History of surgery
The ancient world
The oldest surgery for which we have evidence is trepanation  (also known as trepanning, trephination, trephining or burr hole), in which a hole is drilled or scraped into the skull, thus exposing the dura mater in order to treat health problems related to intracranial pressure and other diseases. Evidence has been found in prehistoric human remains from Neolithic times, in cave paintings, and the procedure continued in use well into recorded history (being described by ancient Greek writers such as Hippocrates among others). Out of 120 prehistoric skulls found at one burial site in France dated to 6500 BC, 40 had trepanation holes. The remains suggest a belief that trepanning could cure epileptic seizures, migraines, and mental disorders. Surprisingly, many prehistoric and premodern patients had signs of their skull structure healing; suggesting that many of those that proceeded with the surgery survived their operation.
In Mehrgarh, in modern day Pakistan, archaeologists made the discovery that the people of Indus Valley Civilization, even from the early Harappan periods (c. 3300 BC), had knowledge of medicine and dentistry. The physical anthropologist that carried out the examinations, Professor Andrea Cucina from the University of Missouri-Columbia, made the discovery when he was cleaning the teeth from one of the men. Later research in the same area found evidence of teeth having been drilled, dating back 9,000 years to 7000 BC.
Indian physician Sushruta (c. 600 BC) taught and practiced surgery on the banks of the Ganges in the area that corresponds to the present day city of Benares in Northern India. Much of what is known about Sushruta is contained in a series of volumes he authored, which are collectively known as the Susrutha Samhita. It is the oldest known surgical text and it describes in exquisite detail the examination, diagnosis, treatment, and prognosis of numerous ailments, as well as procedures on performing various forms of plastic surgery, such as cosmetic surgery and rhinoplasty.
In the Sushruta school, the first person to expound Āyurvedic knowledge was Dhanvantari who then taught it to Divodasa who, in turn, taught it to Sushruta, Aupadhenava, Aurabhra, Paushakalāvata, Gopurarakshita, and Bhoja.
Because of his seminal and numerous contributions to the science and art of surgery, Sushruta is also known by the title "Father of Surgery". The Samhita has some writings that date as late as the 1st century, and some scholars believe that there were contributions and additions to his teachings from generations of his students and disciples. Susrutha is also the father of Plastic Surgery and Cosmetic Surgery since his technique of forehead flap rhinoplasty (repairing the disfigured nose with a flap of skin from the forehead),that he used to reconstruct noses that were amputated as a punishment for crimes, is practiced almost unchanged in technique to this day. This knowledge of plastic surgery existed in India up to the late 18th century as can be seen from the reports published in Gentleman's Magazine (October 1794).
The Susrutha Samhita contains the first known description of several operations, including the uniting of bowel, the removal of the prostate gland, the removal of cataract lenses and the draining of abscesses. Susrutha was also the first surgeon to advocate the practice of operations on inanimate objects such as watermelons, clay plots and reeds; thus predating the modern practice of the surgical workshop by half a millennium.
Researchers have uncovered an Ancient Egyptian mandible, dated to approximately 2650 BC, with two perforations just below the root of the first molar, indicating the draining of an abscessed tooth. Recent excavations of the construction workers of the Egyptian pyramids also led to the discovery of evidence of brain surgery on a laborer, who continued living for two years afterwards.
While surgeons are now considered to be specialized physicians, the profession of surgeon and that of physician had different historical roots. For example, Greek tradition was against opening the body, and the Hippocratic Oath warns physicians against the practice of surgery. Specifically, cutting persons laboring under the stone (i.e. lithotomy, an operation to relieve kidney stones) was to be left to such persons as practice [it]. Of course, most knowledge of surgery comes from dissecting bodies, a science which was repulsive to many healers.
Hua Tuo was a famous Chinese physician during the Eastern Han and Three Kingdoms era. He was the first person to perform surgery with the aid of anesthesia, some 1600 years before the practice was adopted by Europeans.
The medieval world
Abulcasis (Abu al-Qasim Khalaf ibn al-Abbas Al-Zahrawi) was an Andalusian-Arab physician and scientist who practised in the Zahra suburb of Cordoba. He is considered a great medieval surgeon, whose comprehensive medical texts, combining Islamic medicine with Greco-Roman and Indian teachings, shaped European surgical procedures up until the Renaissance. He is often regarded as the Father Of Surgery. Patients and students from all parts of Europe came to him for treatment and advice. According to Will Durant, Cordova was in this period the favourite resort of Europeans for surgical operations.
By the thirteenth century, many European towns were demanding that physicians have several years of study or training before they could practice. Montpellier, Padua and Bologna Universities were particularly interested in the academic side to Surgery, and by the fifteenth century at the latest, Surgery was a separate university subject to Physics. Surgery had a lower status than pure medicine, beginning as a craft tradition until Rogerius Salernitanus composed his Chirurgia, which laid the foundation for the species of the occidental surgical manuals, influencing them up to modern times.
Ambroise Paré pioneered the treatment of gunshot wounds. Among the first modern surgeons were battlefield doctors in the Napoleonic Wars who were primarily concerned with amputation. Naval surgeons were often barber surgeons, who combined surgery with their main jobs as barbers.
In London, an operating theatre or operating room from the days before modern anaesthesia or antiseptic surgery still exists, and is open to the public. It is found in the roof space of St Thomas Church, Southwark, London and is called the Old Operating Theatre.
Foundations of modern surgery
To make its transition to the modern era the art of surgery had to solve three major problems that effectively prevented surgery from progressing into the modern science. These were:
Before modern surgical developments, there was a very real threat that a patient would bleed to death on the table during an operation or while being attended after an accident or wound. The first real progress in combating bleeding had come when early cultures realized they could close wounds using extremes of heat, a procedure called cauterizing. The early cauterization was successful, but only usable in a limited fashion, highly destructive, and painful, with very poor long term outcomes.[verification needed]
The next real breakthrough to come was the invention of ligatures, widely believed to have originated with Abulcasis in the 10th century and improved by Ambroise Paré in the 16th century. A ligature is a piece of material used to tie closed the end of a severed blood vessel to prevent further bleeding. Ligatures form the basis of modern bleeding control, but at the time, they were more of a hazard than a help because the surgeons using them had no concept of infection control.
A final barrier to be overcome was the problem of replacing blood lost. Limiting bleeding is important, but ultimately, a surgeon is fighting a losing battle if blood cannot be replaced, and this final barrier was only conquered when early 20th century research into blood groups allowed the first effective blood transfusions.
The first progress in combating infection was made in 1847 by the Hungarian doctor Ignaz Semmelweis who noticed that medical students fresh from the dissecting room were causing excess maternal death compared to midwives. Semmelweis, despite ridicule and opposition, introduced compulsory handwashing for everyone entering the maternal wards and was rewarded with a plunge in maternal and fetal deaths. However the Royal Society in the UK still dismissed his advice.
The next true progress came when, after reading a paper by Louis Pasteur, the British surgeon Joseph Lister began experimenting with using phenol during surgery to prevent infections. Lister was able to quickly reduce infection rates, a reduction that was further helped by his subsequent introduction of techniques to sterilize equipment, have rigorous hand washing and a later implementation of rubber gloves. Lister published his work as a series of articles in The Lancet (March 1867) under the title Antiseptic Principle of the Practice of Surgery. The work was groundbreaking and laid the foundations for a rapid advance in infection control that saw modern aseptic operating theatres widely used within 50 years (Lister himself went on to make further strides in antisepsis and asepsis throughout his lifetime). The gradual development of germ theory has allowed the final step to be taken to create the highest quality of aseptic conditions in modern hospitals, allowing modern surgeons to perform nearly infection-free surgery.
Anesthesia was discovered by two American dentists, Horace Wells (1815-1848) and William Morton. Before the advent of anesthesia, surgery was a traumatically painful procedure and surgeons were encouraged to be as swift as possible to minimize patient suffering. This also meant that operations were largely restricted to amputations and external growth removals.
Beginning in the 1840s, surgery began to change dramatically in character with the discovery of effective and practical anaesthetic chemicals such as ether and chloroform. In Britain, John Snow pioneered the use of these two anaesthetics. In addition to relieving patient suffering, anaesthesia allowed more intricate operations in the internal regions of the human body. The further discovery of muscle relaxants such as curare also facilitated safer applications.
Timeline of surgical procedures
- c.1900 Cargile membrane employed by surgeons.
Notable individuals in the development of surgery
- (Capasso 2001)
- Restak (2000)
- Brothwell, D.R. Digging up Bones. 1963:126
- biography from Famousmuslims.com accessed 16 April 2007.
- Rabie E. Abdel-Halim, Ali S. Altwaijiri, Salah R. Elfaqih, Ahmad H. Mitwall (2003), "Extraction of urinary bladder described by Abul-Qasim Khalaf Alzahrawi (Albucasis) (325-404 H, 930-1013 AD)", Saudi Medical Journal 24 (12): 1283-1291 .