The farther you look into the past, the farther you look into future

History of surgery
By Dr.Muni krishna

Introduction
Nature is intricate network of living and non living things Human body is one such great creation A surgeon can see gods true work so close If disease is god in medicine ,a surgeon is the only one who sees, feels and touches the god.

 a surgeon is an artist, painting on the canvas of life Name of our field comes from the work we do

Nomenclature Chirurgery
Latin, chirurgia, from the Greek, cheir = hand and ergon = work anglicized to Surgery.

 Ancient man used both plant and animal derivatives to ameliorate his suffering with out true knowledge of human body and disease and with religious beliefs. But surgery evolved with an evidence based treatment during its birth, So birth of surgery can be taken as birth of medicine.

 Example - evidence of trephination existed during 7300-6200 b.c. for letting out blood from skull, in the days when there is no evidence of things like drugs.

Ancient egypt

trephination Circumcision Castration Draining dental abscess

amputation Prosthetic limbs Opiates Traumatic surgery

Ancient India
Sushrutha(600 b.c)-father of plastic surgery "Surgery is the first and the highest division of the healing art, pure in itself, perpetual in its applicability, a working product of heaven and sure of fame on earth" - Sushruta

Sushrutha performing surgery

Ancient Indiasushrutha samhita

Samhita is an encyclopedia of surgery and medicine Division of surgical procedures into excision(chedana), incision(bedana), scraping(lekhana), probing(esana),puncturing(vyadhana), blood letting(sravana) Detailed description of etiologies ,signs and symptoms pertaining to surgery in volume of sutra stana Taught about embryology and anatomy, places for venesection and body positions for each vein and protection of vital structures- sarira stana Control of hemorrhage by ligation,cauterisation both chemical and heat Detailed description of ulcer(vrana) in 6 stages of healing. Methods to practice of surgical skills. Principles of plastic surgery Rhinoplasty and labioplasty procedures

Ancient greece
Hippocrates(460-370 bc) Knowledge from battle fields First documented chest surgeon Used cautery & ligation for hemorrhoids First usage of speculum and proctoscopy Referrence to endoscopy Disliked opening human body

Hippocratic oath
I will not use the knife, not even on sufferers from stone, but will withdraw in favor of such men as are engaged in this work. But in 3rd century b.c -Herophillus: allowed to dissect

Ancient Greece Cladius Galen

Roman of Greek ethnicity Conducted dissections on animals Proposed arterial and venous systems Galen clarified the anatomy of the trachea and was the first to demonstrate that the larynx generates the voice. Galen may have understood the importance of artificial ventilation, because in one of his experiments he used bellows to inflate the lungs of a dead animal. He was the first to recognize that there were distinct differences between venous (dark) and arterial (bright) blood Surgeries for brain, cataracts, traumatic wounds His writings on anatomy was followed up to 16th century A.D.

Ancient China
Hua Tuo 200 B.C Emminent scholar ,physician and surgeon Preparation of an anaesthetic called mafesian from boiled cannabis Executed and scrolls burnt.

Medieval period
5th-14th A.D

Dark period in history of surgery Decline in practice of surgery and physicians gained higher status Surgery was only performed by barber surgeons without proper knowledge.

Barber surgeons

Lucas van Leyden -The Surgeon and the Peasant -1524 -Depicts barber-surgeon

Village barber surgeons

Barber surgeons
Performed on only external injuries like war wounds and removed abscess and boils etc.,

Picture depicting scope of the barber surgeons

Medieval period
Surgeon as a non thinker Surgical art little more than, inferior and crude manual craft.

There is no more science in surgery than in butchering

-Lord Thurlow
Parliamentary debate on establishment of Royal college of surgeons in 1811.

 Surgery was dreaded, people avoided surgery and were subdued only on dire situation. Mortality rate was very high Primarily wound treatment Lancing boils Draining abscesses Suturing injuries -- fixing dislocations.

 surgery has not reached to its technical peak due to lack of four qualities 1. Knowledge of human anatomy 2. Method of controlling hemorrhage and achieving hemostasis. 3. Anesthesia to permit performance of pain free procedures. 4. Explanation of nature of infection along with elaboration of methods to achieve antiseptic and aseptic operating room environment. The first two qualities have been achieved at 16th century but the later two were solved in the final decades of 19th century.

Knowledge of human anatomy

Earlier based on anatomy of animals and primates Galen was first to bring anatomical writings but were based on animals. Andreas Vesalius(1516-1564)

professor of anatomy and surgery in Padua, Italy Bought scientific approach to surgery His great anatomic treatise De Humani Corporis Fabrica Libri Septem (1543) provided fuller and more detailed descriptions of human anatomy

Andreas Vesalius
Proved many of Galens theories to be wrong principle of hands-on education would remain Vesalius' most important and long-lasting contribution to the teaching of anatomy.

These are some of the illustrations of human anatomy in de humani carporis fabrica libri septum

William Harvey(1578-1657)
Harvey was a doctor at St. Bartholomews hospital in London he became interested in anatomy and in particular, the work of Vesalius. Described the proper movement of blood in the body and role of heart in circulation Harvey published details of his work in his book entitled An Anatomical Disquisition on the Movement of the Heart and Blood.

"The only weapon with which the unconscious patient can immediately retaliate upon the incompetent surgeon is hemorrhage-Bulletin of the John Hopkins Hospital 1912; 23: 191 Posed problems both to surgeon and patient Many methods were used since ancient times but cauterization being the common with rod hot iron or boiled oil.
What drug fails to cure knife cures ,what knife fails to cure fire cures, what fire fails to cure is incurableSUSHRUTHA

Method of amputation followed in 1821. -applied en-masse ligature of the limb to control bleeding

-Arab

surgeon Abulcasis used ligation of vessels -Major contribution for hemorrhage control was made by Ambroise Pare

Ambroise Pare
A barber surgeon with great scientific insight Pioneered battle field wound treatment Developed new methods of cauterization with egg yolk, turpentine oil and oil of roses Proposed to ligate individual blood vessels than to attempt to control hemorrhage by means of mass ligation of tissue or with hot oleum. Ligated his own temporal artery for migraine Recommended silk thread ligatures to stop bleeding of blood vessels. He proposed to bring surgery under the wing of medicine Developed many designs of artificial limbs. Served as royal surgeon for many years.

 Idea of Pare motivated many surgeons to develop different ways for stopping blood during surgery. Lister evolved a carbolized catgut suture that was better than any previously produced. He was able to cut the ends of the ligature short, thereby closing the wound tightly, and eliminate the necessity of bringing the ends of the suture out through the incision, a surgical practice that had persisted since the days of Pare. Methods to protect patient from effects of blood loss Idea of blood transfusion on 17th century from animals Human to human transfusions from 19th century

 In 1901, Karl Landsteiner discovered blood groups. Proved reaction between antigen and antibody to be responsible for transfusion reactions. Received Noble prize in1930. Discovered + and - blood groups in 1940 World war I forced for major blood requirement. The war drove doctors to find an answer and in 1915, American doctor Richard Lewisohn found that adding sodium citrate to blood stopped it clotting when it came into contact with the air. In 1916, Francis Rous and James Turner found that adding a citrate glucose solution allowed blood to be stored for even longer

 In 20th century we are able to separate different blood products and are able to use in different situations In the field of surgery we made giant leap of performing major operations with very minimal amount of blood loss with the help of minimal access surgery

Anaesthesia
Used to be single most important factor that made surgery unfriendly to common people. Surgeons like Hua Tuo(200 b c) and Sushrutha tried anaesthesia. In the medieval period many agents like alcohol and opium were tried. Pain made patients to attend to a surgeon very late.

Surgery and speed

Surgeons are clock-driven gladiators ,mainly to minimize pain and shock. Robert Liston is well known for his speed in surgery. Done an amputation in 25sec.(also achieved 300% mortality in a single surgery)

Anaesthesia
In 1275, Raymundus Lillius discovered sweet vitriol, later named Ether. Nitrous Oxide discovered by Priestly in 1772 In 1800, Humphry Davy studied properties of NO and elaborated its anaesthetic effect with personal experience Later ether and nitrous oxide popularised as party drugs in 1840s by young people There were ether parties and laughing gas parties organised Samuel Colt organised many such parties for advertising his revolver.
Raymundus lillius

Joseph priestley

Humphry davy

 The clinical experimentation of ether was done by Crawford Long in 1842 on patient named James venebles for removal of neck tumor, but had not recorded it for medical society. Horace Wells did first clinical demo of nitrous oxide (after seeing in Dr. G Colton presentation) in Massachusetts general hospital, which failed. Later William Thomas Green Morton, assistant to Wells developed inhaler for ether and used it for anaesthesia and gave a public demo in Massachusetts general hospital on october 16,1846 in ether dome under surgeon Dr.John Collin Warren most famous american surgeon.

Horace Wells

Crawford Long

Gentle man this is no humbug

Dr.John Collin Warren

William Thomas Morton

Morton inhaler

Collin Warren (one touching the patient) performing surgery in

ether dome.

 American Samuel Guithre, discovered chloroform But Scottish obstetrician, Sir James W Simpson discovered its anaesthetic properties accidentally while working for preparing ideal anaesthetic compound. Later used vividly in easing labour pains

Later John Snow used it on Queen Victoria in the birth of Prince Leopold, 7 April 1853, from which it was used frequently.

 In the nineteenth century, it was common for a surgeon to operate in an old blood-caked frock coat (to show how experienced he was) and to wash his hands only after the operation. The operating theatre would contain a wooden table and sawdust to soak up the blood. In 1795, Alexander Gordon had argued that mothers who contracted childbed fever after childbirth had been infected by their doctors or midwives, and had recommended that the operator should wash before coming into contact with the mother. All these are condemned as they cant prove it. Post-surgical infection so common that pus felt to be sign of healing Laudable Pus

Ignaz Semmelweis
Ignaz Semmelweis Asst physician in Vienna general hospital. 1847 experiments with washing hands & instruments in chlorine solution to prevent childbed fever Publishes in 1860 Impact ignored James Simpson directly copied Semmelweiss hand-washing routine at his midwifery hospital in Edinburgh Florence Nightingale had introduced the idea of spotless hospital environments. But a complete protocol was not yet established

Louis Pasteur
Major break through in surgery, in fact medicine came with proposal of germ theory by Louis Pasteur. French chemist 1857 and 1860 Demonstrated that fermentation is caused by a living organism (not a chemical reaction) Refuted spontaneous generation Published his works which gave new scope for controlling infection.

Joseph Lister (1827-1912)

Lister initially studied in various quaker schools. Later he studied at University College London and became an assistant surgeon in Edinburgh in 1854 to James Syme. Between 1861 and 1865 he recognised that over half of his amputation patients in Glasgow died as a result of post-operative infection and it was against this background that he began his experimental work with antisepsis He read Pasteurs Germ Theory in 1865 and became convinced that sepsis was being caused by microbes in the air. Using knowledge of carbolic acid used in treating sewage, he dressed a compound tibia fracture with a bandage soaked in carbolic.
He also introduced the use of catgut for ligatures which could be dipped in carbolic to sterilize them, and developed a form of catgut which would dissolve so that threads no longer had to be left dangling outside of the body.

Donkey engine

 From his success he formulated theory of Antisepsis-by using carbolic acid asepsis- by spraying operating room with carbolic acid using his donkey engine. He was one of the 12 original members of the Order of Merit

Infection
Kochs identified many bacteria and postulated his principles which brought radical change in asepsis Proposed that heat is more effective than carbolic acid for killing bacteria. Ernst von Bergmann in 1877 introduced asepsis properly Led to sterilization, cleaning patient, handwashing, eventually gloves and masks

Womens Medical College, 1903

Pioneers in surgery
Though surgery in medieval period was in darkest of its period the efforts of some people revived it . Abu al-Qasim Khalaf ibn al-Abbas Al-Zahrawi (9361013)
He is considered the greatest medieval surgeon to have appeared from the Islamic World, and has been described by many as the father of modern surgery His greatest contribution to medicine is the Kitab al-Tasrif He was the first physician to describe an ectopic pregnancy Ab Al-Qsim's al-Tasrif described both what would later became known as "Kocher's method" for treating a dislocated shoulder and "Walcher position" in obstetrics. Al-Tasrif described how to ligature blood vessels almost 600 years before Ambroise Par Described ligation of temporal artery for migraine 600 years before Pare His use of catgut for internal stitching is still practised in modern surgery Described hereditary nature of hemophilia

Hermann Boerhaave (1668-1738)

He initially studied fine arts and obtained a PhD from the University of Leyden in 1690. He entered medicine at the University of Harderwyk and qualified in 1693 Amongst his greatest contributions to medicine were the use of post-mortem examinations to find the cause of fatal illnesses the use of the Fahrenheit thermometer in the clinical assessment of patients. The syndrome that is named after him he described in 1724 when Grand Admiral of the Dutch Fleet and Prefect of Rhineland, Baron J van Wassenaer died soon after developing chest and abdominal pain after vomiting on a full meal

William Cheselden (1688-1752)

Member of London company of barber surgeons Leading and most prestigious english surgeon of early 18th century Performed private anatomical classes His first major book was The Anatomy of the Human Body, published in 1713, and this became a standard medical text for well over the next one hundred years In 1733 he published Osteographia or the Anatomy of Bones. This was the first full and accurate description of human osseous anatomy. Introduced high operation to remove bladder calculi through suprapubic incision rather than midline perineal lithotomy which took hours He later described a lithotomy through a lateral perineal incision with an operating time of minutes rather than hours Played a pivotal role in separation of surgeons from barbers by bringing an act in parliament in 1745 and established company of surgeons

Sir Percivall Pott(1714-1788)

Born in London Apprenticed Edward Nourse, a surgeon in St Bartholomew's hospital where he prepared dissections for demonstrations He became a surgeon in the same hospital in 1729 He was one of the first doctors to recognize industrial disease when he described the association between work as a chimney sweep and scrotal carcinoma. Potts name is eponymous with Potts disease of spine, Potts fracture, Potts puffy tumor

John Hunter (1728-1793)

Born in scottish family, youngest son of 10 Learned anatomy by helping his brother preparing anatomical dissections Became assistant to William Cheselden and assistant to Pervical pott Slowly developed as a surgeon and established his own anatomy school Written work produced by Hunter had a significant impact on medical practice at that time.
i. ii. iii. iv. Natural history of teeth-coined terms bicuspid,tricuspid,incisors and molars A treatise on veneral disease -described chancre and LGV The digestion of stomach after death-described shock and intussuception Inflammation and Gun-Shot Wounds - he questioned the need to surgically enlarge gun-shot wounds and disproved the belief that gunpowder was poisonous

Described Hunterian ligature-ligation of femoral artery in popliteal aneurysm His pupils include Benjamin Bell, Astley Cooper, Everard Home and Edward Jenner.

Sir Astley Cooper (1768-1841)

Medical studies from his uncle William Cooper a staff surgeon in St.thomas & Guys hospital Wrote The anatomy and surgical treatment of inguinal and congenital hernias regarded by many at the time as a seminal work in the field Described eustachian tube dysfunction and role of myringotomy Innovative work in vascular surgery and research in pathophysiology of cerebral circulation He postulated that it should be possible to treat vascular aneurysmal disease by ligation of the vessel proximal to the lesion Procedure for ligating aorta in illiac artery & ext illiac artery for femoral aneurysm Named after- approach to ext iliac artery ,suspensory ligaments of breast.

Dominique Larrey (1766-1842)

Outstanding surgeon of napolenic era One of the founder of military surgery Assistant surgeon to french army in Rhine 1st to take first aid treatment to battle field with introduction of ambulance and introduced triage Therapeutic usage of maggots and performed 1st amputation of hip Named aftershoulder amputation, mediterranean yellow fever, ligation of femoral artery below inguinal ligament

Ephraim McDowell (1771-1830)

Born in Virginia to an Irish family Medical training in America, later went to Edinburgh and taught by Alexander Munro and John Bell. 1st to perform elective laparotomy(1804)-for removal of ovarian cyst on Mrs. Jane Todd Crawford in a cabin.
"Having never seen so large a substance extracted, nor heard of an attempt, or success attending any operation such as this required, I gave to the unhappy womaninformation of her dangerous situation. The tumorappeared full in view, but was so large we could not take it away entire. We took out fifteen pounds of a dirty, gelatinous looking substance. After which we cut through the fallopian tube, and extracted the sac, which weighed seven pounds and one half. In five days I visited her, and much to my astonishment found her making up her bed.-Ephraim McDowell.

Abraham Colles (1773-1843)

Born at Milmount, near Kilkenny in Ireland in 1773 Selected by nature as surgeon as his interest in surgery developed after a flood in his childhood Received M.D. degree from Edinburgh university Elected as president of Royal college of surgeons in ireland at the age of 28 years In 1811 he published a book entitled Surgical Anatomy, he which he described what is today known as Colles' fascia (the superficial perineal fascia His name is eponymously associated with a fracture of the distal radius with displacement and dorsal angulation, which he accurately described in the Edinburgh Medical and Surgical Journal in 1814 1st surgeon to ligate subclavian artery Introduced the hypothesis of maternal immunity of a syphilitic infant when the mother had not shown signs of the disease

George Guthrie (1785-1856)

Great war surgeon born in London Apprenticed to Dr.Phillips, a surgeon in Palmall Became a member of Royal college of surgeons at the age of 16 years So dedicated to his work once he is responsible for treating 3000 soldiers one evening in battle of Albuera He introduced straight leg splint in treating gunsot wounds of thigh Proposed ligation of both ends of arteries Proposed destruction of dead tissue by mineral acids in hospital gangrene His Treatise on Gunshot Wounds of the Extremities was published in 1813 and contains detailed and graphic accounts of the management of war wounds.

Sir James Paget (1814-1899)

Apprenticed to a local surgeon in Great Yarmouth Received further training in St Bartholomews hospital, and received MRCS at the age of 22. But over all he was a self taught surgeon Learned most of the surgery from post mortem examination and reading German text books In 1836 he has been selected as the one of the founding fellows of Royal college of surgeons and at the age of 36 he became the aris and gale professor of the college One of the first surgeons to correlate the patient symptoms to clinical diagnosis In 1874, he reported a series of 15 cases of chronic ulceration of the nipple in association with breast cancer. He suggested that chronic ulceration induced the cancer but it is now recognized that the nipple changes are part of the neoplastic process. In 1876, he described five cases of 'osteitis deformans' which be believed to be an inflammatory disease process. It is now believed to result from an abnormality of bone remodeling due to an increase in osteoclastic activity, possibly as result of a viral infection.

Theodor Billroth (1829-1894)

German physicist and surgeon Insisted on radical surgical training with prolonged apprenticeship and 2-3 years assistantship Wrote a monograph on relationship between adenomatous polyps and colorectal carcinoma in 1855. He is the 1st to do esophageal resection in 1872 laryngectomy in 1874 excision of rectal cancer in 1876 Best known for two types of partial gastrectomy named after him The first Billroth I partial gastrectomy was performed on a 43 year old woman in 1881 for a pyloric gastric cancer

'the operation lasted, including the slow induction of anesthesia about one and a half hours'. The following day there was 'No weakness, no vomiting and no pain'....'Within the first 24 hours only ice by mouth, then peptone enema with wine. The following day, first every hour and then every half hour, one tablespoon of sour milk. Patient a very understanding women, feels well, lies extremely quiet, sleeps most of the night with the help of a small injection of morphia. No pain in the operative area or a subfebrile reaction-Billroth

Hugh Owen Thomas (1834-1891)

Hugh Owen Thomas is widely regarded by many as great pioneer in British orthopedic surgery who came from a family of bone setters Apprenticed to his uncle, Dr. Owen Roberts ,he later studied medicine in Edinburgh and University College London and qualified MRCS in 1857. He never served with any university lecturer nor was he ever appointed as a house surgeon In the treatment of tuberculosis and fractures, he strongly advocated the use of rest which should be 'enforced, uninterrupted and prolonged which was opposed by many as excision and amputation was employed for chronic disorders In order to achieve rest and Immobilisation he invented several types of splints, with rigid steel bars, that were manufactured in his own work shop by both a blacksmith and a saddler. He also invented a wrench for the reduction of fractures and an osteoclast to break and reset bones His contribution to the management of fractures was not widely recognised until after his death and in particular the onset of the First World War. His nephew, Sir Robert Jones, introduced many of his uncles ideas to the surgical community Thanks to the use of Thomas splint mortality of compound fractures of femur fell from 80% in 1916 to 8% in 1918.

Theodor Kocher (1841-1917)

Born in Bern ,Switzerland and received his education there Graduated in 1865 and published his thesis "Treatment of croupous pneumonia with veratrum compounds." in the same Year ,Student of Billroth and Bernhard von Langenback at age of 31 Done extensive work in Thyroid surgeries ,performed over 2000 surgeries and brought mortality rate from 13%-1% Awarded noble prize in 1909 Other works-descriptions of a manoeuvre to reduce a subluxed shoulder(1870) -radical surgery for carcinoma of the tongue (1880) -an operation for inguinal hernias (1892). -He introduced the use of sterilized silk sutures in surgical practice Named after him:1)toothed surgical clamp 2.anastomatic bowel clamp and curved director 3.sub costal incision for open cholecystectomy 4.pericondylar fracture 5.manoeuvre to mobilize duodenum

Ludwig Courvoisier (1843-1918)

Was born in Basle and completed his graduation there in 1868 He became an assistant to Professor Socin a famous surgeon In 1888 he was selected as professor of surgery extraordinary in Basle university Courvoisier's most important work concerned surgery to the biliary tract. It was he who developed the operation of cholecystectomy and he was one of the first surgeons to remove a stone from the common bile duct. The well known 'Courvoisier's law' is named after him This was first proposed by him in his book 'The pathology and surgery of the gallbladder' published in Leipzig in 1890. Courvoisier was regarded by many as safe rather than brilliant surgeon. He gladly handed over cases to others when confronted with conditions lying outside his experience

Friedrich Trendelenburg (1844-1924)

Born in Berlin, initial medical studies in Glasgow and finally attained M.D in Berlin Trendelenburg played a key role in the great advances in surgery that occurred in Germany in the latter part of the nineteenth century. He founded the German Society of Surgeons and eventually became it president In 1871 he described endotracheal anaesthesia for a patient with a tracheostomy. In 1890 he reported ligation of the long saphenous vein for the treatment of varicose veins. In 1908 he was the first surgeon to attempt, albeit unsuccessfully, a pulmonary embolectomy. Name is eponymous with- tests for saphenofemoral incompetence and identifying the shortening of leg The operative position named after Trendelenburg consists of placing the patient in a 45 degree 'head down' inclination, useful in reducing the venous pressure for varicose vein surgery or to maintain the intestine out of the pelvis for gynaecological procedures. Position was first described by Willy Meyer who had been a student under Trendelenburg His doctoral thesis 'De Veterum Indorum Chirurgiais' discussed ancient Indian surgery

William Halstead (1852-1922)

Born to an English family in New York Graduated from Yale university and became student assistant to John Dalton Went to England and received training with Billroth,Thiersch and Volkman Performed experiments with local anesthesia and cocaine and became addicted to it due to which he was expelled from profession Later his works include 1889 published technique of hernia repair 1890s described radical mastectomy which was named after him 1892 described ligation of subclavian artery 1900s published auto transplantation of parathyroid Founder of surgical training program in John Hopkins which was taken up by many teaching institutes

Sir Frederick Treves (1853-1923)

Was an anatomist and surgeon in London due to which he founded his surgery on anatomy Expert dissector operated neatly, quickly and cautiously. As he is myopic operated close to the wound site Performed many abdominal dissections he was awarded the Jacksonian Prize for his dissertation entitled The pathology, Diagnosis and Treatment of Obstruction of the Intestine in its Various Forms in the Abdominal Cavity. Appendicitis surgery gave enormous fame to him. In his paper, Relapsing Typhilitis treated by Operation, Treves described how he had operated for the first time on patient with appendicitis Treves developed his pathology of typhilitis, perityphilitis paratyphilitis and in chronic cases advocated operating on patients between attacks. In acute cases he advocated delaying surgery until the 5th day of the attack when peritoneal suppuration would become circumscribed His famous patients include King Edward VII and Joseph Merrick ,the elephant man. His name is associated with iliocecal fold

Max Wilms (1867-1918)

Described as diligent and highly intelligent, possessing an exceptional working capacity as well as dextrous surgeon. Extensive work in tumor especially nephrology Believed that tumor cells were formed in embryo Published Die Mischgescwlste while working under F.Trendelenburg in what he described Wilms tumor so vividly that found bases for modern concepts of Wilms tumor Name eponymously associated with: 1.perineal prostatectomy through a later incision 2.anterior and posterior rib resection used in pulmonary tuberculosis Died of septic diphtheria which he acquired from operating on a prisoner with laryngeal diphtheria who survived

Sir Victor Horsley (1857-1916)

Founder of British neurosurgery literally nurtured neurosurgery Made extensive experimentation in localization of brain function He proposed thyroidectomy causes myxoedema in1884 Performed 1st surgical hypophysectomy (experimental) in 1886 1st to remove an extradural tumor from spinal column with complete recovery of paraplegic patient in1887 Described operation for treatment of trigeminal neuralgia through temporal approach in 1891 Prepare Horsleys wax with 7 parts bees wax and 1 part almond oil for stopping bleeding from cranial vault Ardent believer of his ideas like sunstroke was caused by smoking (but he died of sun stroke)

Harvey Cushing (1869-1939)

Graduated from Harvard medical school Initial training from William Halstead Worked with Theoder Kocher and Victor Horsely Pioneered neurosurgery and developed many techniques Works: 1.method of destruction of trigeminal
ganglion in 1900 2.infiltrative analgesia in 1910 3.functioning of pitutary gland and experimental hypophysectomy in1910 4.introduced electro coagulation in1928 5.basophil adenomas in 1932

Endocrine disorder is named after him In addition received Pulitzer prize in 1926 for his book Life of Sir William Ostler

John Finney (1863-1942)

Born in Mississippi and had educational training in Harvard Served as assistant to William Halstead in John Hopkins Finney was regarded internationally as an excellent general surgeon and played an important part in the rapid development of abdominal surgery that took part at the end of the 19th century His operation of pyloroplasty, which he described in 1902, was his most valuable contribution. In his honour the, Finney-Howell Foundation for Cancer Research was founded.

Conrad Ramstedt (1867-1963)

Conrad Ramstedt was born in Hamersleben, a village in central Prussia and graduated in Halle Served as military surgeon for many years After the description of pyloric stenosis by Hirschsprung many attempts were made to relieve obstruction
I. Lobker at Bochum who bypassed the obstruction with a gastrojejunostomy II. In 1907 Fredet suggested an alternative operation in which the muscular coat of the pylorus was divided. In 1908 Weber advocated a similar approach

Ramstedt described two successful operations

In the first patient he attempted to suture the pyloroplasty in a transverse fashion but this failed and the sutures cut out. He covered the muscular defect with an omental patch In the second patient the pyloric incision was left open with no attempt made to close it - the operation which is today eponymously associated with him

Sir Harold Gilles(1882-1960)

Sir Harold Gillies was born in Dunedin in Newzeland. His medical studies were undertaken at Cambridge University and St. Bartholomew's Hospital London. He initially planned a career in otolaryngology before becoming on of the founders of British plastic surgery. During the first World War he treated a large number of patients with facial injuries. At the advent of World War II, Gillies converted the private wing of the Park Prewett Hospital, Basingstoke into a 120bed plastic surgery unit. This unit was known as 'Rooksdown House' and became on of the leading centers for plastic surgery within Great Britain. Pioneered pedicle tube technique Made detailed description of each and every work

Pedicle tube technique

William Spreckley

Sir Archibald McIndoe (1900-1960)

Renowned plastic surgeon ,who was also born in Dunedin New Zealand, cousin to Sir Harold Gilles He published several papers on hepatic disease including two individual papers on the importance of portal cirrhosis and on the structure of the bile canaliculus In America he met Lord Moynihan who was so impressed with his surgical skills that he recommended a permanent career in England. Took plastic surgery on the advice of his cousin McIndoe also held an appointment as a consultant in Plastic Surgery to the Royal Air Force McIndoe fought to improve the pay and conditions of badly injured airmen and 'The Guinea Pig Club' of his ex-patients perpetuates his memory At the Royal College of Surgeons, he became a member of Council in 1946 and vice-president in 1958. He had been Hunterian Professor in 1939 and in 1958 was Bradshaw Lecturer, his subject being facial burns. He helped to found the British Association of Plastic Surgeons and was its third President.

 In 1880, Tait performed the first transabdominal resection of a gangrenous appendix and Rehn performed the first subtotal thyroidectomy for Graves disease In 1884, Bennett and Godlee reported the first successful removal of a brain tumor

Factors for development of surgery in medieval period

Science and technology
Chemistry played an important role. Knowledge of chloroform and carbolic acid helped with anaesthetics and antiseptics, and knowledge of citrates helped with the storage of blood. Clearly Louis Pasteurs scientific work on Germ Theory was very important in the development of Listers ideas, in developing heat sterilisation and in creating aseptic operations William Rntgen discovered x-rays in 1895 when he noticed that certain light rays could pass through human tissue but not bone. After writing up his ideas, he chose not to patent them which meant that people were free to copy them. As a result, the use of x-rays spread very quickly

Other technological breakthroughs in surgery in this period included:

Ophthalmoscope 1851 allowed the interior of the eye to be seen The hypodermic needle 1853 allowing blood transfusions Chloroform inhaler 1850s John Snows invention to prevent overdoses Oesophagoscope 1868 allowed foreign objects in the gullet to be seen and removed Donkey-engine 1877 Listers invention to spray an operation with antiseptic Rectoscope 1895 to see up the rectum Gastroscopes late 1890s to see into the stomach Cardiograph 1903 keeps the beating of the heart monitored during an operation.

communication helped in the development of surgery

During the 19th century there were a great many scientific and medical journals established that allowed ideas to be shared. The Royal College of Surgeons had one which encouraged surgeons to discuss new ideas and problems The Lancet is the famous medical journal, which published the report of Hannah Greeners death to invite discussion on what had caused her demise. Lister read Pasteurs work in a journal which enabled him to develop carbolic. X-rays developed so quickly because Rntgen published his work and made it patent-free. Newspapers reporting surgical news to the public had a role in popularising new techniques. The best example here is the newspapers reporting Queen Victorias use of chloroform whilst giving birth. Surgeons and scientists also travelled and visited each other. Lister travelled around Germany and the USA discussing his ideas with other surgeons. He met with Louis Pasteur in 1892 at a conference of 2,500 surgeons.

 I st world war role in developing surgery

Made a demanding situation for blood transfusions which forced for development of techniques for preserving blood Promoted use of x-rays for identifying bullets in war fronts WW1 decisively advanced skin transplants and plastic surgery. Shells caused horrific facial injuries. Harold Gilles set up a plastic surgery unit in Aldershot and dealt with 2000 cases of facial damage after the Battle of the Somme. Between 1914 and 1921, over 41,000 men in the British Armed Forces lost a limb. This meant that there had to be new developments in prosthetic limbs. New metal alloys and mechanisms were developed Surgeons gained an enormous wealth of experience and were able to try out procedures on patients. The war accelerated their training.

Blossoming of Surgery
By 1870s and 1880s surgeons can operate on head, chest, and abdomen
1886: 1st successful appendectomy 1886: MGH abdominal surgery ward Abdomen now available to surgeons

1880s and 90s: Physiological Surgery

Conserved tissues, preserved anatomy, careful dissection Compare to slash and speed model

 MGH
1841-1845: 37 operations/ year 1847-1851: 98 operations/ year 1898: 3700 operations

Surgery in 1900
Safer Less painful More invasive Less infection risk

Surgery in modern times

surgeons had no choice but to allay society's fear of the surgical unknown by presenting surgery as an accepted part of a newly established medical armamentarium. This would not be an easy task. The immediate consequences of surgical operations, such as discomfort and associated complications, were often of more concern to patients than was the positive knowledge that an operation could eliminate potentially devastating disease processes. Accordingly, the most consequential achievement by surgeons during the early 20th century was ensuring the social acceptability of surgery as a legitimate scientific endeavor and the surgical operation as a therapeutic necessity.

 Surgeons in early 20th century mostly emphasized on operating on the most vital tissues like brain and heart. As a result of the new developments in anesthesia and diagnostic facilities like x-rays this became possible Surgical techniques would, of course, become more sophisticated with the passage of time, but by the conclusion of World War II, essentially all organs and areas of the body had been fully explored. In fact, within a short half-century the domain of surgery had become so well established that the profession's foundation of basic operative procedures was already completed

Highlights in early 20th century

George Vaughan (1859-1948) successfully ligated the abdominal aorta for aneurysmal disease in 1921 Elliott Cutler (1888-1947) performed a successful section of the mitral valve for relief of mitral stenosis in 1923; Walter Dandy (1886-1946) performed intracranial section of various cranial nerves in the 1920s Harvey Cushing introduced electrocoagulation in neurosurgery in 1928 Owen Wangensteen (1898-1981) successfully decompressed mechanical bowel obstructions by using a newly devised suction apparatus in 1932; 1935 pancreaticoduodenectomy for cancer of the pancreas by Allen Oldfather Whipple (1881-1963) Max Peet (1885-1949) presented his splanchnic resection for hypertension in 1935 Walter Freeman (1895-1972) described prefrontal lobotomy as a means of treating various mental illnesses in 1936 Marius Smith-Petersen (1886-1953) described a flanged nail for pinning a fracture of the neck of the femur in 1931 and introduced Vitallium cup arthroplasty in 1939; Vilray Blair (1871-1955) and James Brown (1899-1971) popularized the use of split-skin grafts to cover large areas of granulating wounds;

Highlights in early 20th century

Evarts Graham completed the first successful removal of an entire lung for cancer in 1933; Claude Beck (1894-1971) implanted pectoral muscle into the pericardium and attached a pedicled omental graft to the surface of the heart, thus providing collateral circulation to that organ, in 1935; Earl Padgett (1893-1946) devised an operative dermatome that allowed calibration of the thickness of skin grafts in 1939. 1943 - vagotomy for operative treatment of peptic ulcer disease by Lester Dragstedt Robert Gross (1905-1988) reported the first successful ligation of a patent arterial duct in 1939 and resection for coarctation of the aorta with direct anastomosis of the remaining ends in 1945; John Alexander (1891-1954) resected a saccular aneurysm of the thoracic aorta in 1944

Highlights in early 20th century

In 1945, Blalock and Taussig designed their shunt operation for blue babies In 1948, Dwight Harken and colleagues published an astonishing report describing the successful surgical treatment of mitral-valve disease Robert Gross and colleagues reported in 1952 on openheart surgery to close atrial septal defects in children

Mid 20th century

Two clinical developments truly epitomized the magnificence of postWorld War II surgery and concurrently fascinated the public: the maturation of cardiac surgery as a new surgical specialty and the emergence of organ transplantation

cardiac surgery
From the historical perspective of art, customs, literature, philosophy, religion, and science, the heart has represented the seat of the soul and the wellspring of life itself. Such reverence also meant that this noble organ was long considered a surgical untouchable. a steady march of surgical triumphs in opening successive cavities of the body, the final achievement awaited the perfection of methods for surgical operations in the thoracic space.

cardiac surgery
Luther Hill's (1862-1946) first known successful suture of a wound that penetrated a cardiac chamber was in 1902 Elliott Cutler (1888-1947) performed a successful section of the mitral valve for relief of mitral stenosis in 1923 Dwight Harken (1910-1993) gained extensive battlefield experience in removing bullets and shrapnel in or in relation to the heart and great vessels without a single fatality.
During the Second World War, Harken served in the U.S. Army Medical Corps in London as a surgeon. To treat his patients, he found a way to take out shrapnel safely from the heart by cutting into the wall of a beating heart, then inserting a finger to locate and remove the shrapnel. With this method, he became the first person to have repeated success in heart operation after removing shrapnel from the hearts of 130 soldiers during the war without a single fatality.

 In 1948, Dr. Harken discovered a way similar to how he operated on soldiers to correct mitral stenosis. A small hole would be cut in the heart and a finger would be used to widen the valve. This technique became known as blind surgery or closed heart surgery Harken's concept of intensive care has been adopted worldwide and has improved the chance of survival for patients. He opened the first intensive care unit in 1951. In the 1960s, he developed the first device to help the heart pump

 Charles P .Bailey was an American

cardiac surgeon Worked extensively on mitral valve pathology
According to the colorful Dr Bailey, while working his way through college, he was a salesman for ladies girdles. His knowledge of the construction of that garment and its applied garters gave him the basis for better understanding of the anatomy, as well as the treatment of mitral stenosis.

A deliberate enlargement of the stenotic mitral valve at the commissures either by a splitting technique or by cutting with an instrument worn on and guided by the finger was the approach taken by Bailey

 Despite mounting clinical successes, surgeons who operated on the heart had to contend not only with the quagmire of blood flowing through an area where difficult dissection was taking place but also with the unrelenting toand-fro movement of a beating heart. John Gibbon (1903-1973) addressed this enigma by devising a machine that would take on the work of the heart and lungs while the patient was under anesthesia, in essence pumping oxygen-rich blood through the circulatory system while bypassing the heart so that the organ could be operated on at leisure. The first successful open heart operation in 1953, conducted with the use of a heart-lung machine, was a momentous surgical contribution Gibbon's research paved the way for all future cardiac surgery, including procedures for correction of congenital heart defects, repair of heart valves, and transplantation of the heart.

 Since time immemorial, the focus of surgery was mostly on excision and repair. However, beginning in the 20th century, the opposite end of the surgical spectrumreconstruction and transplantationbecame realities Emerich Ullmann performed the first experimental transplantation of a kidney between dogs in Vienna in 1902. Alex Carel played a sheet anchor role in developing transplantation techniques as he developed revolutionary new suturing techniques to anastomose the smallest of blood vessels

 In 1906, Mathieu Jaboulay, professor of surgery in Lyon, France, connected the renal vessels of a sheep and a pig kidney, respectively, to the brachial vessels of two patients who were dying of renal failure. Using his surgical lan on experimental animals, Carrel began to transplant kidneys, hearts, and spleens. Technically, his research was a success, but some unknown biologic process always led to rejection of the transplanted organ and death of the animal.

Alex Carell

 By the middle of the century, medical researchers had begun to clarify the presence of underlying defensive immune reactions and the necessity of creating immunosuppression as a method to allow the host to accept the foreign transplant Drugs like cyclosporine paved way for maintaining a transplant But the first successful kidney transplant took place in 1954 in Boston by John Merrill, Joseph Murray, and Hartwell Harrison

Cardiac transplantation
Christiaan Neethling Barnard was a South African cardiac surgeon who performed the world's first successful humanto-human heart transplant He worked as assistant to Norman Shumway who did pioneering research in cardiac transplantation He performed the world's first human heart transplant operation on 3 December 1967, in an operation assisted by his brother, Marius Barnard; the operation lasted nine hours and used a team of thirty people.
The patient, Louis Washkansky, was a 54-year-old grocer, suffering from diabetes and incurable heart disease. The donor heart came from a young woman, Denise Darvall, who had been rendered brain damaged in an accident on 2 December 1967, while crossing a street in Cape Town. Dr. Marius Barnard recounted, "Chris stood there for a few moments, watching, then stood back and said,

'It works.'

Pioneers of surgery (20th century)

Noble laureates in medicine and physology
SURGEON Theodor Kocher (18411917) Allvar Gullstrand (18621930) Alexis Carrel (1873-1944) COUNTRY Switzerland Sweden France and United States FIELD (YEAR OF AWARD) Thyroid disease (1909) Ocular dioptrics (1911) Vascular surgery (1912) Vestibular disease (1914) Insulin (1922) Midbrain physiology (1949) Cardiac catheterization (1956) Oncology (1966) Organ transplantation (1990)

Robert Brny (1876Austria 1936) Frederick Banting (1891- Canada 1941) Walter Hess (1881-1973) Switzerland Werner Forssmann (1904-1979) Charles Huggins (19011997) Joseph Murray (1919-) Germany

United States
United States

Pioneers of surgery (20th century)

Charles Huggins (1901-1997) a pioneer in
endocrine therapy for cancer, found that antiandrogenic treatment consisting of orchidectomy or the administration of estrogens could produce long-term regression in patients with advanced prostatic cancer. These observations formed the basis for the current treatment of prostate and breast cancer by hormonal manipulation; Dr. Huggins was awarded the Nobel Prize in 1966 for these monumental discoveries

Francis D. Moore (1913-2001) defined objectives

of metabolism in surgical patients and in 1959 published his widely quoted book Metabolic Care of the Surgical Patient. Moore was also a driving force in the field of transplantation and pioneered the technique of using radioactive isotopes to locate abscesses and tumors

 Jonathan E. Rhoads (1907-2002)in collaboration

with colleagues Harry Vars and Stan Dudrick, described the technique of total parenteral nutrition, which has become an important and lifesaving treatment in the management of a critically ill patient who cannot tolerate standard enteral feedings

Werner Forssmann(1904-1979), awarded noble prize for developing cardiac catheterisation

The radiograph shows successful selfcatheterization of the heart, performed by Werner Forssmann, at the time a 25-year-old surgical intern in Eberswalde, Germany

Minimal invasive surgery

"I would like to see the day when somebody would be appointed surgeon somewhere who had no hands, for the operative part is the least part of the work -Harvey Cushing

In the past two decades the emphasis has shifted to how much less can we do to achieve our goal of treatment

History of laparoscopy
The great physician, Hippocrates of Ancient Greece( circa 460-377 BC) made the original reference to a speculum to examine the rectum. 1585, Aranzi was the first to use a light source for an endoscopic procedure, focusing sunlight through a flask of water and projecting the light into the nasal cavity 1706, The term trocar, was coined in 1706, and is thought to be derived from trochartor troise-quarts, a three-faced instrument consisting of a perforator enclosed in a metal cannula

 1806, Philip Bozzini, built an instrument that could be introduced in the human body to visualize the internal organs. He called this instrument "LICHTLEITER(light conductor). Bozzini used an aluminium tube to visualize the genitourinary tract. The tube, illuminated by a wax candle, had fitted mirrors to reflect images. 1853, Antoine Jean Desormeaux, a French surgeon first introduced the modified 'Lichtleiter" of Bozzini to a patient. For many surgeons he is considered as the "Father of Endoscopy".

 Bruck, a dentist, developed a platinum wire cooled by water to illuminate the inside of the mouth Based on Bruck design, Nitze finally developed his first improved cystoscope in 1855 in which the light rays were gathered into his instrument via mirrors Newman of Glasgow miniaturzed Edison`s invention and incorporated it into the Nitze`s cystoscope(first Laparoscop)

 Georg Kelling of Dresden performed the first cholecystectomy in living dog(COELIOSCOPIE -1902) / the first human laparoscopy with pneumoperitoneum using room air insufflation with Nitze cystoscope. used filtered atmospheric air to create a pneumoperitoneum, with the goal of stopping intra-abdominal bleeding (Ectopic pregnancy, bleeding ulcers, and pancreatitis) Kelling proposed a high-pressure insufflation of the abdominal cavity, a technique he called the "Luft-tamponade" or "airtamponade"

 Jacobaeus of Sweden presented his series of patients who had laparoscopy in 1910 (published a series of over 100 laparoscopy and thoracoscopy(LAPAROSCOPY). 1911, H.C. Jacobaeus, again coined the term "laparothorakoskopie" after using this procedure on the thorax and abdomen. He used to introduce the trocar inside the body cavity directly without employing a pneumoperitoneum Janos Veress of Hungary developed a specially designed spring-loaded needle. Interestingly, Veress did not promote the use of his Veress needle for laparoscopy purposes. He used veress needle for the induction of pneumothorax. Veress needle is the most important instrument today to create pneumo-peritoneum

 1977, First Laparoscopic assisted appendicectomy was performed by Dekok. Appendix was exteriorized and ligated outside. Kurt Semm , a German gyneacilogist introduced the automatic insufflator,first time demonstrated endoloop suturing technique in laparoscopic surgery and performed the first laparoscopic appendicectomy in 1983 The first documented laparoscopic cholecystectomy was performed by Erich Mhe in Germany in 1985. Cholecystectomy is the laparoscopic procedure which revolutionized the general surgery. 1987, Ger reported first laparoscopic repair of inguinal hernia using prototype stapeler. Harry Reich described first laparoscopic hysterectomy using bipolar dessication; later he demonstrated staples and finally sutures for laparoscopic hysterectomy.

 Tempton Udwadia of Hinduja Hospital, Mumbai is accepted by most as the father of Laparoscopic Surgery in India. Pradeep Chowbey of Sir Gangaram Hospital made laparoscopic cholecystectomy popular and acceptable in New Delhi and Northern India with his efforts in early 1990's C Palanivelu of GEMS Hospital Coimbatore developed many advances in laparoscopic surgery and contributed significantly to the growth of Minimal Access Surgery in Southern India around the same time. His work on the pancreas has been appreciated internationally

Robotic surgery
Current trend towards Cushings dream In 1985 a robot, the PUMA 560, was used to place a needle for a brain biopsy using CT guidance In 1988, the PROBOT, developed at Imperial College London, was used to perform prostatic surgery by Dr. Senthil Nathan at Guy's and St Thomas' Hospital, London. 1996, First live telecast of laparoscopic surgery performed remotely via the Internet. (Robotic Telesurgery).

 The da Vinci Surgical System comprises three components: a surgeons console, a patient-side robotic cart with 4 arms manipulated by the surgeon (one to control the camera and three to manipulate instruments), and a high-definition 3D vision system.

Surgical nanorobotics
Surgical nano robots could be introduced into the body through the vascular system or at the ends of catheters into various vessels and other cavities in the human body. A surgical nanorobot, programmed or guided by a human surgeon, could act as a semi-autonomous on-site surgeon inside the human body.

A molecular planetary gear is a mechanical component that might be found inside a medical nanorobot.

 The earliest forms of cellular nanosurgery are already being explored today. For example, a rapidly vibrating (100 Hz) micropipette with a <1-mm tip diameter has been used to completely cut dendrites from single neurons without damaging cell viability A femtolaser acts like a pair of nano-scissors by vaporizing tissue locally while leaving adjacent tissue unharmed We envision biocompatible surgical nanorobots that can find and eliminate isolated cancerous cells, remove microvascular obstructions and recondition vascular endothelial cells, perform noninvasive tissue and organ transplants, conduct molecular repairs on traumatized extracellular and intracellular structures, and even exchange new whole chromosomes for old ones inside individual living human cells.

whatever might be the progression of surgery in the modern world the final thinking of the surgeon must be

-Ambroise Pare I just bandaged , god healed