Evolution of Modern
Surgery:
Historical Overview
K.M.N. Kunzru
MS FRCS DHMSA
Emeritus Consultant Orthopaedic Surgeon
1
SCOPE
2
INTRODUCTION
• Overview
• Details of Instrumentation and Technique
excluded
• Some Specialties only
• EVOLUTION –
Dead Ends Hypertension-Sympathectomy
Dinosaurs Duodenal Ulcers-Gastrectomy
Vagotomy
Myths! “Visceroptosis” (“dropped” organs)
3
ETYMOLOGY1
Greek
Χέίροϋργη (cheirourgy)
χέίρ
(cheir)
Έργον
(ergon)
Χέίροϋργος (cheirourgos)
English
“Treatment by Hand”
Surgery
hand
work, or activity
Surgeon
4
ETYMOLOGY 2
Latin
Older
English
Modern
English
Chirurgia
Chirurgery
Surgery
Chirurgos
Chirurgeon
Surgeon
5
STONE AGE ‘SCENE’
“Life without injury can hardly be
imagined” Wells, 1964
6
Kirkup
The Best Instrument
Wells Cathedral
Sculpture
“Thorn Extraction”
after Kirkup
7
INDIA 1 Suśruta
• Suśruta:
Mid 1st. Millenium
BCE ;
• Kāśī (Varanasi)
• Compendium of
Surgery
Suśrutasaṃhitā
(probably written by
his students)
Kāśī
8
SUŚRUTA 1a
• Taught Anatomy: human and animal
dissection
• Physician: Practised and taught Surgery:
precept , practice (on cadavers, animals)
• Triaged patients: Incurable(“leave alone”),
Relievable( “treat, with caution”), Curable
(“treat with confidence”)
9
SUŚRUTA 1b
• Treated the whole patient, on tri-humoral
basis, systemically and locally
• Described a fracture bed for immobilisation of
limbs and trunk
• 120+ Instruments ,including details of
construction, metallurgy and usage.
• Described a variety of pharmacological and
surgical therapies (Laparotomy/enterotomy)
10
SUŚRUTA’S OPERATIONS
REPRODUCED
11
SURGICAL INSTRUMENTS(NAQVI)
TAXILA
12
INDIA 2 Vāgbhatṭ̣
• Vāgbhatṭ̣ ̣:
Mid 1st. Millenium CE;
• Fled from Sindh to
Mālwā (Central India)
• Two Compendia
• Author: ?homonymous
grandson
Sindh
Mālwā
13
Greece and Rome
• HIPPOCRATES (?460-370 BCE)
• CELSUS (25BCE-50CE) ? Encyclopaedist
• GALEN(90-138CE) Large corpus of
work (in Greek)
14
st
1 .
MILLENIUM CE 1
• European
stagnation
• Christian legends
Ss. Cosmas and
Damian
“transplanting a
leg”
(Emery)
15
st
1 .
MILLENIUM CE 2
• “Dark Ages” in Europe
BUT
• ENLIGHTENMENT in MIDDLE EAST
• Byzantium: (preserved old writings)
• India: Surgery delgated to artisans in the
latter part of the 1st.Millenium.
16
ARABIC TRANSLATIONS
• Ḥunayn-ibn-Ishāq (Joannitus): Baghdadi
Eye Surgeon ; Prolific translator (> 40
books)-- Christian
• Kitāb-l-Sushrud (Sanskrit Old Persian
Syriac in Gundishapur, Iran Arabic)
• Mamoun (Baghdad): Bait-l-Hikmā
(House of Wisdom)
17
SURGERY
• Ḥunayn-ibn-Ishāq (Joannitus):
Ophthalmic Surgery(Couching for
Cataract)
• Al-Rhāzi (Rhazes): Rayy
Baghdad
• Ibn Sinna (Avicenna): Bukhara B’dad
• Al-Zahrāwī(Albucasis):Cordoba,Spain
18
ALBUCASIS (al-Zahārāwī) 1
• ALBUCASIS ‘On Surgery
& Instruments’
• circa 1,000 CE in
Cordoba
• Known from 1188
illustrated manuscript
• This translation 1973
19
“ISLAMIC” EUROPE
European “Re-Education” by contacts with
Arab/Turkish scholars and surgeons :
• Crusades
• Christian Re-conquest of Iberian Peninsula
• Islamic Conquest of Byzantium
• Translation of Ancient Manuscripts
from Arabic to Latin
20
SURGEONS & EUROPEAN
UNIVERSITIES
• ITALY : Salerno Xc, Bologna XIc, Padua XIIc
• FRANCE : Paris XIc, Montpellier XIIc
• Only the literate surgeons wrote: the only
recorded knowledge of European Surgery.
Little knowledge of the artisan surgeon,
who treated the majority
(e.g.Jacques de Beaulieu, “Frére Jacques”,
the 17th. C. lithotomist)
21
WOUND MAN
STUDENT LEAFLET
wounds
weaponry
treatment notes
(de KETHAM, circa 1400)
after Kirkup
22
SURGEONS INSTRUMENTS
BRUNSCHWIG’S
ARMAMENTARIUM,
1497
One of the first printed
books on surgery.
Mostly artisanal tools modified
after Kirkup
23
GUNPOWDER XIIIC
• More serious wounds with greater tissue
trauma and foreign bodies
• Greater risk of Sepsis
• Jean de Vigo ( and others): “Poison of
Gunpowder to be neutralised by boiling
oil”
24
AMBROISE PARÉ(1510-1590) 1
• Born Laval, France
• Apprentice barber-surgeon Paris1532
• Compagnon-chirurgien Hotel Dieu de
Paris
• Military Surgeon --Duc de Montjean,
Colonel General of the French Army
25
AMBROISE PARÉ 2
1537 siege of Turin: momentous discovery
in wound healing. Due to lack of boiling oil
used egg yolk, rose oil and turpentine, with
superior result: much less pain, little pus,
and no fever; healing earlier.
?First controlled trial(Ellis)
26
AMBROISE PARÉ 3
• 1541(post campaign) passed examination
“Community of Barber-Surgeons”
• 17 campaigns
• Surgeon to four Kings
• 1583 First to ligate (not cauterise) blood
vessels in amputation (Amputation through
gangrenous tissue); Amputation Prostheses
• Left mark on European Surgery
27
PARÉ’S PROSTHESES
KIRKUP
28
AMBROISE PARE
“The Workes”
FIRST ENGLISH
TRANSLATION, 1634
after Kirkup
29
Companies of Barber-Surgeons
• Ireland :
Henry VI 1499
• Edinburgh:
James IV 1505
• London :
HenryVIII 1540
• Glasgow:
James VI 1599
30
JOHN WOODALL
(1569-1643)
• Surgeon to East India Company (ashore
and on board)
• Treated Scurvy with Lemon Juice
(long before James Lind)
• “ The Surgion’s Mate” 1617
31
WOODALL
SEA SURGEON’S HANDBOOK
JOHN WOODALL’S
“SURGIONS MATE”
1617
COMPULSORY
PURCHASE FOR ALL
SHIPS SURGEONS OF
THE EAST INDIA
COMPANY
after Kirkup
32
WOODALL’S INSTRUMENT
CHEST
AFTER KIRKUP
Woodall censured for profiteering from sale of chest: compulsory
33
for surgeons of East India Company
THE ‘FATHER’
OF EARLY ENGLISH SURGERY
RICHARD WISEMAN
(c.1620-1676)
Royalist Surgeon Civil
War: battle wounds
Published failures as
well as successes
after Kirkup
34
WISEMAN’S MAJOR WORK
• Eight Chirurgical
Treatises’ (1676)
660 case histories:
Tumours, ulcers,
diseases of the anus,
scrofula, wounds
(including tendon
repair), gunshot
wounds, fractures &
dislocations, Syphilis
after Kirkup
35
SURGEONS IN PARIS
• College St Côme (1210)
• Louis XIV’s fistula cured by Félix(1687)
Collége Royale de Chirurgie formed:
The physicians’ objections were overruled!
• Surgeons of “the Long Robe”-University
trained status, as at St. Come
• Barber- Surgeons of “the Short Robe”; lower
status and only permitted some operations
36
WILLIAM CHESELDEN (1688-1752),
Anatomist & Lithotomist
London Company of
Surgeons-1745
after Kirkup
37
XVIII C
“THE ENLIGHTENMENT”
• Questioning of “received wisdom”
• Advance of Natural Philosophy by
Royal Society (late 17th.C.) and
similar continental bodies
• The Hunter Brothers- London,
Smellie
- Edinburgh
• The Lunar Society in the Midlands
38
JOHN HUNTER
(1728- 1793) 1
• Cheselden’s pupil
• The “Father”ofModern
Scientific Surgery
Human & Comparative
Anatomist,
Physiologist,Pathologist
Surgeon (Exptl.)
• Collector (Museum)
• Teacher
(after Kirkup)
39
JOHN HUNTER
(1728- 1793) 2
•
•
•
•
Dyslexic. Nervous lecturer.
Surgeon General and Royal Sergeant Surgeon
Conservative surgeon Aneurysm Operation
Large part of earnings into anatomical,
physiological and surgical research, and
Collection:
Bought by Government
London Surgeon’s
Company
RCS LONDON
40
ROYAL COLEGE OF SURGEONS OF
LONDON(1800)
• Hunter’s Museum given to Company
on condition: To be housed in a new
building in Lincoln’s Inn Fields
• Independent Trustees
• College: Education & Training of
Surgeons; not just examining body
• Museum to be open to the public
41
ROYAL COLEGE OF SURGEONS OF
ENGLAND(1844)
• Anatomy Act 1832 (College support)
• Conversion to English College, with a
higher diploma by examination :
Fellowship (pre-requisite for senior
appointment)
• Many Fellows continued General
Practice,e.g.Penny Brooks (Olympics)
42
ROYAL COLEGE OF SURGEONS OF
EDINBURGH
“INCORPORATED” 1505
James IV- 15 members
“Surgeon-Apothecaries”
(included Barbers )1657
1722 Dissatisfaction with
Barbers led to litigation;
separation of Surgeons
from Barbers
1817 diplomates became
“Licentiates”
1884 Fellowship by exam.
43
HUNTER’S PUPILS 1
• Jenner: Cow-Pox Vaccination, Hibernation
• Everard Home: (Brother-in-law: St.George’s)
Probably plagiarised Hunter’s work, but got
the Museum for Surgeon’s Company;
Master of Surgeons’ Company (twice);
President RCS England (once); Aneurysm
• Astley Cooper: Surgeon Guy’s; Surgical and
Anatomical Innovator (Aortic Aneurysm);
Anatomy Act; President RCS England (twice)
44
HUNTER’S PUPILS 2
• PHILIP SYNG PHYSICK
(1768-1837)
Surgeon to
Pennsylvania Hospital
and Medical School,
Philadelphia (USA)
• School helped by
British doctors
(Fothergill, Lettsom),
despite the War
45
GEORGE GUTHRIE 1
(1785-1856)
• Wellington’s Surgeon
Peninsular War; Dy. DG
• Ophthalmic Surgery
(first to make artificial
pupil for adherent iris)
• Treatment of Chest
Wounds
• President RCS Eng.(X3)
• Anatomy Act proponent
46
GEORGE GUTHRIE 2
(1785-1856)
• Popularised Flap
Amputations
• High Hospital Mortality
(56%) as opposed to
Field Mortality(19%)
Probably due to dirty
instruments with cross
infection , and other
hospital acquired
diseases (e.g.Typhus)
47
CONTINENTAL GIANTS
SURGEONS 1
• Larrey (1766-1842): Napoleon’s Surgeon
General: Principle of Débridement;
Hypothermia for battlefield amputations;
Ambulance Volante
Field Hospital
• Bichat(1771-1842): Delineation of
Tissues (Traites des Membranes)
Excision of pathological tissues
48
CONTINENTAL GIANTS:
SURGEONS 2
• Dupuytren (Paris) (1777-1835):
Finger Contracture; Ankle fracture
dislocation; Eye Surgery; Hernia Surgery
• Dieffenbach (Berlin) (1792-1847):
“The most skilled surgeon in Europe, in
most fields”
• Stromeyer (Hanover-1804-76): Tenotomy
49
MID-XIXC BARRIERS TO SURGERY
• PAIN
ANAESTHESIA
• INFECTION
ANTI/ ASEPSIS
• PHYSIOLOGY:
EXPERIMENT,
OBSERVATION
50
CONTINENTAL GIANTS :
NON SURGEONS
• G. MORGAGNI(1761) Seats ofDisease
• CLAUDE BERNARD (1813-1878)
Milieu Interieur
• LOUIS PASTEUR(1822-1895)
Germ Theory
• ROBERT KOCH(1843-1910)
Evidential Bacteriology
51
MID XIX C. WATERSHED
• Anaesthesia
• Physiology, Microbiology Anti(A)sepsis
• Unhurried exploration and
reconstruction
• Body Cavity Surgery (for the first time)
• Experimental Surgery pre-operation
52
LISTER-ANTISEPSIS
(1827-1912)
JOSEPH LISTER :UCL graduate(Robert
Liston).Appointed Glasgow Royal
Infirmary.
Carbolic Acid (Phenol) soaks for
wounds, for instruments, and hands
greatly reduced infection in open
fractures:1 deathin11.
(Lancet 1865-66)
Transferred to Edinburgh:
Closed patellar fractures internally
fixed NO INFECTIONS OR DEATHS
n53
53
Prof.Surgery, King’s College, London
THEODOR BILLROTH
(1829-1894)
• Prof.Vienna University
(formerly Zürich):
Training - School of
Surgery;
46 Gastrectomies and
reconstruction,both
benign gastric ulcers
and malignant (21)
• Animal experiments
pre-operation
• Musical:Brahms’s friend
54
Prevention of Infection
• Steam Sterilisation to eliminate microbes:
von Neuber (Kiel 1850-1923), Schimmelbusch
(1889) and von Bergmann(Berlin)
• Halsted (Baltimore): Scrub nurse (fianceé)
allergic to carbolic: rubber surgical gloves
(1889), which became routine
• Macewen (Glasgow 1848-1924): Surgical
Gown and Scrubbing ; boiling instruments(all
steel) First to remove intracranial tumour
55
XX C 1
• Moynihan,Godlee,Lane:GeneralSurgeon;
“Specialism” suspect ( ?charlatans)
• Robert Jones : Orthopaedic Surgery;
Organisation of fracture service
• WWI-Evacuation, Understanding Shock,
Blood Transfusion donor to recipient
• Gillies: Reconstruction Faces and Hands
56
SKIN GRAFTS and FLAPS
• SKIN GRAFTS (Free of fat):
THIERSCH(1822-1895): Partial Thickness
WOLFE (1824-1904): Full thickness
BURNS _ large areas: motorised blades;
animal skin(xenograft)
• FLAPS: Attached to skin at one end or side for
blood supply. Include fat; could have other tissue
(e.g. bone/ muscle for complex reconstruction)
• Pedicle Flap (Gillies): Flap’s edges sewn together to
reduce raw area (prevents infection)
57
XXC 2
• WWII: Worse trauma incidence; Shock
lessons re-learnt; functional restoration
• McIndoe at E.Grinsted: Burnt Faces
• Antibiotics
• Fixation of fractures to allow early
mobility-Küntscher Femoral Rod
• Lung Resection for Cancer and TB
• Cardiac surgery: correct physiology
58
TAUSSIG & BLALOCK (&Thomas)
ALFRED BLALOCK
HELEN
VIVIAN
THOMAS
TAUSSIG
Blalock and Taussig 2
60
Blalock’s Subclavian Shunt
ALFRED BLALOCK
• Blalock’s Diagram
VIVIAN
THOMAS
61
OPEN CARDIAC SURGEY
• Pump Oxygenator: Gibbon (Philadelphia),
Melrose(Hammersmith and Stanford),
Lillhei (Minnessota), Kirklin(Mayo Clinic)
• Open Correction Congenital Defects
• Prosthetic and Animal Valves (Xenografts)
• Myocardial Ischaemia
• Transplant
• Intensive-care, Nursing , Rehabilitation
62
XXC 3a
• ExternalProstheses: Artificial
limbs transformed by material
science, engineering,
biomechanics
• Internal Prostheses: Joints;
Blood Vessels; Heart Valves
63
XXC ENDOSCOPY
• RIGID FLEXIBLE TUBES
• BULBS ROD LENS +
FIBRELIGHT(Hopkins)
• SAFE DISTENSION:CO2;
Modified Ringer;
Glycine
• OPERATIVE EQUIPMENT
64
MICRO-SURGERY
(Operating Microscope & Instruments)
• ENT: Stapes& Cochlear implants, Larynx
• OPHTHALMOLOGY: Cataract(lens), Glaucoma
• NEURO–SURGERY: Brain- tumours, aneurisms
Spinal Cord, Nerve Roots (micro-discectomy)
• PERIPHERAL VESSELS & NERVES-Micro-Neural
& Vascular Suture/ graft ; Replantation
limbs/digits; Brachial Plexus Nerve Graft
• FREE FLAP RECONSTRUCTION
65
ORGAN TRANSPLANT 1
(Live and Cadaver)
• CORNEA:
Free Allograft (like skin)
• CARREL (1873-1944): Vascular Anastomosis
• MEDAWAR;
IMMUNITY
BURNETT :
(SELF/NON-SELF)
• MURRAY (Harvard) : KIDNEYtrnsplnt.(TWINS)
• CALNE (Harvard,R.Free): 6MP- poor results
• STARZL (Colorado): AZATHIOPRINE+STEROIDS
27/33 survived
66
ORGAN TRANSPLANT 2
• CYCLOSPORINE(Calne1978) NEED FOR
HIGH DOSE STEROIDS (and side-effects)
ABOLISHED; partial preservation of immune
reponse
• DONOR MATCHING: increasing sophistication
• OTHER ORGANS: liver, heart, lungs, pancreas
• DONOR SHORTAGE : Reduced RTA mortality
?“Presumed Consent”;
?animal organ ?temp.
67
TUMOURS 1
• WIDER AND DEEPER EXCISION (Halsted’s
Radical Mastectomy)– HIGH FAILURE
• LOCAL EXCISION +- radiation (Patey’s
Local Mastectomy)—NO WORSE
• LOCAL IMPLANTATION of RADIATION
SOURCE ---Radium; Radio-Isotopes
(Iodine, Yttrium, Radon)
SOME SUCCESS
68
TUMOURS 2
• EXTERNAL RADIOTHERAPY-Deep
Xrays,Cobalt, etc. -- Metastateses and
some primary tumours
• CHEMO & HORMONAL THERAPY
• IMMUNOTHERAPY/Tumour Biology
• COMBINED THERAPY
Superior results
69
XX C Last Decade
• Basic Sciences , Engineering , Material Science,
and Diagnostic Modalities have shaped
Surgery_ TEAM WORK
• Surgery at extremes of age
• Cost/Benefit Ratio; NICE; “Rationing”
• Ethics: “Patient’s Welfare paramount”
Hippocrates_ Helsinki(1964)_Tokyo(1975)
• External Regulation--- Government, Insurers
• “FIRST DO NO HARM”- RiskTaking v/sLitigation
70