The history of developments in the field of surgery since the dawn of civilization, leading to modernization of the field to the current scientific era.

1. THE RISE OF
MODERN SURGERY
Dr. Sunil K S Gaur
MS (Surgery),
HIMS,Varanasi, India

2. Why study history?
■ To help us understand the field
today.
■ To make better decisions so that we
don’t repeat the mistakes of the
past.
■ To inspire us
■ To develop critical thinking skills

3. The Beginnings
■ From earliest recorded history through late 19th century – Pre-scientific, Pre-
anaesthetic and Pre-antiseptic times.
■ Operations were always frightening, frequently infected and often fatal.
■ Inevitably for ailments that could be visualized – on skin, just below skin, extremities
or in mouth
■ Till 14th century by Barber-surgeons.
– Vocation passed from father to son
– Ostracized by elite, university educated physicians
– Lanced abscesses, fixed simple fractures, dressed wounds, extracted teeth and
rarely amputated a digit or limb

4. Barber-surgeons
■ According toWikipedia:
“The barber surgeon, one of the
most common European medical
practitioners of the Middle Ages, was generally
charged with caring for soldiers during and
after battle. In this era, surgery was seldom
conducted by physicians, but instead
by barbers, who, possessing razors and
coordination indispensable to their trade, were
called upon for numerous tasks ranging from
cutting hair to amputating limbs.
In this period surgical mortality was
very high, due to blood loss and infection. Yet
since doctors thought that blood letting treated
illness, barbers also applied leeches.
Meanwhile, physicians considered themselves
to be above surgery.[1] Physicians mostly
observed surgical patients and offered
consulting, but otherwise often chose
academia, working in universities, or chose
residence in castles where they treated the
wealthy.”

5. The Beginnings (contd.)
■ Around 15th century, highborn physicians began to show interest in surgery.
■ As surgical techniques evolved wider range of surgeries were performed.
■ Ligated arteries, excised large visible tumours, performed trephinations, reduction of
hernias, performed rudimentary stomas, anal fistulas, cataracts, etc.
■ However, opening the cavities of the body was unknown and dangerous.
■ Despite the imperfection of their knowledge, prescientific surgeons with their
unwavering approach to treatment many a times achieved cure with technical
confidence.

6. The Beginnings (contd.)
■ Though surgeons never needed a diagnostic and pathophysiologic revolution in the style of
physician, they did need elaboration of 4 key elements:
– Knowledge of anatomy These 2 elements started to be
– Control of bleeding addressed by 16th century
– Control of pain 1840s
– Control of infection 1870s
■ Other soon to come
– discoveries like x-ray, blood transfusion, frozen section, etc.
– administrative and organizational events (education & training programs, experimental
surgical laboratories, textbooks, journals and professional societies and licensing boards)
– allowed surgery to emerge as a speciality.

7. Knowledge of Anatomy
■ Around late-1400s: Pope Sixtus IV and Pope ClementVII lifted the long-standing ban of
human dissection.
■ In 1543: AndreasVesalius presented his treatise, De Humani Corporis Fabrica Libri
Septem (On the Fabric of Human Body in Seven Books)
– Corrected errors of past Greek and Roman authorities.
– Had pictures that were scientifically accurate and creatively beautiful: believed to be
works of artists from school ofTitian,Venice.
■ In 1628: William Harvey showed that heart acts as a pump forcing blood in arteries
and back via veins.
■ During 18th and first half of 19th century surgeon-anatomist made some of their most
remarkable observations.

9. Control of Bleeding
■ Ancient medical saying: “Those diseases that medicine does not cure, iron cures; those
that iron cannot cure, fire cures; and those that fire cannot cure are incurable”
■ Application of hot iron or boiling oil for haemostasis.
■ Around 1530s and 40s: Ambroise Pare sought other approaches to staunch
haemorrhage.
– Was a barber-surgeon
– But due to great reputation, served as surgeon-in-chief for 4 French kings
– Made a member of Paris-basedCollege of St. Come

10. Control of Bleeding (contd.)
■ During a battle his supply of boiling oil ran out, so used a paste of egg-yolk, crushed
rose petals and olive oil – later he observed that wounds were neither as inflamed nor
as tender.
■ Thus, started experimenting with alternate methods.
■ Decisive answer came in the form of reintroduction of “ligature” – proved to be a
turning point.
■ Also developed a pinching instrument called bec de corbin (crow’s beak).
■ Did not became very popular immediately due to lack of exposure.
■ Early 18th century: Jean-Louis Petit invented screw compressor tourniquet.

11. Control of Bleeding (contd.)

12. Control of Bleeding (contd.)
■ 1880s: Began experimenting with electric devices
■ 1926:William Bovie developed electro-scalpel which was used by Harvey Cushing.
■ Now many energy devices are used for haemostasis like monopolar and bipolar
electrocautery, harmonic scalpel, vessel sealers etc.

13. Control of Pain
■ In prescientific era, patients refused surgery because of pain.
■ Also, scalpel wielder was more concerned about speed than dissection.
■ Mid 1830s: Nitrous oxide had been discovered
– Initially used as recreational agent.
– After few puffs person lost equilibrium and knocked into nearby object but had little
discomfort.
– This pain relieving potential was recognized by physicians.
■ 1844: Horace Wells, pioneered the use of laughing gas in dentistry.
■ According toWikipedia:
– “He gave a demonstration to medical students at the MassachusettsGeneral Hospital in Boston onJanuary 20, 1845.
However, the gas was improperly administered and the patient cried out in pain.The patient later admitted that
although he cried out in pain, he remembered no pain and did not know when the tooth was extracted.[1]The audience of
students in the surgical theatre jeered "humbug".”

14. Control of Pain (contd.)

15. Control of Pain (contd.)
■ 1846: WilliamT. G. Morton demonstrated the use of sulfuric ether
– in a public demonstration at Massachusetts General Hospital anaesthetized a man
with inhalation of sulfuric ether and a small vascular tumour was excised from the
neck without any pain
– The surgeon John CollinsWarren uttered the five famous words in history of surgery,
“Gentlemen, this is no humbug.”
■ 1885: Nerve blocks,William Halstead
■ At the same time: Spinal anaesthesia by James Corning andAugust Bier
■ 1934: Intravenous anaesthetic agent – SodiumThiopental

16. Control of Pain (contd.)

17. Control of Infection
■ Pain would make surgery difficult, but infection would result in death.
■ 1857: Louis Pasteur showed that fermentation was carried out by invisible “germs”
■ 1860: Refuted the theory of spontaneous generation and demonstrated that germs
contaminated the liquids from outside
■ 1865: Joseph Lister gave concept of antisepsis
– These “germs” were cause of wound healing difficulties
– Proposed use of antiseptic solution (carbolic acid) for hand dipping, wound dressing
and cleaning of surfaces & instruments.
– Also developed sterile absorbable sutures eliminating the need to bring out the ends
from incision

18. Control of Infection (contd.)

19. Control of Infection (contd.)
■ However, acceptance was slow and uneven.
■ Overtime, antisepsis gave way to asepsis.
■ 1878: Rubber gloves developed by India-RubberWorks in Surrey, England
■ 1897: Jan Mikulicz-Radecki developed single-layer gauge mask.

20. Control of Infection (contd.)

21. Other Advances
■ X-rays
– Dec 1895, Wilhelm Roentgen
– By March 1896, first
contributions regarding use of
roentgenography in medicine
were reported

22. Other Advances (contd.)
■ Blood transfusion:
– Earlier scattered reports of
transfusion throughout 19th
century.
– Halstead gave blood to his sister
for post-partum haemorrhage.
– 1901: Karl Landsteiner, ABO
groups
– 1914:WW1, anticoagulants and
refrigeration
– 1937: First blood bank
– 1939: Rh grouping, Landsteiner
– 1939: Separation of plasma and
cells – widely used inWW2 https://www.youtube.com/watch?v=u2tWqs8a0hY
&list=TLGG7I-uBhDmW1gwODAxMjAyMA&index=7

23. Other Advances (contd.)
BloodTransfusion (contd.)

24. Other Advances (contd.)
■ Frozen section – Freezing microtome, 1895
■ Standardized postgraduate surgical education and training programs – Halstead
followed German approach and developed in 1889
■ Experimental surgical research laboratories – 1895, Halstead animal dissection lab.
■ Specialty journals and textbooks – 1880s, Annals of Surgery and Principles and
Practice of Surgery by David H. Agnew.

25. THANKYOU