A BRIEF HISTORY OF

SURGERY

ANCIENT SURGERY

‘WHEN SURGERY BEGAN IT WAS LITTLE MORE THAN OPTIMISTIC BUTCHERY’

The most common form of ancient surgery is bloodletting. The Greeks believed that any imbalance in the 4 humors; phlegm, yellow bile, black bile and blood could cause sickness. For these reasons bloodletting was a logical treatment.

The obvious risk to bloodletting as a treatment was the risk of people bleeding to death.

Early surgery was limited, defective and usually ended in fatality. This has changed thanks to the 4 major surgical breakthroughs of the last 500 years. In this booklet I will try my best to outline the major innovations.

ANATOMY

Leonardo DaVinci was the first person to create accurate drawings of the human anatomy, he didn’t publish these drawings. In 1536 at the age of 22, Andreas Vesalius stole a dead criminal’s body to enable him to make the first comprehensive studies into human anatomy. He took the rotting body back to his house, boiled the skin off the body and re-esembled the bones one by one to create and accurate human skeleton. After he had successfully identified all parts of the human skeleton. He did the same process with other dead bodies for the muscular, organ and nervous systems.

Through his investigations Vesalius was challenged the work of Galen. This deemed over 1300 years of medical training deeply flawed as Vesalius had corrected over 200 mistakes which Galen had made. In 1543 Vesalius published ‘De humani corporis fabrica’ (on the fabric of the human body). Vesalius had changed surgery with the book having completed the first comprehensive study of human anatomy.

The manner in which Vesalius tended to his work could arguably be thought of as more significant than the work itself. By relying on his own observations Vesalius created a new scientific method. His desire to strive for the truth is most evident through his ability to correct his own claims and to continually reshape his thoughts on the human body. Through his attention to detail, he was able to provide clear descriptions and unprecedented anatomical drawings that set a new standard for future medical books.

BLEEDING

When a human loses 3 litres of blood without it being replaced they die. When guns started to be used in wars during the 16th century severe blood and limb loss became more common than before. Before this time hot irons were used to cauterize wounds. During the 16th century the same tools were used to cut hair as were used to amputate a limb.

In 1537 a French barber surgeon called Ambroise Pare was sent as a battlefield surgeon to the Siege of Turin. As a surgeon he ampu-tated limbs, at the time this was an enormously risky procedure, it meant pain and even more blood loss. His patients frequently bled to death before he could boil the cauterizing oil.

During his time as a battlefield surgeon Pare brought back to use of Ligatures to stem blood loss. The technique took nearly 100 years to be adopted as common practice amongst surgeons.

PAIN RELIEF

Up until 1840 if you needed an operation you would be conscious throughout. It seems that victorian surgeons didn’t think pain was a bad thing, they had access to a range of pain reliev-ing techniques which they chose not to use. A couple of the techniques available to Victorian surgeons were hypnosis and alcohol. Hypnosis was not a time effecient option and alcohol proved to be ineffective.

In 1827 16 year old Scottish medical student James Younger Simpson attended his first oper-ation, a breast removal. With no pain relief the surgeon had to perform the operation qucikly. Simpson found the experience so horrific that he temprarily gave up medicine, he then began to think about the importance of pain relief.

In 1846 he received news that American dentist, William Morton had perfomed the first painless surgery using a substance called Ether. Simpson experimented with Ether and found it had problems. Ether was originally made by mixing alcohol with sulphuric acid, it was a popular ‘party’ drink of the time.

It was a very effective anaesthetic which had one drawback, it was extremely flammable. This was a problem in the gas lit hospitals of the time.Ether also irritated people’s throats and made them thrash about, not what the surgeon wants during delicate surgery.

The need for a better anaesthetic was apparent. Simpson tok advantage of this and discovered Chloroform in 1847 during a routine drug binge. The discovery of was not a new one however, it was made 15 years earlier by Doctor Samuel Guthrie after he mixed 2 gal-lons of whiskey with 2 pounds of chloronated lime and fed it to his daughter. Shortly after she passed out. Guthrie advertised it as a stimulant and failed to realise Chloroforms anaesthetic qualities.

Simpson began using Chloroform successfully on patients. Around this time Chloroforms main weakness started to become apparent, that it can be fatal in small doses. Simpson refused to believe this and did not investigate what was causing the deaths.

Doctor Jon Snow (best known for proving cholera is waterborn) became intrigued by the chloroform deaths.Through autopsy reports he noticed the people who died all had certain things in common, they were mostly young, fit and/or fearful. Snow investigated the exact measures of chloroform in the dead bodied and experimented with the doese on animals. Snow soon discovered that Chloroform can badly damage the heart, as chloroform works by reducing the speed in which every cell works in the body. Too high a dosage can stop the heart.

Chloroform is an extremely dangerous drug, the safe dose parameters are very small. A third of a teaspoon can kncok you out and half a tea spoon can kill you. Snow realised that young and fit people needed a higher dose to knock them out, this pushed the amount of chloroform they were taking closer to the fatal dosage.Fearful people would hold their breath and take a deep breath, inhaling a lot of chloroform at once, this is what took the close to the fatal dosage.

Snow invented a chloroform inhaler, this allowed each patient to inhale a consistent dosage. Snow administered chloroform to over 4000 patients, including Queen Victoria, without a single death. He made the drug safer to use, chloroform went on being used in to the 20th century.

In short, James Simpson brought the anaesthetic uses of chloroform to the world and Jon Snow made it safe to use.

INFECTION

Even with the use of anaesthetics the survival rate for operations was less than 50%.

Finding out why this was became an obsession of Hungarian Ignaz Semmelweis. In 1847, the 29 year old Semmelweis began working in the maternity unit of the Vienna General Hospital. He noticed hundreds of women were dying of Childbed Fever, symptons included; swollen abdomen, abcesses, fever and ultimately death. The cause and cure for the disease is unknown. In the hospital there are 2 units, 1 run by midwives, the other by doctors. The mothers in the doctors part of the hospital are 9 times more likely to die of childbed fever.

A doctor friend of Semmelweis cut his hand whilst performing an autopsy, he was dead within a few days. His autopsy results showed a swollen abdomen and abcesses. The symptoms of childbed fever.

Without consulting his superiors Semmelweis posted a notice on the surgery door instructing doctors to wash their hands in chloride of lime

before and after they saw to their patients. This notice was very unpopular with Semmelweis’ peers. Doctors found the handwashing tedious and time consuming and found it to be pointless. Semmelweis hung around the wards day and night and forced his colleagues to wash their hands properly.

The handwashing worked, deaths from childbed fever fell from 10% to less that 3%.

Semmelweis had no rational or scientific information on how or why dirty hands caused disease and death. The women in the hospital were dying from what we now call septicemia (blood poisoning). At the time Semmelweis did not know the exact cause of the disease, but he knew that handwashing could fix the problem.

Without a proper explanation Semmelweis’ colleagues laughed at his evidence and claims. Semmelweis moved back to Budapest, Hungary and became director of the maternity ward at the Saint Rockers Hospital. When he came to the unit 1 in 3 women died of childbed fever.

Semmelweis began a rigorous campaign of cleanliness. Hands, linen and instruments all had to be cleaned between patients.

It took 6 years for Semmelweis to cut the death rate from 33% to less than 1%. Back in Vienna, where they had abandoned his methods hundreds of women died from childbed fever each year. In 1860 Semmelweis published a book about his findings, ‘Etiology, Concept and Prophylaxis of Childbed fever’. The book was badly received and Semmelweis too to heavy drinking and the carnal usage of prostitutes. He was sent to live in a lunatic asylum, in the asylum he became very ill and died of septicemia (childbed fever) aged 47. The same disease that had killed his friends and hundreds of women.

By the time of Semmelweis’ death Louis Pasteur had discovered that microbes cause decay.

In 1865 Scotsman Joseph Lister put together Semmelweis and Pasteur’s findings.

After a friend commented that the hospital Lister worked at smelt of sewage. Lister had the idea to clean the hospital instruments with the same chemical used to get rid of the smell of sewage. Carbolic acid. He used it before he performed surgery on a young boy, the boy survived so Lister chose to use the method again. Soon Lister’s death rates had fallen by 66%. It took 12 years for this to become common practice amongst British surgeons.

a) Autoclave i.e. steam under pressure

b) Boiling water

c) Boiling oil

d) Naked flame

e) Immersion in antiseptics

f) Paraform vapour

g) Dry heat (baking)

VARIOUS METHODS OF STERILISATION.

‘IN SURGERY THERE IS NO SUCCESS WITHOUT FAILURE. NO PROGRESS WITHOUT RISK.’