A Brief History of Surgery


old operating theater

The Old Operating Theater - St. Thomas' Hospital, London


surgeryhole1

Surgery, the process of opening the human body to repair an anatomic problem, really dates back to prehistory, to pre-humans in fact. There is forensic evidence that the Neandertals performed trephination, opening the skull to relieve the pressure of brain swelling from a head injury. This neolithic procedure is still performed today, though now we call it "creating a burr hole" to provide access to the brain.




Given the eternal existance of trauma, being bitten, falling off a pyramid, etc…Surgery could be said to have existed eternally. A simple drainage of an abscess or the setting of a bone are surgical procedures. Medical practice, adjusting physiology through medications, or incantations or diet and lifestyle changes is far younger. Since I am a surgeon, I am partial to the philosophy, "a chance to cut is a chance to cure," but surgeons as a rule begin to get into trouble when they start trying to alter physiology by changing anatomy - an example is "weight loss surgery" which creates weight loss by bypassing the intestines from food, creating weight loss through malnutrition - in fact no living person has ever suffered from too large a stomach or too long an intestine. The simple fact is that we have not yet found a medical way to alter the physiology of weight. But we will, and what then of the people who are malnourished from irreversable operations bypassing their intestines?

But I digress…

A remarkable amount of surgical knowledge and practice was lost in the medieval era by simple ignorance. The Romans fixed hernias - they would get a patient drunk, then push a hot poker into the hernia and groin. This would create a scar that would heal the hernia and prevent recurrence. Granted you would not want this, a third of patients died from the surgery, but only a third or so of those who survived had the hernia come back again. And think how large that hernia would have had to have been to submit to such a procedure. St. Benedict decreed that his monasteries should care for the sick, but only through prayer, and forbade the study of medicine.

leonardo appendixvesalius appendix

The Church in Europe ended up preventing the study of anatomy and physiology over the course of a thousand years, and instead codified the work of Galen and Aristotle, among others as the final word on how the body worked. Unfortunately, those authors suffered similar limitations, particularly from bans on dissections. Galen, for example, is reported to have never dissected a human, and inferred all from what he was able to observe in animals. The resurrection of surgery in Europe, then, came with the Renaissance artists and anatomists with certain outlaw streaks, particularly Leonardo Da Vinci and from Vesalius, whose anatomic drawings, drawn usually from illegal dissections, formed the basis for a new study of human anatomy and physiology as errors in Galen's work became apparant. Leonardo's drawing of the human appendix also forms the basis of the logo of this museum. Vesalius' work, years after Leonardo, is incredibly detailed, and his drawing of the appendix even shows a small fecalith, or stool ball, obstructing the opening of the appendix into the cecum. The Royal Collection in England exhibits the DaVinci drawings in their excellent museum. To see more of Vesalius' anatomic drawings, you can go to the British Library's Vesalius exhibit.

In the 1700's John Hunter successfully combined dissection and careful study of anatomy with surgical practice. This culminated in his successful operation to treat aneurysms of the poplteal artery. Hunter's work led to a scientific professionalism, the use of hypothesis and experimentation, to surgery that led directly to the advances of the ensuing 250 years. John Hunter and his contributions are memorialized, among many places, in this museum in John Hunter Memorial Hall for the Anatomy and Physiology of the Appendix, at the Royal College of Surgeons (Eng) at the Hunterian Museum, which maintains his dissections for viewers, and in a wonderfulbiography, Knife Man which was given to me by a friend and mentor, Russ Nauta, and which I think is just a terrific book.

op table bw

Surgery on the abdominal cavity is a formidable affair – several impeding factors coexist. First, surgery on the abdomen takes time. Early surgery, drainage of an abscess, amputation of a limb, could be done in seconds, an average surgeon of the 1840’s took thirty seconds to amputate a leg.(Hollingham) At the operating theater museum at St. Thomas' Hospital in London (just a terrific museum!), the old operating table still has saw marks on it from amputations. A surgical virtue of the extremities lay in the easy access to the pathology – the incisions through skin and muscle are a part of the surgical treatment of the pathology. The abdominal cavity is different. In abdominal surgery, the incision through skin and muscle are means of access to the pathology. The surgical treatment of the intra-abdominal pathology commences some length of time after the incision. This is quite painful.

The second impeding factor to intra-abdominal surgery is that the pain cascade brings about a number of other physiologic changes, the lead of which is muscular contraction and rigidity. The abdominal muscles are designed to contain and protect the abdominal contents. With contraction they have a tendency to close off any opening into the abdomen. The reflexive abdominal contractions of the abdominal wall musculature will tend to hold the abdominal incision closed, severely limiting the access that the incision was made to obtain.

ephraim mcdowell

All of which is why, although there are reports of planned surgery on the head or extremities dating back to ancient Egypt, the first successful planned laparotomy or surgical treatment of intra-abdominal pathology did not occur until Christmas morning, 1809, when Ephraim McDowell removed a twenty-two pound ovarian mass from Jane Sarah Crawford in the kitchen of his home in Danville, Kentucky. It is reported that Mrs. Crawford sang hymns during her surgery to deflect the pain. Over the ensuing 21 years, Dr. McDowell performed twelve more abdominal surgeries before he abruptly died of a ruptured appendix in 1830.(McMahon; Ellis). His house, and his room for surgery are part of a great museum - The Ephraim McDowell House.

After 1809, with progressive invasions of the abdominal cavity, and the development of anesthesia, surgery progressed rapidly and interventions that would have, and to me still seem, miraculous were developed.

lord lister

By the 1865 Joseph Lister applied the writings of Pasteur to surgery and developed "antiseptic surgery" where surgical instruments and dressings were sterilized before surgery, rather than washed afterwards. Antiseptic surgery has saved countless lives over the past 150 years, and led directly to surgery being really useful for more than the drainage of pus. The Royal College of Surgeons of Edinborough has an excellent exhibit on the life of Lister on the centenary of his death in 1912.

Ten surgeons, four of whom actively practiced surgery, have been awarded the Nobel prize in Medicine. These men , and their accomplishmnts encapsulate the history of surgery for the past 100 years.

Theodor Kocher

Theodore Kocher won the 1909 Prize for, well really discovering everything about the thyroid gland, what it did, how it worked, the role of thyroid hormone in physiology, the anatomy of the gland, and how to safely perform surgery on the gland. His first surgical removals of the thyroid gland were complicated post operatively by severe hypothyroidism and death. This led Kocher to a severe depression, nearly to suicide. Then he discovered thyroid hormone was able to reverse these effects. Surgery on the thyroid is still done through the "Kocher collar incision." Kochers work marks the first true solid organ surgery, and is technically important because it also pioneered the methods by which bleeding is controlled when the blood vessels are buried. Kocher also showed that it is not enough for a surgeon to know the anatomy, a true surgeon needs to understand how deranged anatomy affects physiology.I also really like Kocher clamps in the operating room.

alexiscarrel

Alexis Carrell, a French surgeon working in New York and Chicago, was awarded the 1912 Prize for inventing vascular surgeryby developing the first successful techniques for suturing blood vessels. He also invented the technique for intravenous therapy, and worked with Charles Lindbergh. His legacy is clouded by his support for eugenics, and by his support for Germany and the Vichy regime during World War II.


alexander fleming

Alexander Fleming. Well... Alexander Fleming. Not a practicing surgeon, but a member of the Royal College of Surgeons. Won the 1945 Nobel Prize for the discovery of Penicillin, ushering in the era of antibiotics. Fleming's work has probably saved more lives than any other surgeon in history. He is also the epitome of the old adage "chance favors the well prepared mind." Go to the extraordinarily cool Fleming Laboratory Museum to learn more. As a personal note, I worked with an extraordinary surgeon, Charles Rob, who performed the first carotid surgery, and who operated on Winston Churchill, and who parachuted into Greece during WWII to serve as a guerrilla surgeon, and who is alleged to have been one of Fleming's students. He may have been present when the mold came through the window. He described Fleming as a "wonderful man." I believe it because Dr. Rob was a wonderful man.

WernerForssmann

Werner Forssmann was awarded the 1956 Prize for inventing cardiac catheterization. He was a Urololgist by training and in 1929, while a resident, performed the first catheterization on himself, by threading a urinary catheter through the vein in his elbow and injecting dye and taking an X-ray. . His residency program fired him for the effort, and he went on to practice Urology, but the paper lived on, and, when Medicine was ready, the procedure was revived to great effect.

murray

In 1990 Joseph Murray became the first American born surgeon to be awarded the Nobel Prize for Medicine. He developed transplantation. He performed the first successful kidney transplant in 1954, and then became a leader in the developing the study of transplantation biology and in the development of anti-rejection drugs. To come full circle, Dr. Murray solved the anatomic problem of non-functioning kidneys with the surgical procedure of kidney transplantation - putting new kidneys in, then worked with medications to solve the physiologic problem of the body's rejection of the foreign tissue.

hiromi shinya

The final fronteir of surgery, which transpired as Dr. Murray was being awarded the Nobel prize in 1990, was the development of laparoscopic, or minimally invasive surgery. Various methods of "peeking" inside the body, using tubes lit with candles, then with lights, go back more than a hundred years. The real utility of endoscopy examinations with a scope, was demonstrated in the late 1960's by Hiromi Shinya in Japan and New York City. Dr. Shinya did truly remarkable work in developing fiberoptic procedures for examining the colon, and became so well known as a pioneer in this work that my father, Richard Sedlack was even sent by Mayo Clinic to learn endoscopy from Dr. Shinya.

Patrick Steptoe

The next big advance was in 1980, when Dr. Patrick Steptoe became the first surgeon to use the laparoscopie to visualize the inside of the abdomen to perform surgical procedures usine other instruments inserted through other small incisions. Dr. Steptoe also used the laparoscope to harvest eggs to perform the first in vitro fertilization procedure.

mourat

The early laparoscopes required the first laparoscopic surgeons to look through the eyepiece of the scope, but by 1987, the technology of video cameras had advanced far enough to allow a video camera to be attached to the laparoscope which allowed the surgeon and the assistant to stand erect, and for everyone to see the operation and to participate in the operation. On March 17, 1987 Dr. Phillipe Mouret performed the first laparoscopic cholecystectomy (gallbladder removal) in Lyon, France. From that, progressively more advanced surgeries were quickly performed using the minimally invasive techniques.

An interesting story, in 1989, as laparoscopic cholecystectomy was becoming more common, I was the Chief Surgical Resident at Georgetown. I went to the Chief of General Surgery and suggested we look at learning the procedure. He responded by telling me, "Son, if that's all the respect you have for your chosen profession, perhaps you should have become a Gynecologist." Progress is sometimes slow.