Surgery

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Surgery2017-11-06T19:06:57+00:00

Surgery

Whilst the early history of surgery is awash with pioneers, both unnamed and named, one in particular, Sushruta (600 BC) of ancient India, stands out. He has been called the father of surgery with good reason: his meisterstück, Sushruta Samhita*, a multi-volume textbook of medicine and surgery has 184 chapters, describes over 1100 diseases and over 800 plants, mineral and animal-derived therapies.  

surgery ancient instruments new medical terms

surgical instruments of ancient India

*Scholars now believe that Sushruta Samhita was in fact penned by several guys named Sushruta.

Written in Sanskrit, the work was surprisingly ahead of its time. It asserted that preventing illness was as valuable as curing it and endorsed regular exercise as a way of resisting disease*. Its greatest contribution is in surgery: 

• It advised students of the surgical arts to dissect dead bodies to learn the human geography and to practice their techniques on gourds, leather models and other non-living surrogates 

• It described instruments that are still used today, largely unchanged (see above)

• It described an array of procedures for amputations, hemorrhoids, bladder stones, obstetrics, ophthalmology, and rhinoplasty

*The value of prevention and regular exercise in maintaining health have been rediscovered in the 21st century, 2500 years after originally proposed. 

Whilst Sushruta Samhita was influential in its region and was translated into Arabic, Europe remained in the dark. Bloodletting, pseudoscience, alchemy and belief in the four humours (black bile–melancholy, yellow or red bile, blood, and phlegm) formed the core of medical thought and therapy in the 1500s. This status quo began to crumble with the arrival of Andreas Vesalius and Ambroise Paré. 

Vesalius (1514-1564) was a Flemish physician appointed professor of anatomy the day he graduated at the University of Padua, Italy. Shortly thereafter, he published his ground-breaking work on human anatomy, De humani corporis fabrica at the tender age of 28. It became an instant classic. One of Vesalius’ contemporaries, Ambroise Paré (1510-1590), a French Army surgeon introduced ligation of blood vessels in amputations, which minimized the mess and reduced tissue loss. Paré also formulated a mixture of rose oil, egg yolk and turpentine to cauterize gunshot wounds, replacing the then standard, albeit inhumane, use of boiling oil.  

It is difficult to imagine surgery of the era. The brutal and unbridled barbarism–an unfortunate, but necessary evil wrought by barber-surgeons before anesthesia, made speed a criterion on which the surgeon was often judged. But a successful operation was no guarantee of satisfactory outcomes, given the ever-present reality of often fatal post-operative infections. Another 300 years were to pass before pain could be prevented during surgery and infection prevented after. These two issues were finally addressed in the 19th century. 

Whilst his primacy has been questioned by most historians, William TG Morton (1819-1868), an American dentist, is generally credited with the first use of inhaled ether as a surgical anesthetic (1846, at Massachusetts General Hospital).  News of inhalation anesthesia’s success in preventing intraoperative pain quickly spread and not long afterwards, general anesthesia became the standard of care for major surgery. 

The rapid and unflinching adoption of inhalation anesthesia contrasts sharply with the adoption of antiseptic principles. Ignaz Semmelweis (1818-1865), a young Hungarian-German obstetrician realized, whilst working in the Vienna General Hospital, that the mortality of mothers born in midwife-run wards was one-third that of physician-run wards. The difference between the two was that physicians had often just previously finished an autopsy…but didn’t wash their hands before launching into the delivery…yucky, but true. Semmelweis instituted a hand-washing policy on his wards, et voila! no excess mortality. Because he could offer no viable explanation why (the year was 1847), his peers turned their backs on him, and rejected his conclusions.* 

*Semmelweis died at age 47, a broken bitter man, shortly after being committed to a Viennese insane asylum. It wasn’t until Louis Pasteur disproved the naive theory of spontaneous generation (of life) and recognized bacteria as the cause of pyemia that Semmelweis was vindicated.   

With these two great strides, surgery was no longer to be feared. Regions of the body which were once viewed as No Man’s Lands–in particular the cranial cavity were opened–no pun intended–to surgical management, specifically by Harvey Cushing at Johns Hopkins at the dawn of the 20th century. Cushing brought William Halsted’s meticulous surgical techniques to the new field of neurosurgery and added William Osler’s careful clinical observations and his own penchant for accurate documentation. 

surgical robot image from New Medical Terms

surgical robot

Major, and newsworthy, advances in the OR began to wane between the two wars. The more recent innovations in the field of surgery have been more evolutionary than revolutionary and can be succinctly summarized, per Atul Gawande, MD, with three words:

Professionalization Long gone are the days of surgeons who do it all. Not only do we now have the expectation our surgeons will be competent, but we expect them to specialize and subspecialize. One can cite as an example, ophthalmologic surgeons: some largely limit their practice to cataracts, other to managing glaucoma, and others to the retina.

Minimization As a general rule, the smaller the hole made during a surgical procedure, the more rapid the recuperation and the better the outcome. This began with laparoscopy and other transcutaneous approaches to the operative field and was massively expanded with robotic surgery (bottom image), which has the added advantages of steadier ‘hands’, greater access, or even access itself, to forbidden sites, and facile magnification. 

Routinization In the US alone, 50 million surgical procedures are performed per year; the average American will have 7 operations in his lifetime. Adverse outcomes are rare and become rarer the more experience the surgeon, the OR team, and the hospital’s aftercarers have.  

Reference

https://en.wikipedia.org/wiki/Sushruta

https://en.wikipedia.org/wiki/Sushruta_Samhita

http://haribhakt.com/sushruta-worlds-first-plastic-surgeon-was-from-india/

https://en.wikipedia.org/wiki/Andreas_Vesalius

http://www.hopkinsmedicine.org/neurology_neurosurgery/education/residencies/neurosurgery_residency/dept_history/index.html

http://www.nejm.org/doi/full/10.1056/NEJMra1202392#t=article