The farther you look into the past,the farther you look into future

History of surgeryBy Dr.Muni krishna

Introduction Nature is intricate network of living and non living thingsHuman body is one such great creationA surgeon can see gods true work so closeIf disease is god in medicine ,a surgeon is the only one who sees, feels and touches the god.

a surgeon is an artist, painting on the canvas of lifeName of our field comes from the work we do

Nomenclature ChirurgeryLatin, chirurgia, from theGreek, cheir = hand andergon = workanglicized to Surgery.

Ancient man used both plant and animal derivatives to ameliorate his suffering with out true knowledge of human body and disease and with religious beliefs.But surgery evolved with an evidence based treatment during its birth,So birth of surgery can be taken as birth of medicine.

Example - evidence of trephination existed during 7300-6200 b.c. for letting out blood from skull, in the days when there is no evidence of things like drugs.

Ancient egypttrephinationCircumcisionCastrationDraining dental abscessamputationProsthetic limbsOpiatesTraumatic surgery

Ancient India

Sushrutha(600 b.c)-father of plastic surgery"Surgery is the first and the highest division of the healing art, pure in itself, perpetual in its applicability, a working product of heaven and sure of fame on earth" - Sushruta

Sushrutha performing surgery

Ancient Indiasushrutha samhita Samhita is an encyclopedia of surgery and medicineDivision of surgical procedures into excision(chedana), incision(bedana), scraping(lekhana), probing(esana),puncturing(vyadhana), blood letting(sravana)Detailed description of etiologies ,signs and symptoms pertaining to surgery in volume of sutra stanaTaught about embryology and anatomy, places for venesection and body positions for each vein and protection of vital structures- sarira stanaControl of hemorrhage by ligation,cauterisation both chemical and heatDetailed description of ulcer(vrana) in 6 stages of healing.Methods to practice of surgical skills.Principles of plastic surgeryRhinoplasty and labioplasty procedures

Ancient greeceHippocrates(460-370 bc)Knowledge from battle fieldsFirst documented chest surgeonUsed cautery & ligation for hemorrhoidsFirst usage of speculum and proctoscopyReferrence to endoscopyDisliked opening human body

Hippocratic oathI will not use the knife, not even on sufferers from stone, but will withdraw in favor of such men as are engaged in this work.But in 3rd century b.c -Herophillus: allowed to dissect

Ancient Greece Cladius Galen Roman of Greek ethnicityConducted dissections on animalsProposed arterial and venous systemsGalen clarified the anatomy of the trachea and was the first to demonstrate that the larynx generates the voice. Galen may have understood the importance of artificial ventilation, because in one of his experiments he used bellows to inflate the lungs of a dead animal.He was the first to recognize that there were distinct differences between venous (dark) and arterial (bright) bloodSurgeries for brain, cataracts, traumatic woundsHis writings on anatomy was followed up to 16th century A.D.

Ancient ChinaHua Tuo 200 B.CEmminent scholar ,physician and surgeonPreparation of an anaesthetic called mafesian from boiled cannabisExecuted and scrolls burnt.

Medieval period5th-14th A.DDark period in history of surgeryDecline in practice of surgery and physicians gained higher statusSurgery was only performed by barber surgeons without proper knowledge.

Barber surgeonsLucas van Leyden-The Surgeon and the Peasant-1524-Depicts barber-surgeonVillage barber surgeons

Barber surgeonsPerformed on only external injuries like war wounds and removed abscess and boils etc., Picture depicting scope of the barber surgeons

Medieval periodSurgeon as a non thinker Surgical art little more than, inferior and crude manual craft.

There is no more science in surgery than in butchering -Lord Thurlow Parliamentary debate on establishment of Royal college of surgeons in 1811.

Surgery was dreaded, people avoided surgery and were subdued only on dire situation.Mortality rate was very highPrimarily wound treatmentLancing boilsDraining abscessesSuturing injuries -- fixing dislocations.

surgery has not reached to its technical peak due to lack of four qualities 1. Knowledge of human anatomy 2. Method of controlling hemorrhage and achieving hemostasis. 3. Anesthesia to permit performance of pain free procedures. 4. Explanation of nature of infection along with elaboration of methods to achieve antiseptic and aseptic operating room environment.The first two qualities have been achieved at 16th century but the later two were solved in the final decades of 19th century.

Knowledge of human anatomy Earlier based on anatomy of animals and primates Galen was first to bring anatomical writings but were based on animals.

professor of anatomy and surgery in Padua, ItalyBought scientific approach to surgeryHis great anatomic treatise De Humani Corporis Fabrica Libri Septem (1543) provided fuller and more detailed descriptions of human anatomy

Andreas Vesalius(1516-1564)

Andreas VesaliusProved many of Galens theories to be wrong principle of hands-on education would remain Vesalius' most important and long-lasting contribution to the teaching of anatomy.

These are some of the illustrations of human anatomy in de humani carporis fabrica libri septum

William Harvey(1578-1657)Harvey was a doctor at St. Bartholomews hospital in Londonhe became interested in anatomy and in particular, the work of Vesalius.Described the proper movement of blood in the body and role of heart in circulationHarvey published details of his work in his book entitled An Anatomical Disquisition on the Movement of the Heart and Blood.

"The only weapon with which the unconscious patient can immediately retaliate upon the incompetent surgeon is hemorrhage-Bulletin of the John Hopkins Hospital 1912; 23: 191Posed problems both to surgeon and patientMany methods were used since ancient times but cauterization being the common with rod hot iron or boiled oil.

What drug fails to cure knife cures ,what knife fails to cure fire cures, what fire fails to cure is incurableSUSHRUTHA

Method of amputation followed in 1821.-applied en-masse ligature of the limb to control bleeding-Arab surgeon Abulcasis used ligation of vessels-Major contribution for hemorrhage control was made by Ambroise Pare

Ambroise PareA barber surgeon with great scientific insightPioneered battle field wound treatmentDeveloped new methods of cauterization with egg yolk, turpentine oil and oil of rosesProposed to ligate individual blood vessels than to attempt to control hemorrhage by means of mass ligation of tissue or with hot oleum.Ligated his own temporal artery for migraineRecommended silk thread ligatures to stop bleeding of blood vessels.He proposed to bring surgery under the wing of medicineDeveloped many designs of artificial limbs.Served as royal surgeon for many years.

Idea of Pare motivated many surgeons to develop different ways for stopping blood during surgery.Lister evolved a carbolized catgut suture that was better than any previously produced. He was able to cut the ends of the ligature short, thereby closing the wound tightly, and eliminate the necessity of bringing the ends of the suture out through the incision, a surgical practice that had persisted since the days of Pare.Methods to protect patient from effects of blood lossIdea of blood transfusion on 17th century from animalsHuman to human transfusions from 19th century

In 1901, Karl Landsteiner discovered blood groups.Proved reaction between antigen and antibody to be responsible for transfusion reactions.Received Noble prize in1930.Discovered + and - blood groups in 1940World war I forced for major blood requirement.The war drove doctors to find an answer and in 1915, American doctor Richard Lewisohn found that adding sodium citrate to blood stopped it clotting when it came into contact with the air.In 1916, Francis Rous and James Turner found that adding a citrate glucose solution allowed blood to be stored for even longer

In 20th century we are able to separate different blood products and are able to use in different situationsIn the field of surgery we made giant leap of performing major operations with very minimal amount of blood loss with the help of minimal access surgery

Anaesthesia Used to be single most important factor that made surgery unfriendly to common people.Surgeons like Hua Tuo(200 b c) and Sushrutha tried anaesthesia.In the medieval period many agents like alcohol and opium were tried.Pain made patients to attend to a surgeon very late.

Surgery and speedSurgeons are clock-driven gladiators ,mainly to minimize pain and shock.Robert Liston is well known for his speed in surgery.Done an amputation in 25sec.(also achieved 300% mortality in a single surgery)

Anaesthesia In 1275, Raymundus Lillius discovered sweet vitriol, later named Ether.Nitrous Oxide discovered by Priestly in 1772In 1800, Humphry Davy studied properties of NO and elaborated its anaesthetic effect with personal experienceLater ether and nitrous oxide popularised as party drugs in 1840s by young peopleThere were ether parties and laughing gas parties organisedSamuel Colt organised many such parties for advertising his revolver.

Raymundus lilliusJoseph priestleyHumphry davy

The clinical experimentation of ether was done by Crawford Long in 1842 on patient named James venebles for removal of neck tumor, but had not recorded it for medical society.Horace Wells did first clinical demo of nitrous oxide (after seeing in Dr. G Colton presentation) in Massachusetts general hospital, which failed.Later William Thomas Green Morton, assistant to Wells developed inhaler for ether and used it for anaesthesia and gave a public demo in Massachusetts general hospital on october 16,1846 in ether dome under surgeon Dr.John Collin Warren most famous american surgeon.

Horace WellsCrawford Long

Gentle man this is no humbug Collin Warren (one touching the patient) performing surgery in ether dome.William Thomas MortonMorton inhalerDr.John Collin Warren

American Samuel Guithre, discovered chloroform But Scottish obstetrician, Sir James W Simpson discovered its anaesthetic properties accidentally while working for preparing ideal anaesthetic compound.Later used vividly in easing labour pains

Later John Snow used it on Queen Victoria in the birth of Prince Leopold, 7 April 1853, from which it was used frequently.

In the nineteenth century, it was common for a surgeon to operate in an old blood-caked frock coat (to show how experienced he was) and to wash his hands only after the operation. The operating theatre would contain a wooden table and sawdust to soak up the blood.In 1795, Alexander Gordon had argued that mothers who contracted childbed fever after childbirth had been infected by their doctors or midwives, and had recommended that the operator should wash before coming into contact with the mother. All these are condemned as they cant prove it.Post-surgical infection so common that pus felt to be sign of healingLaudable Pus

Ignaz Semmelweis

Ignaz SemmelweisAsst physician in Vienna general hospital.1847 experiments with washing hands & instruments in chlorine solution to prevent childbed feverPublishes in 1860Impact ignoredJames Simpson directly copied Semmelweiss hand-washing routine at his midwifery hospital in EdinburghFlorence Nightingale had introduced the idea of spotless hospital environments.But a complete protocol was not yet established

Louis PasteurMajor break through in surgery, in fact medicine came with proposal of germ theory by Louis Pasteur.French chemist1857 and 1860Demonstrated that fermentation is caused by a living organism (not a chemical reaction)Refuted spontaneous generationPublished his works which gave new scope for controlling infection.

Joseph Lister (1827-1912)

Lister initially studied in various quaker schools.Later he studied at University College London and became an assistant surgeon in Edinburgh in 1854 to James Syme.Between 1861 and 1865 he recognised that over half of his amputation patients in Glasgow died as a result of post-operative infection and it was against this background that he began his experimental work with antisepsisHe read Pasteurs Germ Theory in 1865 and became convinced that sepsis was being caused by microbes in the air.Using knowledge of carbolic acid used in treating sewage, he dressed a compound tibia fracture with a bandage soaked in carbolic.He also introduced the use of catgut for ligatures which could be dipped in carbolic to sterilize them, and developed a form of catgut which would dissolve so that threads no longer had to be left dangling outside of the body.Donkey engine

From his success he formulated theory of Antisepsis-by using carbolic acid asepsis- by spraying operating room with carbolic acid using his donkey engine.He was one of the 12 original members of the Order of Merit

Infection Kochs identified many bacteria and postulated his principles which brought radical change in asepsisProposed that heat is more effective than carbolic acid for killing bacteria.Ernst von Bergmann in 1877 introduced asepsis properlyLed to sterilization, cleaning patient, handwashing, eventually gloves and masks

Womens Medical College, 1903

Pioneers in surgeryThough surgery in medieval period was in darkest of its period the efforts of some people revived it . Abu al-Qasim Khalaf ibn al-Abbas Al-Zahrawi (9361013) He is considered the greatest medieval surgeon to have appeared from the Islamic World, and has been described by many as the father of modern surgeryHis greatest contribution to medicine is the Kitab al-TasrifHe was the first physician to describe an ectopic pregnancyAb Al-Qsim's al-Tasrif described both what would later became known as "Kocher's method" for treating a dislocated shoulder and "Walcher position" in obstetrics. Al-Tasrif described how to ligature blood vessels almost 600 years before Ambroise ParDescribed ligation of temporal artery for migraine 600 years before PareHis use of catgut for internal stitching is still practised in modern surgeryDescribed hereditary nature of hemophilia

Hermann Boerhaave (1668-1738)He initially studied fine arts and obtained a PhD from theUniversity of Leyden in 1690. He entered medicine at the University of Harderwyk and qualified in 1693Amongst his greatest contributions to medicine were the use of post-mortem examinations to find the cause of fatal illnessesthe use of the Fahrenheit thermometer in the clinical assessment of patients.The syndrome that is named after him he described in 1724 when Grand Admiral of the Dutch Fleet and Prefect of Rhineland, Baron J van Wassenaer died soon after developing chest and abdominal pain after vomiting on a full meal

William Cheselden (1688-1752)Member of London company of barber surgeonsLeading and most prestigious english surgeon of early 18th centuryPerformed private anatomical classesHis first major book was The Anatomy of the Human Body, published in 1713, and this became a standard medical text for well over the next one hundred yearsIn 1733 he published Osteographia or the Anatomy of Bones. This was the first full and accurate description of human osseous anatomy.Introduced high operation to remove bladder calculi through suprapubic incision rather than midline perineal lithotomy which took hours He later described a lithotomy through a lateral perineal incision with an operating time of minutes rather than hoursPlayed a pivotal role in separation of surgeons from barbers by bringing an act in parliament in 1745 and established company of surgeons

Sir Percivall Pott(1714-1788)Born in LondonApprenticed Edward Nourse, a surgeon in St Bartholomew's hospital where he prepared dissections for demonstrationsHe became a surgeon in the same hospital in 1729He was one of the first doctors to recognize industrial disease when he described the association between work as a chimney sweep and scrotal carcinoma.Potts name is eponymous with - Potts disease of spine, Potts fracture, Potts puffy tumor

John Hunter(1728-1793)

Born in scottish family, youngest son of 10Learned anatomy by helping his brother preparing anatomical dissectionsBecame assistant to William Cheselden and assistant to Pervical pottSlowly developed as a surgeon and established his own anatomy schoolWritten work produced by Hunter had a significant impact on medical practice at that time.

Described Hunterian ligature-ligation of femoral artery in popliteal aneurysmHis pupils include Benjamin Bell, Astley Cooper, Everard Home and Edward Jenner.

Natural history of teeth-coined terms bicuspid,tricuspid,incisors and molarsA treatise on veneral disease -described chancre and LGVThe digestion of stomach after death-described shock and intussuceptionInflammation and Gun-Shot Wounds - he questioned the need to surgically enlarge gun-shot wounds and disproved the belief that gunpowder was poisonous

Sir Astley Cooper(1768-1841)

Medical studies from his uncle William Cooper a staff surgeon in St.thomas & Guys hospitalWrote The anatomy and surgical treatment of inguinal and congenital hernias regarded by many at the time as a seminal work in the fieldDescribed eustachian tube dysfunction and role of myringotomyInnovative work in vascular surgery and research in pathophysiology of cerebral circulationHe postulated that it should be possible to treat vascular aneurysmal disease by ligation of the vessel proximal to the lesionProcedure for ligating aorta in illiac artery & ext illiac artery for femoral aneurysmNamed after- approach to ext iliac artery ,suspensory ligaments of breast.

Dominique Larrey (1766-1842)

Outstanding surgeon of napolenic eraOne of the founder of military surgeryAssistant surgeon to french army in Rhine1st to take first aid treatment to battle field with introduction of ambulance and introduced triageTherapeutic usage of maggots and performed 1st amputation of hipNamed after- shoulder amputation, mediterranean yellow fever, ligation of femoral artery below inguinal ligament

Ephraim McDowell (1771-1830)

Born in Virginia to an Irish familyMedical training in America, later went to Edinburgh and taught by Alexander Munro and John Bell.1st to perform elective laparotomy(1804)-for removal of ovarian cyst on Mrs. Jane Todd Crawford in a cabin."Having never seen so large a substance extracted, nor heard of an attempt, or success attending any operation such as this required, I gave to the unhappy womaninformation of her dangerous situation. The tumorappeared full in view, but was so large we could not take it away entire. We took out fifteen pounds of a dirty, gelatinous looking substance. After which we cut through the fallopian tube, and extracted the sac, which weighed seven pounds and one half. In five days I visited her, and much to my astonishment found her making up her bed.-Ephraim McDowell.

Abraham Colles (1773-1843)

Born at Milmount, near Kilkenny in Ireland in 1773Selected by nature as surgeon as his interest in surgery developed after a flood in his childhoodReceived M.D. degree from Edinburgh universityElected as president of Royal college of surgeons in ireland at the age of 28 years In 1811 he published a book entitled Surgical Anatomy, he which he described what is today known as Colles' fascia (the superficial perineal fasciaHis name is eponymously associated with a fracture of the distal radius with displacement and dorsal angulation, which he accurately described in the Edinburgh Medical and Surgical Journal in 18141st surgeon to ligate subclavian arteryIntroduced the hypothesis of maternal immunity of a syphilitic infant when the mother had not shown signs of the disease

George Guthrie (1785-1856)

Great war surgeon born in LondonApprenticed to Dr.Phillips, a surgeon in PalmallBecame a member of Royal college of surgeons at the age of 16 yearsSo dedicated to his work once he is responsible for treating 3000 soldiers one evening in battle of AlbueraHe introduced straight leg splint in treating gunsot wounds of thighProposed ligation of both ends of arteriesProposed destruction of dead tissue by mineral acids in hospital gangreneHis Treatise on Gunshot Wounds of the Extremities was published in 1813 and contains detailed and graphic accounts of the management of war wounds.

Sir James Paget (1814-1899)

Apprenticed to a local surgeon in Great YarmouthReceived further training in St Bartholomews hospital, and received MRCS at the age of 22.But over all he was a self taught surgeonLearned most of the surgery from post mortem examination and reading German text booksIn 1836 he has been selected as the one of the founding fellows of Royal college of surgeons and at the age of 36 he became the aris and gale professor of the collegeOne of the first surgeons to correlate the patient symptoms to clinical diagnosis In 1874, he reported a series of 15 cases of chronic ulceration of the nipple in association with breast cancer. He suggested that chronic ulceration induced the cancer but it is now recognized that the nipple changes are part of the neoplastic process. In 1876, he described five cases of 'osteitis deformans' which be believed to be an inflammatory disease process. It is now believed to result from an abnormality of bone remodeling due to an increase in osteoclastic activity, possibly as result of a viral infection.

Theodor Billroth (1829-1894)

German physicist and surgeonInsisted on radical surgical training with prolonged apprenticeship and 2-3 years assistantshipWrote a monograph on relationship between adenomatous polyps and colorectal carcinoma in 1855.He is the 1st to do esophageal resection in 1872 laryngectomy in 1874 excision of rectal cancer in 1876Best known for two types of partial gastrectomy named after him The first Billroth I partial gastrectomy was performed on a 43 year old woman in 1881 for a pyloric gastric cancer 'the operation lasted, including the slow induction of anesthesia about one and a half hours'. The following day there was 'No weakness, no vomiting and no pain'....'Within the first 24 hours only ice by mouth, then peptone enema with wine. The following day, first every hour and then every half hour, one tablespoon of sour milk. Patient a very understanding women, feels well, lies extremely quiet, sleeps most of the night with the help of a small injection of morphia. No pain in the operative area or a subfebrile reaction-Billroth

Hugh Owen Thomas (1834-1891)

Hugh Owen Thomas is widely regarded by many as great pioneer in British orthopedic surgery who came from a family of bone settersApprenticed to his uncle, Dr. Owen Roberts ,he later studied medicine in Edinburgh and University College London and qualified MRCS in 1857. He never served with any university lecturer nor was he ever appointed as a house surgeonIn the treatment of tuberculosis and fractures, he strongly advocated the use of rest which should be 'enforced, uninterrupted and prolonged which was opposed by many as excision and amputation was employed for chronic disorders In order to achieve rest and Immobilisation he invented several types of splints, with rigid steel bars, that were manufactured in his own work shop by both a blacksmith and a saddler. He also invented a wrench for the reduction of fractures and an osteoclast to break and reset bones His contribution to the management of fractures was not widely recognised until after his death and in particular the onset of the First World War. His nephew, Sir Robert Jones, introduced many of his uncles ideas to the surgical communityThanks to the use of Thomas splint mortality of compound fractures of femur fell from 80% in 1916 to 8% in 1918.

Theodor Kocher (1841-1917)

Born in Bern ,Switzerland and received his education thereGraduated in 1865 and published his thesis "Treatment of croupous pneumonia with veratrum compounds." in the same Year ,Student of Billroth and Bernhard von Langenback at age of 31Done extensive work in Thyroid surgeries ,performed over 2000 surgeries and brought mortality rate from 13%-1%Awarded noble prize in 1909Other works-descriptions of a manoeuvre to reduce a subluxed shoulder(1870) -radical surgery for carcinoma of the tongue (1880) -an operation for inguinal hernias (1892). -He introduced the use of sterilized silk sutures in surgical practice Named after him:1)toothed surgical clamp 2.anastomatic bowel clamp and curved director 3.sub costal incision for open cholecystectomy 4.pericondylar fracture 5.manoeuvre to mobilize duodenum

Ludwig Courvoisier (1843-1918)

Was born in Basle and completed his graduation there in 1868He became an assistant to Professor Socin a famous surgeonIn 1888 he was selected as professor of surgery extraordinary in Basle universityCourvoisier's most important work concerned surgery to the biliary tract. It was he who developed the operation of cholecystectomy and he was one of the first surgeons to remove a stone from the common bile duct. The well known 'Courvoisier's law' is named after himThis was first proposed by him in his book 'The pathology and surgery of the gallbladder' published in Leipzig in 1890.Courvoisier was regarded by many as safe rather than brilliant surgeon. He gladly handed over cases to others when confronted with conditions lying outside his experience

Friedrich Trendelenburg (1844-1924)

Born in Berlin, initial medical studies in Glasgow and finally attained M.D in BerlinTrendelenburg played a key role in the great advances in surgery that occurred in Germany in the latter part of the nineteenth century. He founded the German Society of Surgeons and eventually became it presidentIn 1871 he described endotracheal anaesthesia for a patient with a tracheostomy. In 1890 he reported ligation of the long saphenous vein for the treatment of varicose veins. In 1908 he was the first surgeon to attempt, albeit unsuccessfully, a pulmonary embolectomy.Name is eponymous with- tests for saphenofemoral incompetence and identifying the shortening of legThe operative position named after Trendelenburg consists of placing the patient in a 45 degree 'head down' inclination, useful in reducing the venous pressure for varicose vein surgery or to maintain the intestine out of the pelvis for gynaecological procedures.Position was first described by Willy Meyer who had been a student under TrendelenburgHis doctoral thesis 'De Veterum Indorum Chirurgiais' discussed ancient Indian surgery

William Halstead (1852-1922)

Born to an English family in New YorkGraduated from Yale university and became student assistant to John DaltonWent to England and received training with Billroth,Thiersch and VolkmanPerformed experiments with local anesthesia and cocaine and became addicted to it due to which he was expelled from professionLater his works include 1889 published technique of hernia repair 1890s described radical mastectomy which was named after him 1892 described ligation of subclavian artery 1900s published auto transplantation of parathyroidFounder of surgical training program in John Hopkins which was taken up by many teaching institutes

Sir Frederick Treves (1853-1923)

Was an anatomist and surgeon in London due to which he founded his surgery on anatomyExpert dissector operated neatly, quickly and cautiously. As he is myopic operated close to the wound sitePerformed many abdominal dissections he was awarded the Jacksonian Prize for his dissertation entitled The pathology, Diagnosis and Treatment of Obstruction of the Intestine in its Various Forms in the Abdominal Cavity.Appendicitis surgery gave enormous fame to him.In his paper, Relapsing Typhilitis treated by Operation, Treves described how he had operated for the first time on patient with appendicitisTreves developed his pathology of typhilitis, perityphilitis paratyphilitis and in chronic cases advocated operating on patients between attacks. In acute cases he advocated delaying surgery until the 5th day of the attack when peritoneal suppuration would become circumscribedHis famous patients include King Edward VII and Joseph Merrick ,the elephant man. His name is associated with iliocecal fold

Max Wilms (1867-1918)

Described as diligent and highly intelligent, possessing an exceptional working capacity as well as dextrous surgeon.Extensive work in tumor especially nephrologyBelieved that tumor cells were formed in embryoPublished Die Mischgescwlste while working under F.Trendelenburg in what he described Wilms tumor so vividly that found bases for modern concepts of Wilms tumor Name eponymously associated with: 1.perineal prostatectomy through a later incision 2.anterior and posterior rib resection used in pulmonary tuberculosisDied of septic diphtheria which he acquired from operating on a prisoner with laryngeal diphtheria who survived

Sir Victor Horsley (1857-1916)

Founder of British neurosurgery literally nurtured neurosurgeryMade extensive experimentation in localization of brain functionHe proposed thyroidectomy causes myxoedema in1884Performed 1st surgical hypophysectomy (experimental) in 18861st to remove an extradural tumor from spinal column with complete recovery of paraplegic patient in1887Described operation for treatment of trigeminal neuralgia through temporal approach in 1891Prepare Horsleys wax with 7 parts bees wax and 1 part almond oil for stopping bleeding from cranial vaultArdent believer of his ideas like sunstroke was caused by smoking (but he died of sun stroke)

Harvey Cushing (1869-1939)

Graduated from Harvard medical schoolInitial training from William HalsteadWorked with Theoder Kocher and Victor HorselyPioneered neurosurgery and developed many techniquesWorks: 1.method of destruction of trigeminal ganglion in 1900 2.infiltrative analgesia in 1910 3.functioning of pitutary gland and experimental hypophysectomy in1910 4.introduced electro coagulation in1928 5.basophil adenomas in 1932Endocrine disorder is named after himIn addition received Pulitzer prize in 1926 for his book Life of Sir William Ostler

John Finney (1863-1942)

Born in Mississippi and had educational training in Harvard Served as assistant to William Halstead in John HopkinsFinney was regarded internationally as an excellent general surgeon and played an important part in the rapid development of abdominal surgery that took part at the end of the 19th centuryHis operation of pyloroplasty, which he described in 1902, was his most valuable contribution.In his honour the, Finney-Howell Foundation for Cancer Research was founded.

Conrad Ramstedt (1867-1963)

Conrad Ramstedt was born in Hamersleben, a village in central Prussia and graduated in HalleServed as military surgeon for many yearsAfter the description of pyloric stenosis by Hirschsprung many attempts were made to relieve obstruction

Ramstedt described two successful operationsLobker at Bochum who bypassed the obstruction with a gastrojejunostomyIn 1907 Fredet suggested an alternative operation in which the muscular coat of the pylorus was divided. In 1908 Weber advocated a similar approachIn the first patient he attempted to suture the pyloroplasty in a transverse fashion but this failed and the sutures cut out. He covered the muscular defect with an omental patchIn the second patient the pyloric incision was left open with no attempt made to close it - the operation which is today eponymously associated with him

Sir Harold Gilles(1882-1960)Sir Harold Gillies was born in Dunedin in Newzeland.His medical studies were undertaken at Cambridge University and St. Bartholomew's Hospital London.He initially planned a career in otolaryngology before becoming on of the founders of British plastic surgery. During the first World War he treated a large number of patients with facial injuries.At the advent of World War II, Gillies converted the private wing of the Park Prewett Hospital, Basingstoke into a 120-bed plastic surgery unit. This unit was known as 'Rooksdown House' and became on of the leading centers for plastic surgery within Great Britain.Pioneered pedicle tube techniqueMade detailed description of each and every work

Pedicle tube techniqueWilliam Spreckley

Sir Archibald McIndoe (1900-1960)Renowned plastic surgeon ,who was also born in Dunedin New Zealand, cousin to Sir Harold GillesHe published several papers on hepatic disease including two individual papers on the importance of portal cirrhosis and on the structure of the bile canaliculusIn America he met Lord Moynihan who was so impressed with his surgical skills that he recommended a permanent career in England.Took plastic surgery on the advice of his cousinMcIndoe also held an appointment as a consultant in Plastic Surgery to the Royal Air ForceMcIndoe fought to improve the pay and conditions of badly injured airmen and 'The Guinea Pig Club' of his ex-patients perpetuates his memoryAt the Royal College of Surgeons, he became a member of Council in 1946 and vice-president in 1958. He had been Hunterian Professor in 1939 and in 1958 was Bradshaw Lecturer, his subject being facial burns. He helped to found the British Association of Plastic Surgeons and was its third President.

In 1880, Tait performed the first transabdominal resection of a gangrenous appendix and Rehn performed the first subtotal thyroidectomy for Graves disease In 1884, Bennett and Godlee reported the first successful removal of a brain tumor

Factors for development of surgery in medieval periodScience and technologyChemistry played an important role. Knowledge of chloroform and carbolic acid helped with anaesthetics and antiseptics, and knowledge of citrates helped with the storage of blood. Clearly Louis Pasteurs scientific work on Germ Theory was very important in the development of Listers ideas, in developing heat sterilisation and in creating aseptic operations William Rntgen discovered x-rays in 1895 when he noticed that certain light rays could pass through human tissue but not bone. After writing up his ideas, he chose not to patent them which meant that people were free to copy them. As a result, the use of x-rays spread very quickly

Other technological breakthroughs in surgery in this period included:Ophthalmoscope 1851 allowed the interior of the eye to be seenThe hypodermic needle 1853 allowing blood transfusionsChloroform inhaler 1850s John Snows invention to prevent overdosesOesophagoscope 1868 allowed foreign objects in the gullet to be seen and removedDonkey-engine 1877 Listers invention to spray an operation with antisepticRectoscope 1895 to see up the rectumGastroscopes late 1890s to see into the stomachCardiograph 1903 keeps the beating of the heart monitored during an operation.

communication helped in the development of surgeryDuring the 19th century there were a great many scientific and medical journals established that allowed ideas to be shared. The Royal College of Surgeons had one which encouraged surgeons to discuss new ideas and problemsThe Lancet is the famous medical journal, which published the report of Hannah Greeners death to invite discussion on what had caused her demise. Lister read Pasteurs work in a journal which enabled him to develop carbolic. X-rays developed so quickly because Rntgen published his work and made it patent-free.Newspapers reporting surgical news to the public had a role in popularising new techniques. The best example here is the newspapers reporting Queen Victorias use of chloroform whilst giving birth.Surgeons and scientists also travelled and visited each other. Lister travelled around Germany and the USA discussing his ideas with other surgeons. He met with Louis Pasteur in 1892 at a conference of 2,500 surgeons.

I st world war role in developing surgery

Made a demanding situation for blood transfusions which forced for development of techniques for preserving bloodPromoted use of x-rays for identifying bullets in war frontsWW1 decisively advanced skin transplants and plastic surgery. Shells caused horrific facial injuries. Harold Gilles set up a plastic surgery unit in Aldershot and dealt with 2000 cases of facial damage after the Battle of the Somme.Between 1914 and 1921, over 41,000 men in the British Armed Forces lost a limb. This meant that there had to be new developments in prosthetic limbs. New metal alloys and mechanisms were developedSurgeons gained an enormous wealth of experience and were able to try out procedures on patients. The war accelerated their training.

Blossoming of SurgeryBy 1870s and 1880s surgeons can operate on head, chest, and abdomen1886: 1st successful appendectomy1886: MGH abdominal surgery wardAbdomen now available to surgeons1880s and 90s: Physiological SurgeryConserved tissues, preserved anatomy, careful dissectionCompare to slash and speed model

MGH1841-1845: 37 operations/ year1847-1851: 98 operations/ year1898: 3700 operationsSurgery in 1900 SaferLess painfulMore invasiveLess infection risk

Surgery in modern timessurgeons had no choice but to allay society's fear of the surgical unknown by presenting surgery as an accepted part of a newly established medical armamentarium. This would not be an easy task. The immediate consequences of surgical operations, such as discomfort and associated complications, were often of more concern to patients than was the positive knowledge that an operation could eliminate potentially devastating disease processes. Accordingly, the most consequential achievement by surgeons during the early 20th century was ensuring the social acceptability of surgery as a legitimate scientific endeavor and the surgical operation as a therapeutic necessity.

Surgeons in early 20th century mostly emphasized on operating on the most vital tissues like brain and heart.As a result of the new developments in anesthesia and diagnostic facilities like x-rays this became possibleSurgical techniques would, of course, become more sophisticated with the passage of time, but by the conclusion of World War II, essentially all organs and areas of the body had been fully explored. In fact, within a short half-century the domain of surgery had become so well established that the profession's foundation of basic operative procedures was already completed

Highlights in early 20th centuryGeorge Vaughan (1859-1948) successfully ligated the abdominal aorta for aneurysmal disease in 1921 Elliott Cutler (1888-1947) performed a successful section of the mitral valve for relief of mitral stenosis in 1923; Walter Dandy (1886-1946) performed intracranial section of various cranial nerves in the 1920sHarvey Cushing introduced electrocoagulation in neurosurgery in 1928Owen Wangensteen (1898-1981) successfully decompressed mechanical bowel obstructions by using a newly devised suction apparatus in 1932; 1935 pancreaticoduodenectomy for cancer of the pancreas by Allen Oldfather Whipple (1881-1963) Max Peet (1885-1949) presented his splanchnic resection for hypertension in 1935Walter Freeman (1895-1972) described prefrontal lobotomy as a means of treating various mental illnesses in 1936Marius Smith-Petersen (1886-1953) described a flanged nail for pinning a fracture of the neck of the femur in 1931 and introduced Vitallium cup arthroplasty in 1939; Vilray Blair (1871-1955) and James Brown (1899-1971) popularized the use of split-skin grafts to cover large areas of granulating wounds;

Highlights in early 20th centuryEvarts Graham completed the first successful removal of an entire lung for cancer in 1933; Claude Beck (1894-1971) implanted pectoral muscle into the pericardium and attached a pedicled omental graft to the surface of the heart, thus providing collateral circulation to that organ, in 1935; Earl Padgett (1893-1946) devised an operative dermatome that allowed calibration of the thickness of skin grafts in 1939.1943 - vagotomy for operative treatment of peptic ulcer disease by Lester DragstedtRobert Gross (1905-1988) reported the first successful ligation of a patent arterial duct in 1939 and resection for coarctation of the aorta with direct anastomosis of the remaining ends in 1945; John Alexander (1891-1954) resected a saccular aneurysm of the thoracic aorta in 1944

Highlights in early 20th centuryIn 1945, Blalock and Taussig designed their shunt operation for blue babiesIn 1948, Dwight Harken and colleagues published an astonishing report describing the successful surgical treatment of mitral-valve diseaseRobert Gross and colleagues reported in 1952 on open-heart surgery to close atrial septal defects in children

Mid 20th centuryTwo clinical developments truly epitomized the magnificence of postWorld War II surgery and concurrently fascinated the public: the maturation of cardiac surgery as a new surgical specialty and the emergence of organ transplantation cardiac surgeryFrom the historical perspective of art, customs, literature, philosophy, religion, and science, the heart has represented the seat of the soul and the wellspring of life itself. Such reverence also meant that this noble organ was long considered a surgical untouchable.a steady march of surgical triumphs in opening successive cavities of the body, the final achievement awaited the perfection of methods for surgical operations in the thoracic space.

cardiac surgeryLuther Hill's (1862-1946) first known successful suture of a wound that penetrated a cardiac chamber was in 1902Elliott Cutler (1888-1947) performed a successful section of the mitral valve for relief of mitral stenosis in 1923Dwight Harken (1910-1993) gained extensive battlefield experience in removing bullets and shrapnel in or in relation to the heart and great vessels without a single fatality.During the Second World War, Harken served in the U.S. Army Medical Corps in London as a surgeon. To treat his patients, he found a way to take out shrapnel safely from the heart by cutting into the wall of a beating heart, then inserting a finger to locate and remove the shrapnel. With this method, he became the first person to have repeated success in heart operation after removing shrapnel from the hearts of 130 soldiers during the war without a single fatality.

In 1948, Dr. Harken discovered a way similar to how he operated on soldiers to correct mitral stenosis. A small hole would be cut in the heart and a finger would be used to widen the valve. This technique became known as blind surgery or closed heart surgeryHarken's concept of intensive care has been adopted worldwide and has improved the chance of survival for patients. He opened the first intensive care unit in 1951. In the 1960s, he developed the first device to help the heart pump

Charles P .Bailey was an American cardiac surgeonWorked extensively on mitral valve pathology

A deliberate enlargement of the stenotic mitral valve at the commissures either by a splitting technique or by cutting with an instrument worn on and guided by the finger was the approach taken by Bailey

According to the colorful Dr Bailey, while working his way through college, he was a salesman for ladies girdles. His knowledge of the construction of that garment and its applied garters gave him the basis for better understanding of the anatomy, as well as the treatment of mitral stenosis.

Despite mounting clinical successes, surgeons who operated on the heart had to contend not only with the quagmire of blood flowing through an area where difficult dissection was taking place but also with the unrelenting to-and-fro movement of a beating heart.John Gibbon (1903-1973) addressed this enigma by devising a machine that would take on the work of the heart and lungs while the patient was under anesthesia, in essence pumping oxygen-rich blood through the circulatory system while bypassing the heart so that the organ could be operated on at leisure. The first successful open heart operation in 1953, conducted with the use of a heart-lung machine, was a momentous surgical contributionGibbon's research paved the way for all future cardiac surgery, including procedures for correction of congenital heart defects, repair of heart valves, and transplantation of the heart.

Since time immemorial, the focus of surgery was mostly on excision and repair. However, beginning in the 20th century, the opposite end of the surgical spectrumreconstruction and transplantationbecame realitiesEmerich Ullmann performed the first experimental transplantation of a kidney between dogs in Vienna in 1902.Alex Carel played a sheet anchor role in developing transplantation techniques as he developed revolutionary new suturing techniques to anastomose the smallest of blood vessels

In 1906, Mathieu Jaboulay, professor of surgery in Lyon, France, connected the renal vessels of a sheep and a pig kidney, respectively, to the brachial vessels of two patients who were dying of renal failure.Using his surgical lan on experimental animals, Carrel began to transplant kidneys, hearts, and spleens. Technically, his research was a success, but some unknown biologic process always led to rejection of the transplanted organ and death of the animal.

Alex Carell

By the middle of the century, medical researchers had begun to clarify the presence of underlying defensive immune reactions and the necessity of creating immunosuppression as a method to allow the host to accept the foreign transplantDrugs like cyclosporine paved way for maintaining a transplantBut the first successful kidney transplant took place in 1954 in Boston by John Merrill, Joseph Murray, and Hartwell Harrison

Cardiac transplantationChristiaan Neethling Barnard was a South African cardiac surgeon who performed the world's first successful human-to-human heart transplantHe worked as assistant to Norman Shumway who did pioneering research in cardiac transplantationHe performed the world's first human heart transplant operation on 3 December 1967, in an operation assisted by his brother, Marius Barnard; the operation lasted nine hours and used a team of thirty people.The patient, Louis Washkansky, was a 54-year-old grocer, suffering from diabetes and incurable heart disease. The donor heart came from a young woman, Denise Darvall, who had been rendered brain damaged in an accident on 2 December 1967, while crossing a street in Cape Town.

Dr. Marius Barnard recounted, "Chris stood there for a few moments, watching, then stood back and said, 'It works.'

Pioneers of surgery (20th century)Noble laureates in medicine and physology

SURGEONCOUNTRYFIELD (YEAR OF AWARD)Theodor Kocher (1841-1917)SwitzerlandThyroid disease (1909)Allvar Gullstrand (1862-1930)SwedenOcular dioptrics (1911)Alexis Carrel (1873-1944)France and United StatesVascular surgery (1912)Robert Brny (1876-1936)AustriaVestibular disease (1914)Frederick Banting (1891-1941)CanadaInsulin (1922)Walter Hess (1881-1973)SwitzerlandMidbrain physiology (1949)Werner Forssmann (1904-1979)GermanyCardiac catheterization (1956)Charles Huggins (1901-1997)United StatesOncology (1966)Joseph Murray (1919-)United StatesOrgan transplantation (1990)

Pioneers of surgery (20th century)Charles Huggins (1901-1997) a pioneer in endocrine therapy for cancer, found that antiandrogenic treatment consisting of orchidectomy or the administration of estrogens could produce long-term regression in patients with advanced prostatic cancer. These observations formed the basis for the current treatment of prostate and breast cancer by hormonal manipulation; Dr. Huggins was awarded the Nobel Prize in 1966 for these monumental discoveriesFrancis D. Moore (1913-2001) defined objectives of metabolism in surgical patients and in 1959 published his widely quoted book Metabolic Care of the Surgical Patient. Moore was also a driving force in the field of transplantation and pioneered the technique of using radioactive isotopes to locate abscesses and tumors

Jonathan E. Rhoads (1907-2002)in collaboration with colleagues Harry Vars and Stan Dudrick, described the technique of total parenteral nutrition, which has become an important and lifesaving treatment in the management of a critically ill patient who cannot tolerate standard enteral feedingsWerner Forssmann(1904-1979), awarded noble prize for developing cardiac catheterisation The radiograph shows successful self-catheterization ofthe heart, performed by Werner Forssmann, at the timea 25-year-old surgical intern in Eberswalde, Germany

Minimal invasive surgery

In the past two decades the emphasis has shifted to how much less can we do to achieve our goal of treatment

"I would like to see the day when somebody would be appointed surgeon somewhere who had no hands, for the operative part is the least part of the work -Harvey Cushing

History of laparoscopy

The great physician, Hippocrates of Ancient Greece( circa 460-377 BC) made the original reference to a speculum to examine the rectum.1585, Aranzi was the first to use a light source for an endoscopic procedure, focusing sunlight through a flask of water and projecting the light into the nasal cavity1706, The term trocar, was coined in 1706, and is thought to be derived from trochartor troise-quarts, a three-faced instrument consisting of a perforator enclosed in a metal cannula

1806, Philip Bozzini, built an instrument that could be introduced in the human body to visualize the internal organs. He called this instrument "LICHTLEITER(light conductor). Bozzini used an aluminium tube to visualize the genitourinary tract. The tube, illuminated by a wax candle, had fitted mirrors to reflect images.1853, Antoine Jean Desormeaux, a French surgeon first introduced the modified 'Lichtleiter" of Bozzini to a patient. For many surgeons he is considered as the "Father of Endoscopy".

Bruck, a dentist, developed a platinum wire cooled by water to illuminate the inside of the mouthBased on Bruck design, Nitze finally developed his first improved cystoscope in 1855 in which the light rays were gathered into his instrument via mirrorsNewman of Glasgow miniaturzed Edison`s invention and incorporated it into the Nitze`s cystoscope(first Laparoscop)

Georg Kelling of Dresden performed the first cholecystectomy in living dog(COELIOSCOPIE -1902) / the first human laparoscopy with pneumoperitoneum using room air insufflation with Nitze cystoscope.used filtered atmospheric air to create a pneumoperitoneum, with the goal of stopping intra-abdominal bleeding (Ectopic pregnancy, bleeding ulcers, and pancreatitis)Kelling proposed a high-pressure insufflation of the abdominal cavity, a technique he called the "Luft-tamponade" or "air-tamponade"

Jacobaeus of Sweden presented his series of patients who had laparoscopy in 1910 (published a series of over 100 laparoscopy and thoracoscopy(LAPAROSCOPY).1911, H.C. Jacobaeus, again coined the term "laparothorakoskopie" after using this procedure on the thorax and abdomen. He used to introduce the trocar inside the body cavity directly without employing a pneumoperitoneumJanos Veress of Hungary developed a specially designed spring-loaded needle. Interestingly, Veress did not promote the use of his Veress needle for laparoscopy purposes. He used veress needle for the induction of pneumothorax. Veress needle is the most important instrument today to create pneumo-peritoneum

1977, First Laparoscopic assisted appendicectomy was performed by Dekok. Appendix was exteriorized and ligated outside.Kurt Semm , a German gyneacilogist introduced the automatic insufflator,first time demonstrated endoloop suturing technique in laparoscopic surgery and performed the first laparoscopic appendicectomy in 1983The first documented laparoscopic cholecystectomy was performed by Erich Mhe in Germany in 1985.Cholecystectomy is the laparoscopic procedure which revolutionized the general surgery.1987, Ger reported first laparoscopic repair of inguinal hernia using prototype stapeler.Harry Reich described first laparoscopic hysterectomy using bipolar dessication; later he demonstrated staples and finally sutures for laparoscopic hysterectomy.

Tempton Udwadia of Hinduja Hospital, Mumbai is accepted by most as the father of Laparoscopic Surgery in India. Pradeep Chowbey of Sir Gangaram Hospital made laparoscopic cholecystectomy popular and acceptable in New Delhi and Northern India with his efforts in early 1990'sC Palanivelu of GEMS Hospital Coimbatore developed many advances in laparoscopic surgery and contributed significantly to the growth of Minimal Access Surgery in Southern India around the same time. His work on the pancreas has been appreciated internationally

Robotic surgery Current trend towards Cushings dreamIn 1985 a robot, the PUMA 560, was used to place a needle for a brain biopsy using CT guidanceIn 1988, the PROBOT, developed at Imperial College London, was used to perform prostatic surgery by Dr. Senthil Nathan at Guy's and St Thomas' Hospital, London. 1996, First live telecast of laparoscopic surgery performed remotely via the Internet. (Robotic Telesurgery).

The da Vinci Surgical System comprises three components: a surgeons console, a patient-side robotic cart with 4 arms manipulated by the surgeon (one to control the camera and three to manipulate instruments), and a high-definition 3D vision system.

Surgical nanoroboticsSurgical nano robots could be introduced into the body through the vascular system or at the ends of catheters into various vessels and other cavities in the human body.A surgical nanorobot, programmed or guided by a human surgeon, could act as a semi-autonomous on-site surgeon inside the human body.

A molecular planetary gear is a mechanicalcomponent that might be found inside a medical nanorobot.

The earliest forms of cellular nanosurgery are already being explored today. For example, a rapidly vibrating (100 Hz) micropipette with a

whatever might be the progression of surgery in the modern world the final thinking of the surgeon must be

-Ambroise PareI just bandaged , god healed

****The painting is set in the surgical amphitheater. Gross is in command. He is surrounded by surgical assistants, the patient, and the patients mother. Tiers of medical students are in the background. Bandages and instruments are in the foreground. The patient has osteomyelitis and Dr. Gross is explaining how to remove a segment of diseased femur. He is receiving chloroform anesthesia. *Ward One was handled by the medical students and that Ward Two was handled by midwifery students. Medical students came straight to the wards from the autopsy rooms with soiled hands and instruments; midwifery students didnt. When the two groups swapped over, Ward Two became the place to die**Together, they would stand as signposts along the new surgical highway. Fascination with the heart goes far beyond that of clinical medicine*2 years after Cutlers memorable operation, Sir Henry Souttar performed the first successful finger dilation of a stenotic mitral valve.*The techniques used to join the vessels together were those developed and described by Alexis Carrel, who had been a young surgeon in Jaboulays unit*