystoscope
1911: Berheim Proctoscope
1918: Goetz Pneumoperitoneum
1929: Kalk 135 scope
1934: Ruddock forceps and Cautery
1936: Boesch sterilization
1938: Veress Needle
1977: Dekok assisted appendectomy
1983: Semm appendectomy
1985: Mhe Cholecystectomy
1996 : Robotic Surgery
 Twenty-First Century
Surgery
New Energy Devices:
A- Electrical Devices: diathermy, Bipolar
B- Ultrasonic Dissectors

Lasers

Staplers: open and endo-

Powered Devices

Adhesives: Glue, Fibrin,

 Replacements and
Prothesis
Orthopedics: Joint and Bone Replacement
Vascular: Grafts
History of Bariatric
Surgery
 History of Bariatric
Surgery
Weight loss (bariatric) surgery is a unique field, in that
one operation can cure a person of numerous medical
diseases including diabetes, hypertension, high
cholesterol, sleep apnea, chronic headaches, venous
stasis disease, urinary incontinence, liver disease, and
arthritis.
Bariatric surgery is the only proven method that

results in durable weight loss.

Technological development combined with failure of

dieting, marked improvement in the quality of life and

the quick recovery with minimally invasive techniques
caused marked increase in the number of bariatric
procedures in the last 10 years
 American Medical Association
(AMA)
On 18th of June 2013 the AMA, the largest
medical organization in the USA, voted to
consider

Obesity a disease

What does this mean ?

 Restrictive and
Malabsorptive
Weight loss operations can be divided into restrictive
procedures and malabsorptive procedures
Malabsorptive procedures reduce the absorption of calories,
proteins and other nutrients
Restrictive operations decrease food intake and promote a
feeling of fullness (satiety) after meals

Restrictive Procedures: Vertical Banded Gastroplasty, Gastric

Plication, Adjustable Gastric Banding, Sleeve Gastrectomy
Malabsorptive Procedures: Biliopancreatic Diversion
(Scopinaro), Biliopancreatic Diversion with duodenal switch,
Single Anastomosis Duodeno-ileal Bypass (SADI-S)
Combined Procedures: Gastric Bypasses
 Jejunoileal Bypas
Kremen and Linner (1954)
 Jejunoileal Bypass:
Obsolete
The first operations designed solely for the purpose of
weight loss
The jejunoileal bypass (JIB) induced a state of
malabsorption by bypassing most of the intestines
while keeping the stomach intact
The weight loss with the JIB was very good
Two types of complications: complications due to short
bowel, and complications due to a long blind loop
Liver Failure, Renal Stones, Electrolyte disturbance
due to diarrhea, protein-calorie malnutrition, night
blindness (from vitamin A deficiency), osteoporosis
(from vitamin D deficiency)
 Gastric Bypass
Drs. Mason and Ito initially developed this procedure in the 1966
Gastric bypass was based on the weight loss observed among

patients undergoing partial stomach removal for ulcers

Over several decades, Gastric Bypass (GBP) has been modified

The RYGBP was the most commonly performed operation for

weight loss in the United States until 2013

Initially the operation was performed as a loop bypass with a

much larger stomach

Because of bile reflux that occurred with the loop configuration,

the operation is now performed as a Roux-en-Y with a limb of

intestine connected to a very small stomach pouch which
prevents the bile from entering the upper part of the stomach
and esophagus
Mason Gastric Bypass
(1966)
 Loop Gastric Bypass
Transvers Gastric
Division
Gastric Pouch 100 cc
Retention of the

Fundus of the
Stomach
Loop

Gastrojejunostomy
Proximal Anastomosis

close to the DJ
 Roux-en-Y Gastric Bypass
Bile Reflux Gastritis
caused Mason to
develop RYGBP
 Combined Procedures
In the standard RYGBP, the amount of intestine bypassed is not
enough to create malabsorption of protein or other macronutrients
The bypassed portion of intestine is where the majority of calcium
and iron absorption takes place, anemia and osteoporosis are the
most common long-term complications
Therefore, lifelong mineral supplementation is mandatory, with
Vitamin B 1 (thiamine) and Vitamin B 12. Lifelong follow-up with a
bariatric program and daily multi-vitamins are strongly recommended
prevent nutritional complications
RYGBP is considered the gold standard Bariatric Procedure in USA
The obesity-related comorbidities improve or even cured with GBP
including T2 DM (so-called insulin resistant), hypertension, high
cholesterol, arthritis, venous stasis disease, bladder incontinence,
liver disease, headaches, heartburn, sleep apnea and many other
disorders
GBP results in marked improvements in quality of life
 Mini-Gastric Bypass (One
Anastomosis Gastric Bypass)
MGB/OGB was
invented by Rutledge
in the USA in 1997
It consists of creating

a gastric pouch/tube
along the lesser
curve of the stomach
and making a gastro-
jejunostomy at 2 m
from the D-J
 Advantages of MBGB
MGB is easier to perform
It includes a single anastomosis
It avoids internal herniation that may occur

with RYGBP
It avoids the complications of jejuno-

jejunosotmy
 Mortality Risk
The risk of dying in the first month after a
RYGBP from complications of the operation
is about 0.2 to 0.5% in expert centers
Studies have demonstrated that the

mortality rate from hospitals with a low

experience with the procedure is far higher
than that reported by expert centers
Vertical Banded Gastroplasty
(VBG)
Vertical Banded Gastroplasty is
Obsolete
VBG causes Reflux
esophagitis

Weight Regain

Inadequate long
term Weight Loss
 Biliopancreatic Diversion
Scopinaro Prof. of
Surgery, Univ. of
Genoa, Italy
invented
Biliopancreatic
Diversion in 1976-
1979
 Biliopancreatic Diversion
(Scopinaro Operation)
Resection of part of
the stomach
Stomach residue

around 500 cc
Roux-en-Y

gastrojejunostomy
with alimentary
limb of 200 cm and
a common channel
of 50 cm
 Biliopancreatic Diversion
(Scopinaro Operation)

Performed in limited centers because of

malnutrition due to malabsorption

Very successful weight loss

Biliopancreatic Diversion with
Duodenal Switch
(Hess and Hess, 1986)
 Duodenal Switch
Wide Sleeve Gastrectomy

Division of the Duodenum 2-3 cm after the

pylorus

Roux-en-Y duodeno-ileostomy
 DS: limited spread
Technically complex

Malabsorptive procedure

Requires follow-up in a specialized center

Sleeve Gastrectomy
 Sleeve Gastrectomy
Sleeve Gastrectomy was adopted by Gagner
as a standalone operation in 2002
It was part of the Bilio-pancreatic

diversion/Duodenal Switch procedure

Some risky patients were subjected to the

operation in two stages sleeve gastrectomy

first, followed by duodeno-jejunostomy
They demonstrated good weight loss
That is why it started an option for high risk

morbidly obese patients

 Sleeve Gastrectomy
Most performed procedure

Technically easier

Restrictive, no malabsoprtive component

Weight loss around 60 % EWL in 1 year

Weight Regain
Experimental Operations

Gastric Plication

SASI

(Sleeve Gastrectomy with Single

Anastomosis Stomach Ileal Anastomosis)

 Study Questions
1. Discuss Surgical Practice in Ancient Egypt
2. Outline the Evidence of Surgical Practice in Ancient Egypt
3. Mention 3 of the surgeons that affected a great development in
the history of surgery, and outline the main achievements of each
4. Explain why Al-Zahrawi is considered the father of modern surgery
5. Describe medicine and surgery in the Islamic Era
6. Outline the developments that separated surgery from barbery
7. Mention the milestones in the history of Surgery
8. Mention 3 surgeons that transformed surgery into a science and
outline the work of each
9. Describe the contributions of the following surgeons: Ambroise
Par, Avicenna, Hippocrates, John Hunter, Kocher, Cushing
10. Discuss the History of Bariatric Surgery
Thank You
Thank You