Dr. Ahmed Saleem
FICMS
TUCOM / 3rd Year / 2015
History of Surgery
IMPORTANCE OF UNDERSTANDING SURGICAL HISTORY
Clearly, the study of medicine is a lifelong learning process that should be an enjoyable and rewarding
experience. For a surgeon, the study of surgical history can contribute toward making this educational
effort more pleasurable and can provide constant invigoration. Tracing the evolution of what one does on a
daily basis and understanding it from a historical perspective become enviable goals. In reality, there is no
way to separate present-day surgery and one's own clinical practice from the experience of all surgeons and
all the years that have gone before.
HISTORICAL RELATIONSHIP BETWEEN SURGERY AND MEDICINE
Despite outward appearances, it was actually not until the latter decades of the 19th century that the
surgeon truly emerged as a specialist within the whole of medicine to become a recognized and respected
clinical practitioner. Similarly, it was not until the first decades of the 20th century that surgery could be
considered to have achieved the status of a real profession.
With the breathtaking advances made in pathologic anatomy and experimental physiology during the 18th
and the first part of the 19th centuries, physicians would soon adopt a therapeutic viewpoint that had long
been prevalent among surgeons.
The art and craft of surgery, for all its practical possibilities, would be severely restricted until the discovery
of anesthesia in 1846 and an understanding and acceptance of the need for surgical antisepsis and asepsis
during the 1870s and 1880s. Still, surgeons never needed a diagnostic and pathologic revolution in the
manner of the physician. Despite the imperfection of their scientific knowledge, the pre–modern era
surgeon did cure with some technical confidence.
That the gradual evolution of surgery was superseded in the 1880s and 1890s by the rapid introduction of
startling new technical advances was based on a simple culminating axiom—the four fundamental clinical
prerequisites that were required before a surgical operation could ever be considered a truly viable
therapeutic procedure had finally been identified and understood:
1) Knowledge of human anatomy
2) Method of controlling hemorrhage and maintaining intraoperative hemostasis
3) Anesthesia to permit the performance of pain-free procedures
4) Explanation of the nature of infection along with the elaboration of methods necessary to achieve an
antiseptic and aseptic operating room environment
The first two prerequisites were essentially solved in the 16th century, but the latter two would not be fully
resolved until the ending decades of the 19th century. In turn, the ascent of 20th century scientific surgery
would unify the profession and allow what had always been an art and craft to become a learned vocation.
Page 1 of 5
KNOWLEDGE OF HUMAN ANATOMY
Few individuals have had an influence on the history of surgery as overwhelmingly as that of the Andreas
Vesalius (1514-1564). As professor of anatomy and surgery in Padua, Italy, Vesalius taught that human
anatomy could be learned only through the study of structures revealed by human dissection. In particular,
his great anatomic treatise De Humani Corporis Fabrica Libri Septem (1543) provided fuller and more
detailed descriptions of human anatomy than any of his illustrious predecessors did. Most importantly,
Vesalius corrected errors in traditional anatomic teachings propagated 13 centuries earlier by Greek and
Roman authorities, whose findings were based on animal rather than human dissection. Even more radical
was Vesalius' blunt assertion that anatomic dissection must be completed by physician/surgeons
themselves; this principle of hands-on education would remain Vesalius' most important and long-lasting
contribution to the teaching of anatomy.
METHOD OF CONTROLLING HEMORRHAGE
The position of Ambroise Paré (1510-1590) in the evolution of surgery remains of supreme importance. He
represents severing of the final link between surgical thought and techniques of the ancients and the push
toward more modern eras. Although other surgeons made similar observations about the difficulties and
nonsensical aspects of using boiling oil as a means of cauterizing fresh gunshot wounds, Paré's use of a less
irritating emollient of egg yolk, rose oil, and turpentine brought him lasting fame and glory. Among Paré's
important corollary observations was that when performing an amputation, it was more efficacious to
ligate individual blood vessels than to attempt to control hemorrhage by means of mass ligation of tissue or
with hot oleum. He described that the free or cut end of a blood vessel was doubly ligated and the ligature
was allowed to remain undisturbed in situ until, as a result of local suppuration, it was cast off.
PATHOPHYSIOLOGIC BASIS OF SURGICAL DISEASES
Although it would be another 3 centuries before the anesthesia, was discovered, much of the scientific
understanding concerning efforts to relieve discomfort secondary to surgical operations was based on the
18th century work of England's premier surgical scientist, John Hunter (1728-1793). Considered one of the
most influential surgeons of all time, his endeavors stand out because of the prolificacy of his written word
and the quality of his research, especially in using experimental animal surgery as a way to understand the
pathophysiologic basis of surgical diseases. Most impressively, Hunter relied little on the theories of past
authorities but rather on personal observations, with his fundamental pathologic studies first described in
the renowned textbook A Treatise on the Blood, Inflammation, and Gun-Shot Wounds (1794). Ultimately,
his voluminous research and clinical work resulted in a collection of more than 13,000 specimens, which
became one of his most important legacies to the world of surgery.
Page 2 of 5
ANESTHESIA
The inability of surgeons to complete pain-free operations had been among the most terrifying of medical
problems. In the preanesthetic era, surgeons were forced to be more concerned about the speed with
which an operation was completed than with the clinical efficacy of their dissection, patients refused or
delayed surgical procedures for as long as possible to avoid the personal horror of experiencing the
surgeon's knife. Analgesic, narcotic, and soporific agents such as hashish, mandrake, and opium had been
put to use for thousands of years. However, the systematic operative invasion of body cavities and the
inevitable progression of surgical history could not occur until an effective means of rendering a patient
insensitive to pain was developed.
As anatomic knowledge and surgical techniques improved, the search for safe methods to prevent pain
became more pressing. By the early 1830s, chloroform, ether, and nitrous oxide had been discovered. It
soon became evident to various physicians and dentists that the pain-relieving qualities of ether and nitrous
oxide could be applicable to surgical operations and tooth extraction. On October 16, 1846, William T. G.
Morton (1819-1868), a Boston dentist, persuaded John Collins Warren (1778-1856), professor of surgery at
the Massachusetts General Hospital, to let him administer sulfuric ether to a surgical patient from whom
Warren went on to painlessly remove a small, congenital vascular tumor of the neck. After the operation,
Warren, greatly impressed with the new discovery, uttered his famous words: “Gentlemen, this is no
humbug.”
Few medical discoveries have been so readily accepted as inhalational anesthesia. News of the momentous
event spread rapidly throughout the United States and Europe, and a new era in the history of surgery had
begun. Within a few months after the first public demonstration in Boston, ether was used in hospitals
throughout the world. Yet no matter how much it contributed to the relief of pain during surgical
operations and decreased the surgeon's angst, the discovery did not immediately further the scope of
elective surgery. Such technical triumphs awaited the recognition and acceptance of antisepsis and asepsis.
Anesthesia helped make the illusion of surgical cures more seductive, but it could not bring forth the final
prerequisite: all-important hygienic reforms.
ANTISEPSIS, ASEPSIS, AND UNDERSTANDING THE NATURE OF INFECTION
In many respects, the recognition of antisepsis and asepsis was a more important event in the evolution of
surgical history than the advent of inhalational anesthesia was. Without antisepsis and asepsis, major
surgical operations more than likely ended in death rather than just pain. Clearly, surgery needed both
anesthesia and antisepsis, but in terms of overall importance, antisepsis proved to be of greater singular
impact.
In the long evolution of world surgery, the contributions of several individuals stand out as being
preeminent. Lister, an English surgeon, can be placed on such a select list because of his monumental
efforts to introduce systematic, scientifically based antisepsis in the treatment of wounds and the
performance of surgical operations.
Page 3 of 5
It was evident to Lister that a method of destroying bacteria by excessive heat could not be applied to a
surgical patient. He turned, instead, to chemical antisepsis and, after experimenting with zinc chloride and
the sulfites, decided on carbolic acid. By 1865, Lister was instilling pure carbolic acid into wounds and onto
dressings. He would eventually make numerous modifications in the technique of dressings, the manner of
applying and retaining them, and the choice of antiseptic solutions of varying concentrations. Although the
carbolic acid spray remains the best remembered of his many contributions, it was eventually abandoned in
favor of other germicidal substances. Lister not only used carbolic acid in the wound and on dressings but
also went so far as to spray it in the atmosphere around the operative field and table. A second important
advance by Lister was the development of sterile absorbable sutures. He believed that much of the deep
suppuration found in wounds was created by previously contaminated silk ligatures. Lister evolved a
carbolized catgut suture that was better than any previously produced.
As a professional group, German-speaking surgeons would be the first to grasp the importance of
bacteriology and the germ theory. Consequently, they were among the earliest to expand on Lister's
message of antisepsis, with his spray being discarded in favor of boiling and use of the autoclave. The
availability of heat sterilization engendered sterile aprons, drapes, instruments, and sutures. Similarly, the
use of facemasks, gloves, hats, and operating gowns also naturally evolved. By the mid-1890s, less clumsy
aseptic techniques had found their way into most European surgical amphitheaters and were approaching
total acceptance by American surgeons. Any lingering doubts about the validity and significance of the
momentous concepts that Lister had put forth were eliminated on the battlefields of World War I. There,
the importance of just plain antisepsis became an invaluable lesson for scalpel bearers.
X-RAYS
Especially prominent among other late 19th century discoveries that had an enormous impact on the evolution of
surgery was research conducted by Wilhelm Roentgen (1845-1923), which led to his 1895 elucidation of x-rays.
Having grown interested in the phosphorescence from metallic salts that were exposed to light, Roentgen made a
chance observation when passing a current through a vacuum tube and noticed a greenish glow coming from a
screen on a shelf 9 feet away. This strange effect continued after the current was turned off. He found that the screen
had been painted with a phosphorescent substance. Proceeding with full experimental vigor, Roentgen soon realized
that there were invisible rays capable of passing through solid objects made of wood, metal, and other materials.
Most significant, these rays also penetrated the soft parts of the body in such a manner that the more dense bones of
his hand were able to be revealed on a specially treated photographic plate. In a short time, numerous applications
were developed as surgeons rapidly applied the new discovery to the diagnosis and location of fractures and
dislocations and the removal of foreign bodies.
TURN OF THE 20TH CENTURY
By the late 1890s, the interactions of political, scientific, socioeconomic, and technical factors set the stage
for what would become a spectacular showcasing of surgery's newfound prestige and accomplishments.
Surgeons were finally wearing antiseptic-looking white coats. Patients and tables were draped in white, and
basins for bathing instruments in bichloride solution abounded. Suddenly all was clean and tidy, with
conduct of the surgical operation no longer a haphazard affair. This reformation would be successful not
because surgeons had fundamentally changed but because medicine and its relationship to scientific inquiry
had been irrevocably altered.
Page 4 of 5
WORLD WAR I
As with most armed conflicts, because of the massive human toll, especially battlefield injuries, tremendous
strides were made in multiple areas of surgery. Undoubtedly, the greatest surgical achievement was in the
treatment of wound infection. On the battlefront, sepsis was inevitable. Most attempts to maintain aseptic
technique proved inadequate, but the treatment of infected wounds by antisepsis was becoming a
pragmatic reality.
Surgeons experimented with numerous antiseptic solutions and various types of surgical dressing. A
principle of wound treatment entailing débridement and irrigation eventually evolved. Henry Dakin (1880-
1952), an English chemist, and Alexis Carrel (1873-1944), the Nobel prize–winning French American
surgeon, were the principal protagonists in the development of this extensive system of wound
management.
LAST HALF OF THE 20TH CENTURY
The decades of economic expansion after World War II had a dramatic impact on surgery's scale. Spacious
hospital complexes were built represented the scientific advancement of the healing arts.
The overwhelming impact of World War II on surgery was the sudden expansion of the profession and the
beginnings of an extensive distribution of surgeons. Large urban and community hospitals established
surgical education and training programs and found it a relatively easy matter to attract interns and
residents. For the first time, residency programs in general surgery were rivaled in growth and educational
sophistication by those in all the special fields of surgery. These changes served as fodder for further
increases in the number of students entering surgery.
FUTURE TRENDS
Throughout most of its evolution, the practice of surgery has been largely defined by its tools and the
manual aspects of the craft. The last decades of the 20th century saw unprecedented progress in the
development of new instrumentation and imaging techniques. These refinements have not come without
noticeable social and economic cost. Advancement will assuredly continue, for if the study of surgical
history offers any lesson, it is that progress can always be expected, at least relative to technology. There
will be more sophisticated surgical operations with better results. Eventually, automation may even
robotize the surgeon's hand for certain procedures. Still, the surgical sciences will always retain their
historical roots as fundamentally a manually based art and craft.
To study the fascinating history of our profession, with its many magnificent personalities and outstanding
scientific and social achievements, may not necessarily help us predict the future of surgery. However, it
does shed much light on the clinical practices of our own time. To a certain extent, if surgeons in the future
wish to be regarded as more than mere technicians, the profession needs to better appreciate the value of
its past experiences. Surgery has a distinguished heritage that is in danger of being forgotten. Although the
future of the art, craft, and science of surgery remains unknown, it assuredly rests on a glorious past.
Page 5 of 5