Evolution of Modern Surgery:

Historical Overview

K.M.N. KunzruMS FRCS DHMSA

Emeritus Consultant Orthopaedic Surgeon1

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SCOPE

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INTRODUCTION• Overview• Details of Instrumentation and Technique

excluded• Some Specialties only• EVOLUTION –

Dead Ends Hypertension-Sympathectomy Dinosaurs Duodenal Ulcers-Gastrectomy

VagotomyMyths! “Visceroptosis” (“dropped” organs)

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ETYMOLOGY1

Greek EnglishΧέίροϋργη (cheirourgy) “Treatment by Hand”

Surgeryχέίρ (cheir) hand Έργον (ergon) work, or activityΧέίροϋργος (cheirourgos) Surgeon

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ETYMOLOGY 2

Latin Older Modern English English

Chirurgia Chirurgery Surgery

Chirurgos Chirurgeon Surgeon

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STONE AGE ‘SCENE’“Life without injury can hardly be

imagined” Wells, 1964

Kirkup6

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The Best Instrument

Wells Cathedral

Sculpture

“Thorn Extraction”

after Kirkup

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INDIA 1 Suśruta• Suśruta:

Mid 1st. Millenium BCE ;

• Kāśī (Varanasi)

• Compendium of Surgery Suśrutasam hitā (probably written by his students)

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Kāśī

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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”)

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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)

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SUŚRUTA’S OPERATIONSREPRODUCED

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SURGICAL INSTRUMENTS(NAQVI)

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TAXILA

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INDIA 2 Vāgbhatt

• Vāgbhatt : Mid 1st. Millenium CE;

• Fled from Sindh to Mālwā (Central India)• Two Compendia • Author: ?homonymous grandson

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SindhMālwā

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Greece and Rome• HIPPOCRATES (?460-370 BCE)

• CELSUS (25BCE-50CE) ? Encyclopaedist

• GALEN(90-138CE) Large corpus of work (in Greek)

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1st. MILLENIUM CE 1• European

stagnation• Christian legends

Ss. Cosmas and Damian “transplanting a leg” (Emery)

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1st. 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.

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ARABIC TRANSLATIONS

• Hunayn-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)

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SURGERY• Hunayn-ibn-Ishāq (Joannitus):

Ophthalmic Surgery(Couching for Cataract)

• Al-Rhāzi (Rhazes): Rayy Baghdad• Ibn Sinna (Avicenna): Bukhara B’dad• Al-Zahrāwī(Albucasis):Cordoba,Spain

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ALBUCASIS (al-Zahārāwī) 1• ALBUCASIS ‘On Surgery

& Instruments’ • circa 1,000 CE in

Cordoba• Known from 1188

illustrated manuscript

• This translation 1973

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“ISLAMIC” EUROPEEuropean “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

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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)

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WOUND MAN

STUDENT LEAFLET wounds weaponry treatment notes

(de KETHAM, circa 1400)

after Kirkup

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SURGEONS INSTRUMENTS

BRUNSCHWIG’S ARMAMENTARIUM,

1497 One of the first printed

books on surgery. Mostly artisanal tools -

modified

after Kirkup

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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”

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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

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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)

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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

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PARÉ’S PROSTHESES

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KIRKUP

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AMBROISE PARE “The Workes”

FIRST ENGLISH TRANSLATION, 1634

after Kirkup

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Companies of Barber-Surgeons

• Ireland : Henry VI 1499

• Edinburgh: James IV 1505

• London :HenryVIII 1540

• Glasgow:James VI 1599

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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

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WOODALLSEA SURGEON’S HANDBOOK

JOHN WOODALL’S “SURGIONS MATE” 1617

COMPULSORY PURCHASE FOR ALL SHIPS SURGEONS OF THE EAST INDIA COMPANY

after Kirkup

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WOODALL’S INSTRUMENT CHEST

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Woodall censured for profiteering from sale of chest: compulsory for surgeons of East India Company

AFTER KIRKUP

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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

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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

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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

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WILLIAM CHESELDEN (1688-1752), Anatomist & Lithotomist

London Company of Surgeons-1745 after Kirkup

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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 Midlands38

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JOHN HUNTER (1728- 1793) 1

• Cheselden’s pupil • The “Father”ofModern

Scientific SurgeryHuman & Comparative Anatomist, Physiologist,PathologistSurgeon (Exptl.)

• Collector (Museum)• Teacher (after Kirkup)

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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

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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

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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)

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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

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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)

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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

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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

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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)

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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

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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

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MID-XIXC BARRIERS TO SURGERY

• PAINANAESTHESIA

• INFECTION ANTI/ ASEPSIS

• PHYSIOLOGY: EXPERIMENT, OBSERVATION 50

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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

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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

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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

Prof.Surgery, King’s College, London

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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 friend54

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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

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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

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SKIN GRAFTS and FLAPS

• SKIN GRAFTS (Free of fat):THIERSCH(1822-1895): Partial ThicknessWOLFE (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)

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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

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TAUSSIG & BLALOCK (&Thomas)

VIVIAN THOMAS

HELEN TAUSSIG

ALFRED BLALOCK

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Blalock and Taussig 2

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Blalock’s Subclavian Shunt

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ALFRED BLALOCK

• Blalock’s Diagram

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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

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XXC 3a

• ExternalProstheses: Artificial limbs transformed by material science, engineering, biomechanics

• Internal Prostheses: Joints; Blood Vessels; Heart Valves

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XXC ENDOSCOPY • RIGID FLEXIBLE TUBES• BULBS ROD LENS +

FIBRELIGHT(Hopkins)• SAFE DISTENSION:CO2;

Modified Ringer; Glycine

• OPERATIVE EQUIPMENT

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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

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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

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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.

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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

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TUMOURS 2

• EXTERNAL RADIOTHERAPY-Deep Xrays,Cobalt, etc. -- Metastateses and some primary tumours

• CHEMO & HORMONAL THERAPY • IMMUNOTHERAPY/Tumour Biology

• COMBINED THERAPY Superior results

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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

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