The History of Surgery

1
The History of Surgery

• Hughes Evans
• History of Medicine

2
19th Century Rise of Surgery

• Early 19th century surgery
• Introduction of Antisepsis
• Introduction of Anesthesia
• Rise of the Hospital
• Role of Civil War
• Industrialization
• Professional issues

3
Pre-1800 Surgery

• Traditionally distinct from physicians
• Surgery is derived from Greek words for work and
  hand

4
Surgeons vs Physicians

• Surgeons
• Barber-surgeon Guild
• Often illiterate
• Apprenticeship
• Mister
• Tool central

• Physicians
• Physician Guilds
• More intellectual
• Attended University
• Doctor
• Eschewed use of tools

5
Barber-surgeon

• Lucas van Leydan
• The Surgeon and the Peasant
• 1524
• Depicts barber-surgeon

6
Early 19th Century Surgery

• Surgery was dreaded
• Patients avoided surgery pain
• Mortality was high
• 19 amputations prior to 1850
• Primarily wound treatment
• Lancing boils
• Draining abscesses
• Suturing injuries

7
Surface wound treatments
8
Tools of the trade

• 1846 scarifier

• 1863 cupping set

9
Infection

• Post-surgical infection so common that pus felt
  to be sign of healing
• Laudable Pus
• Gangrene common
• Stench

10
Surgery and Pain

• Made surgery more difficult
• Delayed treatment
• Patients allowed wounds and tumors to grow and
  fester
• Notion of consent was different
• Drugs like opium, hemp, hashish, whiskey
• Unpredictable, unsafe
• Speed essential

11
Surgery and Pain

• In case of amputation, it was the custom to
  bring the patient into the operating room and
  place him upon the table. The surgeon would
  stand with his hands behind his back and would
  say to the patient, Will you have your leg off,
  or will you not have it off? If the patient
  lost courage and said, No, he had decided not
  to have the leg amputated, he was at once carried
  back to his bed in the ward. If, however, he
  said, Yes, he was immediately taken firmly in
  hand by a number of strong assistants and the
  operation went on regardless of whatever he might
  say thereafter. If his courage failed him after
  this crucial moment, it was too late and no
  attention was paid to his cries of protest. It
  was found to be the only practicable method by
  which an operation could be performed under the
  gruesome conditions which prevailed before the
  advent of anesthesia.

12
Surgery and Speed

• Surgeon was a clock-driven gladiator
• Minimize shock and pain
• Speed at the price of tissue damage

13
19th C Surgery

• Street clothes
• Bare hands
• Unclean and reused instruments
• Assistants were medical students and junior
  doctors
• Often performed at home

14
Anesthesia

• Horace Wells
• Dentist
• Reported use of Nitrous Oxide
• 1844

15
Anesthesia

• William E Clarke
• ether
• Crawford Long MD
• 1842
• Georgia surgeon
• Ether

16
WT Morton and MGH

• WT Morton, dentist
• October 1846
• 1st public demonstration of ether
• Mass General Hospital
• Not 1st surgical use of ether

17

• Demonstration of ether in the Ether Dome, October
  16, 1846

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Chloroform

• 1847
• James Young Simpson

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Effect of anesthesia on surgery

• operations increased
• Mortality increased
• Risk assocd w/ anesthetics
• Explosion
• Underanesthetized and overanesthetized
• Decreased patient fear
• Surgery lasted longer

20
Effect of anesthesia on surgery

• Not adopted immediately or universally
• Restricted in military
• Too expensive for charity patients
• Questioned on moral grounds
• Obstetrical anesthesia
• Socio-economic and racial disparities

21
Impact of the Civil War
22

• Amputation, c. 1863

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Impact of Civil War

• Important training ground
• Exposure to injuries and infections
• Value of hospitals

24
Rise of Hospitals

• During 19th C most surgery performed in the home
• Mortality 3-5x higher in hospitals
• Hospitals for charity cases
• Social stigma

25
Rise of hospitals

• 1800 2 hospitals
• Pennsylvania Hosp
• New York Hospital
• 1821 Mass General Hospital 3
• 1873 178 hospitals
• 1909 4359 hospitals

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Forces contributing to rise of hospitals

• Professional
• Nurses/ anesthetists/ orderlies available
• Location for teaching/ learning
• Immigration
• Urbanization
• Lack of extended families
• Poverty/ expense of health care
• Technology and surgical equipment available

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• Bellevue Hospital, 1880s

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Infection

• Post-surgical infection rises in 19thc
• Crowded hospitals
• Infection in hospitals
• Increase in traumatic injuries
• Hospitalism
• Gangrene, erysipelas, pyema
• Associated with large, old buildings
• Led to new hospital design w/ ventilation and
  more space

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• Bellevue, 1860

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• Pennsylvania Hospital, 1911

31
Infection control

• Ignaz Semmelweis
• 1847 experiments w/ washing hands instruments
  in chlorine solution to prevent childbed fever
• Publishes in 1860
• Impact ignored

32
Louis Pasteur

• French chemist
• 1857 and 1860
• Demonstrated that fermentation is caused by a
  living organism (not a chemical reaction)
• Refuted spontaneous generation

• Louis Pasteur

33
Antisepsis and Joseph Lister

• British Surgeon
• Influence Pasteur
• Pus/ infection caused by microbes in air
• 1867 introduces Antisepsis
• Carbolic acid
• Rinse hands and instruments

34
Antiseptic Surgery

• Antiseptic Surgery, 1882

35
Antisepsis

• Coincides with heightened public interest in
  cleanliness and hygiene
• Erratically adopted, especially in America
• Solution caustic
• Many physicians opposed germ theory
• By 1880s, generally though not uniformly adopted
• Lister didnt wash his hands operated in street
  clothes

36
Robert Koch
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Robert Koch

• 1843-1910, German
• 1876 discovers anthrax
• 1882 mycobacterium tuberculosis
• Demonstrates bacteria have specific etiological
  relationship to disease

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Robert Koch, contd

• Made bacteriology clinically applicable
• refined culture and dye techniques
• Kochs postulates
• Experimental process showing organism A causes
  disease B

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Kochs Postulates, 1882

• Organism must be present in all cases of the
  diseased condition but not in healthy animals
• Organism must be isolated and grown in pure
  culture
• Culture must induce disease experimentally
• Organism can be reisolated from experimental
  infection

40
Impact of Germ Theory

• Idea of disease specificity
• Allowed possibility of equating disease with an
  organism
• Reclassification of disease
• Dynamic conception of disease

41
Impact of Germ Theory

• Belief that medicine could fight disease, improve
  public health
• provided scientific rationale for public
  health/hygiene efforts
• Shifted attention from internal organs to
  external invaders
• ironically reinforced prejudices about outsiders

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Impact contd

• Provided theoretical foundation for diagnosis and
  therapy
• Specific therapy for infectious diseases
• Search for vaccines, antitoxins, magic bullets

43
Asepsis

• Introduced by Ernst von Bergmann in 1877
• Recognition that hands, body, instruments were
  more likely source of infection than air
• Led to sterilization, cleaning patient,
  handwashing, eventually gloves and masks
• By 1890s most hospitals used autoclaves
• However, many surgeries still performed in homes

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• Hayes Agnew, 1886

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• The Agnew Clinic, 1889 (Thomas Eakins)

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• Hahnemann Hospital, 1899

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• 1901

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• Mobile, 1904

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• Womens Medical College, 1903

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Blossoming of Surgery

• By 1870s and 1880s surgeons can operate on head,
  chest, and abdomen
• 1886 1st successful appendectomy
• 1886 MGH abdominal surgery ward
• Abdomen now available to surgeons
• 1880s and 90s Physiological Surgery
• Conserved tissues, preserved anatomy, careful
  dissection
• Compare to slash and speed model

51
Increase in operations

• MGH
• 1841-1845 37 operations/ year
• 1847-1851 98 operations/ year
• 1898 3700 operations
• Surgery in 1900
• Safer
• Less painful
• More invasive
• Less infection risk

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The Century of the Surgeon

• 1870-1970
• Explosion in surgical techniques
• New areas of the body accessible
• Attention to detail and tissue