HISTORY OF SURGERY

Dr. Arvind Rai Associate Professor Dept. of Surgery GMC Bhopal

A SHORT HISTORY OF MEDICINE:

"Doctor, I have an ear ache.
Doctor s responseresponse2000 B.C. - "Here, eat this root." 1000 B.C. - "That root is heathen, say this prayer. 1850 A.D. - "That prayer is superstition, drink this potion." 1940 A.D. - "That potion is snake oil, swallow this pill." 1985 A.D. - "That pill is ineffective, take this antibiotic." 2000 A.D. - "That antibiotic is artificial. Here, eat this root!"

INTRODUCTION Those who forget the past are condemned to repeat it Santayana If I have seen farther than others, it was because I was standing on the shoulders of giants. Sir Issac Newton
Like all other specialties of science, the history of SURGERY starts with the history of mankind itself. Treating injury, deformity or wound dressing was the most important for survival in the primitive era. Although it was not actually until the later half of the 19th century that it emerged as a recognized and respected discipline.

INTRODUCTION -contd

 

Surgery is the oldest discipline of medicine. Use of medicaments by the first doctors (medici) (medici) separated medicine from surgery. Medicus possessed knowledge of diseases and application of medicaments. A good surgeon had to possess intrinsic manual skills that had much lower esteem.

INTRODUCTION contd


As Sir William Osler rightly put it as: It is astonishing that with how little reading a doctor can practice medicine, but it is not astonishing how badly he may do it Similarly Hippocrates, Father of Medicine contained his view of surgery and surgical horizon in only one sentence: "He who wishes to be a surgeon should go to war Celsus elaborated this in his own language

The 3rd part of Medicine is that which cures by hands. It does not omit medicaments & regulated diets [the other parts of Medicine] but does most by hand.

The effects of this treatment are more obvious than any other kind in as much as in diseases since luck helps much, and the same things are often salutory, often of no use at all, it may be doubted whether recovery has been due to Celsus, Aulus Cornelius, fl. A.D. 14. His extant work, De re medicina, consists of eight books on medicine believed to have been written c.A.D. 30. His was one of the first works to be rediscovered and printed (Florence, 1478) during the Renaissance and was very influential medicines or to a sound body or good luck.

But that part of medicine which cures by hand, it is obvious that all improvements comes chiefly from this even if it is assisted somewhat in other ways

Celsus

INTRODUCTION -contd


But the journey of surgery could progress only as its preliminary requirements were met. These were:
 -Knowledge

of anatomy.  -Methods for hemostasis.  -Anaesthesia for pain free procedures.  -Methods to achieve antisepsis and prevention of infections.

INTRODUCTION -contd

As gradually these prerequisities were met which occurred in the 16th century through the ending decades of the 19th century that the surgery acquired its present day face. The history of Surgery can be arbitrary divided into following phases of development :

BEFORE CHRIST


The first surgical procedures were performed in the Neolithic Age (about 10,000 to 6000 BC). Trepanning, a procedure in which a hole is drilled in the skull to relieve pressure on the brain, may have been performed as early as 8000 BC. In the ancient India Surgery was at the forefront of medicine. Cutting the nose as punishment for wrong doing and other deformities of the body created the need for the reconstructive or plastic surgery. Although the depth of development of surgery in the different civilizations was different in spite of the traced uniformity in the approach to elementary interventions.

BEFORE CHRIST contd



The earliest written literature on SURGICAL discipline is the SUSRUTA SAMHITA, compiled SAMHITA, by Susruta who is regarded as the Father of Indian Surgery . Compiled somewhere between 800BC800BC-400AD, it reveals that the ancient Indians set fractures, performed amputations, excised tumors, repaired Hernias and excelled in cataract operations apart from plastic and reconstructive surgery. Susruta is even depicted to have performed bowel anastomoses using ants heads as staples.

PAVED BATHROOM AND BRICKWALL MOHENJO-DARO (c.3300BC)

SUSHRUTHA, SURGEON OF ANCIENT INDIA, PERFORMING AN ARTIFICIAL EAR LOBE (BY ROBERT ATHOM).

Divided into incision, excision, scraping, puncturing, probing, extraction, provoking secretion, and suturing. Over 100 surgical instruments were described The hand was the most important instrument

Susutra described and used more than 150 surgical instrument many of which resemble modern surgical instruments

The famous Indian physician who wrote the CHARAK SAMHITA

BEFORE CHRIST contd



There have been still earlier evidences of Egyptians being aware of liver abscesses in 4000 B.C., While peptic ulcer perforations were well known to Romans in about 2000 B.C. But still at that time Surgery remained a domain of craftsmen: barbers and bath-attendants. bath-

An Arab Surgeon Performing the ancient cataract Operation called COUCHING first described by

SUSHRUTHA.

FIRST 17 CENTURIES


During this period very little advancement was made in surgical craft. Surgeons were given a lower status as compared to physicians by society. However in the Islamic countries a Surgeon was given a more honored place. By the fifteenth century barber- surgeons routinely barberserved royal courts in Europe. Even though the scope of surgery at that time was limited the period saw many remarkable achievements.

FIRST 17 CENTURIES -contd

Celsus described first operation for hernia in early part of 1st century A.D.

De re medicina, consists of eight books on medicine believed to have been written c.A.D. 30 by Celsus.

FIRST 17 CENTURIES -contd



In 1316 the French surgeon Guy de Chauliac published Chirurgia magna (Great Surgery). This massive text describes how to remove growths, repair hernias and treat fractures using slings and weights. The text helped surgery gain respect as a serious science.

At this time a new order of surgeons arose in France. They were called surgeons of the long robe, distinguished from the barber surgeons who were known as surgeons of the short robe. The barber surgeons had little medical training, while the surgeons of the long robe were studied physicians and considered such practices as bloodletting primitive. Corporations, or guilds, of surgeons of the long robe were formed in several countries.

In 1559 A.D. a comprehensive text book on hernia was published by Stromayr, in which he differentiated between indirect and direct hernias. French royal barber surgeon Felix cured king Louis XIV of an anal fistula. Ren Descartes (1596-1650) Philosopher and (1596mathematician gave the Principle of Verification: do not believe it if you cannot prove it. Surgery and autopsies became acceptable, and human dissection became common (Michelangelo, da Vinci)

FIRST 17 CENTURIES -contd



The first recorded splenectomy was perfomed by Adrian Zarcaelli in 1549 A.D. However the main achievements of this period were in understanding of


AnatomyAnatomy- Andreas Vesalius (1514-1564) (1514[ Vesalius's work was revolutionary, as he was among the first to perform thorough cadaver dissections himself. He showed that Galen's anatomy was merely an attempt to apply animal structure to the human body. ] HemostasisHemostasis- Ambroise Pare (1510-1590) (1510-

Thus the two first prerequisites were met.

French surgeon Ambroise Par, often called the Father of modern surgery. Par successfully employed the method of ligating, "I dressed the wound, but God healed him," or tying off, arteries to control bleeding, thus eliminating the old method of cauterizing, or searing, the bleeding part with a red-hot iron or boiling oil.
He devised many instrument for cauterisation

FIRST 17 CENTURIES -contd An interesting fact is that the British physicians learned the art of Rhinoplasty, one of the most common surgeries being performed then by the Indian Surgeons in the days of the East India Company.

PREPRE-ANAESTHETIC ERA


When people started understanding the pathopathophysiology of diseases, the need for surgery was actually realized. However in the absence of anesthesia, asepsis, and antibiotics the surgery was still primitive. Inept attempts at treatment of incarcerated and strangulated hernias were made. Rudimentary colostomies and ileostomies were made by simply incising skin over an expanding intra abdominal mass, representing the end stage of long standing intestinal obstruction.

PREPRE-ANAESTHETIC ERA -contd



In 1716 A.D. Berta did first surgical resection of liver when he amputated a part of liver protruding through a stab wound. In 1736 A.D. Claudius Amyand performed first appendectomy. In1770A.D. Littre s hernia and in 1777A.D. Richter s hernia were described.

PREPRE-ANAESTHETIC ERA -contd

Inspite of all these achievements the scope of surgery was limited because absence of anesthesia, antisepsis and antibiotics precluded a Laparotomy.

THE DAY THAT CHANGED THE FUTURE

October 16th 1846 William T. G. Morton a Boston dentist administered sulfuric ether to a surgical patient to give first General Anesthesia. Anesthesia.

Although American surgeon Crawford W. Long used anesthesia in 1842 during the removal of tumors but did not publish his results until 1849.

1865 the British surgeon Joseph Lister applied Pasteur's work to surgery, developing antiseptic (germ-killing) techniques including the use of a carbolic acid spray to kill germs in the operating room before surgery. This helped eliminate postoperative infection. Other physicians, including Austrian Ignaz Semmelweiss and American Oliver Wendell Holmes, determined that bacteria are also carried on the hands and clothing and transferred from patient to patient by the physician. These physicians pioneered simple techniques such as washing hands and changing into clean clothing before surgery that prevent wound contamination during surgery.

Alexander Fleming discovered Penicillin

PREPRE-ANTIBIOTIC ERA


With the availability of anesthesia and asepsis developed by Joseph Lister in later half of 19th century, surgeons practically explored every part of abdominal cavity. Among the most important accomplishments was mastering the technique of stomach surgery. The first successful stomach resection was performed by Theodor Billroth in Vienna on January 29th, 1881 [ BILLROTH -I opn.] The patient, a 43-year-old woman, 43-yearTherese Heller survived almost 4 months and died for cancer spread.

Theodore Billroth 1829-1894 1829-

PREPRE-ANTIBIOTIC ERA -contd

Billroth, Billroth, was first to perform resection of stomach with the technique of gastrogastrojejunal anastomosis BILLROTH II opn. on January 15th, 1885. This technique is still being used in a variety of modifications.

PREPRE-ANTIBIOTIC ERA -contd



Mikulicz performed the first pyloroplasty operations independently in 1886 He invented numerous novel operative solutions which have been widely accepted and used up till now.

He operated on a patient with perforated peptic ulcer and commented : "Every doctor, faced with a perforated ulcer of the stomach or intestine, must consider opening of the abdomen, sewing up the hole, and averting a possible or actual inflammation by careful cleansing of the abdominal cavity". cavity". He was thus the first one to suture a perforated ulcer.

Drainage of Appendicular Abscess successfully done on King Edward VII in 1902



This event gained a lot of attention and Surgery gained acceptance indeed it became fashionable

PREPRE-ANTIBIOTIC ERA -contd



The unique discovery of Wilhelm Conrad Roentgen truly changed the world and immediately became a useful tool for medical science. The introduction of radiological examinations ushered the way to diagnostic procedures until then based on clinical verification alone. The discovery of the blood groups A, B, and O by Austrian pathologist Karl Landsteiner

Prior to the 19th century, surgical training was an apprenticeship program, with knowledge passed from teacher to pupil. pupil. Bernhard Rudolf Konrad von Langenbeck (1810-1887) was the (1810first to establish formal surgical training which included techniques of surgery, histology and pathology. Langenbeck trained many of the eminent surgeons of the time. He was followed by William Stewart Halsted, who encouraged Halsted, universities and medical schools to cooperate in the training of surgeons, and formed programs which have developed into the modern residency training programs. He also introduced the use of rubber gloves to surgery, and emphasized care in handling tissues and the use of meticulous hemostasis techniques during surgery.

PREPRE-ANTIBIOTIC ERA -contd

One name that is responsible for bringing revolution in the field of surgery is of William Stewart Halsted (1852-1922).


He developed the concept of sterile modern operation rooms. He showed that research based on anatomic, pathologic and physiologic principles and animal experiments can make it possible to develop sophisticated operative procedures. He insisted on meticulous and safe dissection rather than technical brilliance and speed.
He brought the residency systems of training surgeons.

MODERN AGE


Introduction of the Halstedian principles marked the beginning of modern era in the field of surgery. Working with these principles initial few decades of last century were spent in making surgery a fine art from a crude craft. Trials were in vogue to suggest finer changes in established surgical procedures. Simultaneously this period saw some revolutionary developments viz-

DEVELOPMENT OF ENDOSCOPIC PROCEDURES First attempts to view body cavities were made using a candle, and then gas burning flame allowing for a brighter light. The attempts were unsuccessful due to inadequate illumination. In the early 1900s first lighted telescopes were used. After Edison's invention of the bulb, it was used in the first gastroscope constructed by Jan Mikulicz-Radecki (1850-1905) in collaboration Mikulicz(1850with Josef Leiter

First Endoscopy done by a surgeon Michlich

In 1901 Kelling used cystoscope to do first diagnostic laparoscopy in a canine model. Jacobeus performed first endoscopy in humans in 1911. Kalk introduced the dual trochar system in 1929. Verres invented spring-loaded obturator needle for pneumoperitoneum in 1938.

Semm developed automatic CO2 insufflator in 1960s. First lapaorscopic appendectomy was performed in 1983 by Semm. First laparoscopic cholecystectomy was performed in 1987 by Philip Mouret. First Laparoscopic Cholecystectomy in India was done by Dr. Tempton E Udewadia. Guiness book of world record has the fastest Laparoscopic Cholecystectomy 5 minutes in the name of Dr. Pradip Chowbey, Delhi a pass out of Medical College Jabalpur

TRANSPLANTATION


The modern era of transplantation began in 1950 with the knowledge of techniques for anastomosing blood vessels developed by Mathieu Jabouley and Alexis Carrel at the beginning of the 20th century. The first successful transplant was a Kidney transplant done by Joseph Murray et al.at the Bringham hospital in Boston in 1954. Tom Starzl performed first human liver transplant in 1963.

Alexis carrel 1873-1945 nobel for vascular suture & organ transplant

In 1967, Dr.Christian Bernard performed the first human heart transplant in Cape town, South Africa. In 1968 Roy Calne revolutionised the transplantation with the demosntration of the immunosupressive properties of Cyclosporin which improved the results of transplant acceptance. In 1981,the first ever successful combined Heart Lung transplant was performed by Dr.BruceReitz.

In 1987 Fakert Belzer developed University of Wisconsin Solution- A new Liver and pancreas Solutionpreserving solution Researches are under way to overcome the most important limiting factor in transplantation i.e the shortage of donors by way of stem cell harvesting and genetic engineering. It will be no farther away when the surgeons will be getting the readymade organs to make transplantation a common day to day procedure.

STAPLING DEVICES


Preliminary staplers were first used in early years of last century. The credit for developing modern staplers goes to USSR where Scientific Research Institute for Surgical Apparatus and Instruments first developed them in 1950s. The staplers reached United States in1960s, where they popularized by U.S. Surgical Corporation.

 Hemicorporectomy or translumbar amputation is probably the most mutilating operation ever to be described in surgical literature. Treatment for pelvic malignancy First proposed in 1951 and performed in 1960 Two of the first three patients died within days of oedema; one survived 19 years A series of 10 cases reported from New York in 1982

Modern technologies like digitisation & optics, use of radiofrequency, LASERS allow for so many more types of surgeries that werent possible before The endoscope is one of them key hole surgeries The field is continuously changing

ROBOTICS IN SURGERY


The most recent advance is the use of Robots in Surgery. Conceptualized by the US Army for the distant management of war victims at the battlefield. Presently robots are used for performing prostatectomies,heart surgeries etc. It will be long when almost all the surgeries will be performed by a robot being monitored by the surgeon. The Great Leap of Faith
  

Surgery without physically seeing or touching patients Computer is becoming more involved Nintendo surgeons Virtual Reality

Integration of Computer Science for training purposes



19851985- Puma 560

19941994- AESOP

20012001- Da Vinci

But here the story of the surgery doesn t end, this is just a mere beginning, there is a lot more to come; for no one knows what the time holds in his wrapped hands in the near future.

               

Cyst Diagnosis Dilate Dislocation Duodenum Enema False Labor Genes Groin Hernia Hymen Impotent Labor Pain Lactose Lymph Microbes

short for sister person with slanted nose the late British Princess Diana this is the place couple in blue jeans not a friend pretending to work blue denim to mash to a pulp/smile she is close by greetings to several males distinguished/well-known distinguished/wellhurt at work people without feet walk unsteadily small dressing gowns

                 

Obesity Pacemaker Protein Pulse Pus Red Blood Count Rupture Secretion Subcutaneous Suture Tablet Tumor Ultrasound Urine Varicose Vas Deferens Vein Vitreous Humor

City of Obe winner of Nobel Peace Prize in favor of teens grain small cat Dracula Ecstasy hiding anything not cute enough Gujarati for "what do you want" small table extra pair radical noise opposite of you're out very close extremely different at what time? both witty & funny.

Good surgeons know how to operate, better surgeons when to operate, and the best when not to operate.

Is there anybody less evidence based than surgeons?

Yes
Politicians Managers Editors

THANK YOU

SCHEDULE FOR INTERNAL ASSESSMENT EXAMINATIONS

S. No 1. 2. 3.

Name of examination
Ward leaving test-I First sessional exam. Ward leaving test-II

Marks
40 100 40

Timing of examination
II Prof.(4th semester) Final prof. part-I(6TH semester) Final prof. part-II(8TH or 9th semester) Final prof. part-II(8TH semester) Final prof. part-II(9TH semester)

4. 5.

Second sessional exam. Preuniversity exam.

160 160

Total Marks-500
NOTE-75% attendance is must for eligibility of ward leaving test,sessional, Preuniversity& university examinations