Wednesday, January 18, 2017

Advancements in Surgery Through the Ages

by Lisa J. Fulghum, 6-5-15

Imagine yourself standing in a medical tent on September 17, 1862 not far from Sharpsburg, Maryland, as the bloody battle of Antietam rages on the other side of the bridge. With nearly 22,000 dead and many more wounded after just 12 hours of fighting, what is a good surgeon to do? Your shirt is stained with the blood of the many you have already treated, yet more men than you can count lay suffering nearby. With only 98 medical officers to serve the entire Union army and just 24 for the Confederates when the war began, trained medical professionals are still hard to find.1 It will be a very long night. Your options are as limited as the precious time you have.

Ether and chloroform (when they are available) are the only viable methods of anesthesia, besides a stiff shot of whiskey. The best surgeons, commonly called butchers by reporters and patients, are the ones who are quick and hopefully accurate. Amputation is the most common surgery of the day, and a good surgeon can amputate a limb in just 15 minutes.2

Standing amidst the grizzly scene, you call for another cup of coffee, wipe your surgical saw on your apron and look for the nearest patient who is likely to survive long enough to complete a surgery. Inwardly, you hope that one day you will have a better method for dealing with such carnage.

An estimated 60,000 amputations were performed during the Civil War. Nearly 75% of amputees survived the surgery, though that depended greatly on the limb that was amputated. A forearm amputation mortality rate was 14%, but legs amputated at the hip had an 88% mortality rate.3

History of Surgery
Since the beginning of time, man has developed and refined instruments for surgical procedures and for healing people. Throughout our history, humankind has had notable physicians who made monumental contributions to medical science.

As early as 600 B.C. Sushruta , India’s preeminent surgeon, pioneered rhinoplasty and other forms of plastic surgery. Since cutting off a person’s nose was a common punishment, Sushruta’s expertise was highly valued.4 Among other things, believe it or not, he even documented cataract surgery.5 Developing and documenting 120 surgical instruments (in bronze, silver, and iron) and employing many relatively modern techniques, Sushruta was revered as a master physician 150 years before Hippocrates.

Around 1000 A.D. Abu al-Qasim al-Zahrawi (a.k.a. Albucasis in Europe), the master Muslim physician of Spain, wrote a 30-volume medical encyclopedia called Al-Tasrif (The Method of Medicine). It was the medical reference text used for over 500 years. Albucasis invented and described over 200 new instruments. With hand sketches of what instruments looked like, how they were constructed and how they were to be used, he documented instruments like his obstetric forceps and an urethrascope. Not only was he the first author to describe an ectopic pregnancy and the hereditary nature of hemophilia, but he also pioneered sublimation and distillation for the preparation of medicines. Albucasis described ligatures 600 years before Paré adopted their use, even using catgut for internal stitches so the stitches would dissolve as the patient healed.6

Surgery was not always the prestigious profession that it is today. During the middle ages in Europe, surgery was considered a lesser profession, and physicians did not deal with such things. The local barber was frequently the town surgeon.

Stop the Bleeding
During the Middle Ages, one of the major hindrances of a successful surgery was excessive bleeding. Medical innovators like Guy de Chauliac emerged. He released (1363) his 7-volume library of surgical knowledge, the Chirurgia Magna, in which he described the use of a tourniquet for blood control during an amputation. In his work, he also described intubation, suturing, blood clotting, and the use of surgical instruments.7

By the mid-1500s Ambroise Paré, a barber-surgeon, introduced the lost art of ligatures to control blood flow in wounds or during surgeries like amputation. He favored ligatures over cauterization that was the preferred method of the day, because ligatures reduced the pain patients suffered. Paré invented the crow’s beak hemostat to stop blood flow during amputation.8

Kill the Pain
The pain of surgery was a limiting factor. A doctor could only operate for the length of time a patient could endure. The introduction of anesthesia opened the door for a host of new procedures.

Humphrey Davy, the scientist who discovered the elements potassium and sodium, was one of the first to identify the anesthetic properties of nitrous oxide and ether in 1799. Both were used as recreational drugs at the time. In 1842 Dr. Crawford W. Long, who had observed the effects of ether at some of their nitrous oxide parties, was likely the first to use it in surgery. He administered it to James Venable before removing a cyst from James’ neck.9

In Scotland a year later (1847) James Young Simpson was assisting a woman with a difficult childbirth and used ether to minimize her pain. Because of the side effects, he began experimenting with chloroform. Chloroform was soon accepted, and even Queen Victoria used it for childbirth.

Physicians then began looking for a local anesthetic. The birth of the hypodermic needle (1850s) allowed for intravenous anesthetics.10 Surgeons like William Stewart Halsted, who was one of the “Big Four” founding professors of Johns Hopkins, was one of the first to explore the use of cocaine as a local anesthetic. He would inject the anesthetic into a nerve trunk to numb an entire limb or the spinal cord.11

Incidentally, it was he who introduced the radical mastectomy for treatment of breast cancer. In addition, he also invented the Halsted Mosquito Forceps, a small pair of hemostatic forceps. One of the other “Big Four” was Howard Atwood Kelly, who developed the Kelly Forceps, one of the most popular and commonly used hemostatic forceps.

With the introduction of anesthetics, medical science continued its forward advance. However, the discovery of effective anesthetics came with unintended consequences. While it made non-traumatic surgery possible and allowed for longer and more complicated surgeries, it also opened the patient to a greater chance of infection.12 By the mid-1800s when the use of anesthetics was the norm, it was not uncommon for a European hospital to have an 80% mortality rate for surgical patients.13

Wash Up
When physicians learned to combat infection, we cleared another medical hurdle. Honey, willow bark, balsam, wine, and vinegar were used historically as antiseptics to dressed wounds. However, before the mid-1800s, there was little concern for cleanliness among physicians. At that time, a bloody apron was considered a badge of honor. In 1795, Scottish physician Alexander Gordon suggested that doctors could transmit contagions, and he recommended that obstetricians wash their hands and clothes before treating patients. Opposing the standards of the day, American physician Oliver Wendell Holmes concluded in 1843 that the spread of puerperal fever (after childbirth) was connected with unwashed doctors. Independently, Hungarian doctor Ignāz Semmelweis made the same conclusion in 1847. Implementation of new cleanliness guidelines lead to a maternal mortality drop from a high of 18% to about 1%. Amazingly, these doctors understood what to do but not why.14

Louis Pasteur proved the existence of airborne microorganisms. By 1862, he completed his first tests indicating that bacteria cause wine, beer, and milk to sour. He then pioneered the process of pasteurization to kill the microorganism. Pasteur continued his extraordinary research in germ theory and went on to invent vaccinations for diseases like cholera, tuberculosis, and small pox.15

Following these discoveries, Joseph Lister put it all together. He determined that if airborne bacteria caused wine to spoil, then airborne microorganisms could also cause infection after surgery or childbirth. In 1865, he pioneered a method of using carbolic acid (phenol) as an antiseptic for treating wounds. He published his work in 1867 in The Lancet. It was not fully accepted until the 1890s when Heinrich Koch proved that germs cause disease.

Lister introduced sterile catgut for internal stitches. He also tied bones together with sterile, silver wire and left it inside of the patients. This was a revolutionary idea, because previously, the germs left behind by such a procedure would have caused gangrene and certain death.16 Lister also invented the Lister bandage scissors.

Hurdles to Modern Surgery
While the mechanics and instruments in a surgeon’s toolkit have changed dramatically through the ages, surgery still remains an intricate and delicate handicraft practiced and perfected by the gifted and skilled. As the science of surgery has evolved, three major hurdles had to be overcome: the control of bleeding, the control of pain, and the control of infection. In the last 150 years, these incredible medical advancements have completely revolutionized the surgical process and given humankind a much brighter future.

Now, as you stand in a modern operating theater, garbed in a sterile gown complete with surgical mask, binocular loupes and neoprene gloves, you can marvel at the array of gadgetry to monitor the patient’s heart rate, O2 levels, and blood pressure. The lead surgeon is assisted by a staff of anesthesiologists, nurses, and technicians. Complex surgeries of critical organs can take hours as skilled surgeons work miracles never before even imagined. The civil war surgeon would have marveled at the spectacle of a laser surgery, laparoscopy, MRI and CT technology, chemotherapy, and robotic surgery. Given the phenomenal advances of the last century, we have to wonder what revolutionary breakthroughs await us in the next 150 years. Will you be the Louis Pasteur, Ambroise Paré, Albucasis, or Joseph Lister of our modern age?


Civil War Medical Care, Battle Wounds, and Disease (Civil War Medical Care, Battle Wounds, and Disease) 02/10/02
Clements, I.P. History of Surgical Amputation (HowStuffWorks)
Billings, J. (2001). Hardtack and coffee, or the unwritten story of Army life. Scituate, Mass.: Digital Scanning. (Internet Scientific Publications) Sushruta: The first Plastic Surgeon in 600 B.C. by S Saraf, R Parihar
Roy, P., Mehra, K., & Deshpande, P. (1975). Cataract surgery performed before 800 B.C. British Journal of Ophthalmology, 59(171)
Albucasis (Doctor - the Father of Modern Surgery)
Guy de Chauliac
Ambroise Paré
Dr. Long’s Discovery
Blatner, A. (2009, February 16). Anesthesia / History of Medicine. The Discovery and Invention of Anesthesia.
The Four Founding Physicians
Lamont, A. (1992, March 1). Joseph Lister: Father of Modern Surgery.
Henderson, D.K., Lee, L., and Palmore, T (2014, June 1) The Contemporary Semmelweis Reflex: History as an Imperfect Educator
Louis Pasteur (2014)

A Purdue University graduate, Lisa Fulghum is the Content Director at WPI. For nearly 50 years, WPI has been supplying laboratory equipment for life science researchers, including a variety of German and Swiss made surgical instruments.

Image: This toolkit is over 100 years old.



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