HISTORY of

SURGERY
“ If you donʼt know history, then you don't know
anything. You are a leaf that doesnʼt know it is a
part of a tree. “
Michael Crichton
 SURGERY
• The branch of medicine that employs
operations in the treatment of disease or injury

• Surgery can involve cutting, abrading, suturing,

or otherwise physically changing body tissues
and organs.

• from Greek kheirourgia, from kheirourgos

"working or done by hand," from kheir "hand”
+ ergon "work"
SURGERY in the ANCIENT ERA
• The first surgical techniques were developed
to treat injuries and traumas

• A combination of archaeological and

anthropological studies offer insight into
man's early techniques for suturing
lacerations, amputating unsalvageable limbs,
and draining and cauterizing open wounds
 Ancient Egyptians
• good at practical first aid
• reset dislocated joints, and they
could mend broken bones
• They could also stitch wounds.
• Archaeologists have found stone
carvings in Egypt showing surgical
instruments
• And there are Egyptian papyri
which speak of cautery and surgery
• Egyptian surgery, however, did not
venture inside the body
 Mesopotamia
• Hammurabi reigns between 1795-1750 BC

• Code of laws
• largely considered the earliest-known
example of code announced to the public

• Code of Hammurabi
• one of the earliest Bablyonian code of laws
• 282 laws itself contains specific legislation
regulating surgeons and medical compensation as
well as malpractice and victim's compensation
 Code of Hammurabi
— If a physician make a large incision with an operating knife and
cure it, or if he open a tumor (over the eye) with an operating
knife, and saves the eye, he shall receive ten shekels in money
— If a physician make a large incision with the operating knife,
and kill him, or open a tumor with the operating knife, and cut
out the eye, his hands shall be cut off.
— If a physician make a large incision in the slave of a freed man,
and kill him, he shall replace the slave with another slave.
— If he had opened a tumor with the operating knife, and put out
his eye, he shall pay half his value.
— If a physician heals the broken bone or diseased soft part of a
man, the patient shall pay the physician five shekels in money.
— If he were a freed man he shall pay three shekels.
— If he were a slave his owner shall pay the physician two
shekels.
 — Greek City-States are
Ancient Greeks constantly at war

— Excellent in First Aid

— Learned setting broken

and dislocated bones

— No evidence that they

successfully operated
inside the body
 Ancient Greeks
— The ancient Greeks believed in
the humoral theory
— which proposed that there are 4
humors :
— Blood
— Phlegm
— Black Bile
— Yellow Bile

— humors in the human body were

in balance, good health was
guaranteed
— Hippocrates
 Cladius Galenus
• Galen of Pergamon
• “The greatest innovator”
- Loves dissecting and experiment on animals then relate to human
body
- During his time, dissecting humans is illegal

• as the originator of the

experimental method in
medical investigation

• throughout his life dissected

animals in his quest to
understand how the body
functions
 Sushruta
• One of the earliest surgeons
of the recorded history (600
B.C.)

• Believed to be the first

individual to describe plastic
surgery
• “Father of plastic surgery”

• Treatise 'Sushruta
Samhitaʼ
which is one of the
oldest treatise dealing with
surgery in the world
- Descriptions on Surgical Procedures
 Early Surgical Procedures
Trepanation
• trepanning, trephination, trephining or burr hole
• The oldest operation for which evidence exists
• a hole is drilled or scraped into the skull for exposing
the dura mater
• to treat health problems related to intracranial
pressure and other diseases
• Evidence has been found in prehistoric human remains
from Proto-Neolithic and Neolithic times, in cave
paintings
• being described by ancient Greek writers such as
Hippocrates among others
Trepanation
SURGERY IN THE
EARLY TIMES
 Blood Letting
• began around 3000 years ago with the Egyptians
• Most common procedure for almost 2 thousand years
• then continued with the Greeks and Romans, the Arabs
and Asians, then spread through Europe during the Middle
Ages and the Renaissance
• an imbalance of the four humors.
• Therefore, treatment consisted of removing an amount of
the excessive humor by various means such as
• Bloodletting
• Purging
• catharsis,
• diuresis
• In the 1st century bloodletting was already a
common treatment, but when Galen of
Pergamum (129–200 AD) declared blood as
the most dominant humor, the practice of
venesection gained even greater importance

• Losing blood was considered beneficial

• Done to balance the humours
• Fevers, apoplexy, headache were result of too
much blood (Galen)
Blood Letting
Divided into:
1. Generalized Method
• Venesection and Arteriotomy
• Median Cubital Vein
2. Localized Method
• Scarification with cupping
• Leeches
• Francois Broussais proposed in his Histoire
des phlegmasies ou inflammations
chroniques (1808) that all disease resulted
from excess build up of blood

• the surgeon would tie the arm to make the

veins swell, cut the patient and drain out a
certain amount of blood

• a process which was called ʻbreathing a veinʼ

 Blood letting
• divided into:
• generalized method (venesection and arteriotomy)
• localized method (scarification with cupping and
leeches)
• Venesection was the most common procedure
• usually involved the median cubital vein at the elbow
 Leeches
• Leeches used for bloodletting usually involved the
medicinal leech, Hirudo medicinalis
• At each feeding a leech can ingest about 5 to 10 ml
of blood, almost 10 times its own weight
Barber Surgeons
• White – Bloodletting
rod

• Red – Bloodied
bandage

• Blue – many believe

that this represents
veins
 Barber-Surgeons
• medical practitioners who provided a
wide-range of services during the
medieval and early modern periods
• Services: enemas, selling
medicines, blood letting,
performing surgery, pulling teeth,
cutting hair

• The first barber-surgeons to be

recognized as such worked in
monasteries around 1000 A.D

• In 1540, when Henry VIII integrated

the two through the establishment of
the Barber-Surgeons Company

• 1745
19th Century
• The surgeon truly emerged as a specialist
within the whole arena of medicine to become
a recognized and respected clinical physician
Mid-19th Century
• Medicine appeared as the more progressive
branch, with Surgery lagging behind

• The art and craft of surgery, for all its practical

possibilities, would be severely restricted
• Despite outward appearances, it was actually
not until the latter decades of the 19th
century that the surgeon truly emerged as a
specialist within the whole arena of medicine
to become a recognized and respected
clinical physician

• Similarly, it was not until the first decades of

the 20th century that surgery could be
considered to have achieved the status of a
bona fide profession
• With the breathtaking advances made in pathologic
anatomy and experimental physiology during the 18th and
first part of the 19th centuries, physicians would soon
adopt a therapeutic viewpoint that had long been
prevalent among surgeons.

• It was no longer a question of just treating symptoms; the

actual pathologic problem could ultimately be understood.
Internal disease processes that manifested themselves
through difficult to treat external signs and symptoms
were finally described via physiology-based
experimentation or viewed pathologically through the lens
of a microscope
 Four fundamental clinical prerequisites:

1. Knowledge of human anatomy

2. Method of controlling hemorrhage and
maintaining intraoperative hemostasis
3. Anesthesia to permit the performance of
pain-free procedures
4. Explanation of the nature of infection, along
with the elaboration of methods necessary
to achieve an antiseptic and aseptic
operating room environment
• Before this time, the scope of surgery
remained limited. Surgeons,
• or at least those medical men who used the
sobriquet
• surgeon, whether university-educated or
trained in private
• apprenticeships, at best treated only simple
fractures, dislocations, and abscesses and
occasionally performed amputations with
dexterity, but also with high mortality rates
 Andreas Vesalius (1514-1564)
• Andries Van Wesel

• Taught that human anatomy

could be learned only
through the study of
structures revealed by
human dissection
7 Books on Structure of the Human Body
• De Humani Corporis Fabrica
Libri Septem (1543) – 1st
truly scientific anatomical
textbook in Medical History
• The mandible consisted of one bone (not 2)

• The human sternum consisted of 3 bones (not 7)

• Disproved Galenʼs claim of a porous interventricular system

• Believed that the brain and nervous center as the center of

the mind and emotion, not the heart

• Disproved that men had more teeth than women

The Four Fundamental Clinical Prerequisites

1. Knowledge of human anatomy

2. Method of controlling hemorrhage and
maintaining intraoperative hemostasis
3. Anesthesia to permit the performance of
pain-free procedures
4. Explanation of the nature of infection, along
with the elaboration of methods necessary
to achieve an antiseptic and aseptic
operating room environment
Ambroise Paré (1510-1590)
• Royal surgeon
• He was also part of the
Parisian Barber Surgeon
guild.
• In 1536, joined the army
• A tincture of egg yolk,
turpentine, and oil of
roses
• Rejected use of cautery,
instead use ligatures to
tie individual blood
vessels
The Four Fundamental Clinical Prerequisites

1. Knowledge of human anatomy

2. Method of controlling hemorrhage and
maintaining intraoperative hemostasis
3. Anesthesia to permit the performance of
pain-free procedures
4. Explanation of the nature of infection, along
with the elaboration of methods necessary
to achieve an antiseptic and aseptic
operating room environment
Anesthesia
 John Hunter (1728-1793)
• stressed the relationship
between structure and function
in all kinds of living creatures
• believed that surgeons should
understand how the body
adapted to and compensated for
damage due to injury, disease or
environmental changes.
• A Treatise on the Blood,
Inflammation, and Gun-Shot
Wounds (1794)
• Father of scientific surgery
Pre- Anesthesia era
Surgery as ‘a humiliating spectacle of the futility of
science’ and the surgeon as ‘a savage armed with
a knife’
John Hunter, 1750

ÒWhen the dreadful steel was plunged into the

breast—cutting through veins—arteries—flesh—
nerves—I needed no injunctions not to restrain my
cries. I began a scream that lasted unintermittingly
during the whole time of the incision—& I almost
marvel that it rings not in my Ears still!
• Fanny Burney, 1811
Operating table
Ether Frolics
• As anatomic knowledge
and surgical technique
improved, the search for
safe methods to prevent
pain

• Early 1830s : chloroform,

ether, and nitrous oxide (
laughing gas parties,
ether frolics)
 William T.G. Morton (1819-1868)
• Oct. 16, 1846
• John Collins Warren, a
professor of Surgery at
the Massachusetts
General Hospital
• Sulfuric ether
• First public
demonstration of
anesthesia in surgery
Crawford Williamson
Long (1815 - 1878)
• An American surgeon
and pharmacist

• The first to use ether

anesthesia for surgery
on March 30, 1842
The Four Fundamental Clinical Prerequisites

1. Knowledge of human anatomy

2. Method of controlling hemorrhage and
maintaining intraoperative hemostasis
3. Anesthesia to permit the performance of
pain-free procedures
4. Explanation of the nature of infection, along
with the elaboration of methods necessary
to achieve an antiseptic and aseptic
operating room environment
John Collins Warren (1778 -1856)
• 1st Dean of Harvard Medical
School
• Founding member of the
Massachusetts General
Hospital
• Founder of the New England
Journal of Medicine
— In many respects, the recognition of antisepsis
and asepsis was a more important event in the
evolution of surgical history than the advent of
inhalational anesthesia
— However, if anesthesia had never been
conceived, a surgical procedure could still be
performed, albeit with much difficulty
— Without antisepsis and asepsis, major surgical
operations more than likely ended in death
rather than just pain
 Joseph Lister (1827 - 1912)
• Lister, an English surgeon
• It was evident to Lister that a
method of destroying bacteria
by excessive heat could not be
applied to a surgical patient.
• He turned, instead, to chemical
antisepsis
• decided on carbolic acid
(phenol)
• A second important advance by
Lister was the development of
sterile absorbable sutures
 Heat Sterilization
• Charles Chamberland
invented the steam sterilizer
(1881)
• known as the autoclave

• The availability of heat

sterilization led to the
development of sterile
aprons, drapes, instruments,
and sutures

• Similarly, the use of face

masks, gloves, hats, and
operating gowns also
naturally evolved.
 Surgical Gloves
• 1842, Thomas Watson suggested the
use of surgical gloves during operations

• 1890ʼs when William Stewart Halstead

• asked the Goodyear Tire and Rubber
Company to make two pairs of gloves
made for one of his scrub nurses, who
was having allergic reactions

• Eventually, the rest of the surgical

team started wearing gloves too,
and by 1897, all of the surgeons at
Hopkins were wearing rubber gloves
 Wilhelm Roentgen (1845-1923)
— Roentgen made a chance
observation when he passed
a current through a vacuum
tube and noticed a greenish
glow coming from a screen
on a shelf nine feet away

— soon realized that there

were invisible rays capable
of passing through solid
objects made of wood,
metal, and other materials
• these rays also penetrated the
soft parts of the body in such a
manner that the more dense
bones of his hand were able to
be revealed on a specially
treated photographic plate
• Called it x-rays, from the
mathematical designation, “x”
meaning unknown
 ASCENT OF
SCIENTIFIC SURGERY
 William Stewart Halsted (1852-1922)
• He introduced a new surgery and
showed that research based on
anatomic, pathologic, and
physiologic principles and the use
of animal experimentation made it
possible to develop sophisticated
operative procedures and perform
them clinically with outstanding
results

• developed and disseminated a

different system of surgery so
characteristic that it was termed a
school of surgery
— At Johns Hopkins, Halsted
was credited with starting the
first formal surgical residency
training program in the
United States

— Harvey Cushing

— One of the Big Four founders

of Johns Hopkins Hospital
— Pioneered modern surgical principles

— Tenets of Halsted

— pioneered treatments for breast cancer,

hernias and gallstones.

— Performed the 1st radical mastectomy for

breast cancer in the US

— introduction of the latex surgical glove

 Tanets of Halsted
Halsted Principles
— Handle tissues gently
— Achieve meticulous hemostasis
— Preserve vascularity
— Ensure strict asepsis
— Close the wound without tension
— Achieve good approximation of tissues
— Avoid dead space
• Internationalization

• In 1924 ,Halsted and Hermann Kuẗ tner

(1870-1932), director of the surgical clinic
in Breslau, Germany instituted the first
known official exchange of surgical
residents

• Halsted firmly believed that young surgeons

achieved greater clinical maturity by observing
the practice of surgery in other countries.
• Formation of national and international surgical societies

• For the most part, professional societies began as a means

of providing mutual improvement via personal interaction
with surgical peers and the publication of presented papers
• The emergence and development of periodicals devoted to
surgical subjects proved to be important adjuncts to the
professionalization process of surgery.

• Unlike surgeons of earlier centuries, who were known to

guard so-called trade secrets closely, members of these
new organizations were emphatic about publishing their
meetings.

• The first of these surgical societies was the Académie Royale

de Chirurgie in Paris, with its Mémoires appearing sporadically
from 1743 through 1838
Early Publications
• Bulletins of the Société de Chirurgie of Paris (1847)

• the Verhandlungen of the Deutsche Gesellschaft für

Chirurgie (1872)

• the Transactions of the American Surgical

Association (1883)
• Monthly journals

ØAugust Richterʼs (1742-1812)

ØChirurgische Bibliothek (1771)
ØJoseph Malgaigneʼs (1806-1865)
ØJournal de Chirurgie (1843)
ØBernard Langenbeckʼs (1810-1887)
ØArchiv für Klinische Chirurgie (1860)
ØLewis Pilcherʼs (1844-1917)
ØAnnals of Surgery (1885)

• had a tremendous impact on updating and

continuing the education of surgeons
 World War 1
— Undoubtedly, the greatest
surgical achievement was in the
treatment of wound infection

— Trench warfare in soil

contaminated by decades of
cultivation and animal manure
made every wounded soldier a
potential carrier of any number
of pathogenic bacilli

— On the battlefront, sepsis was

inevitable.
 Alexis Carrel (1873- 1944)
• Together with Henry Dakin
developed the Carrel Dakin
method of treating wounds
based on chlorine (Dakin
solution)
• Triangulation technique of
suturing blood vessels
• Nobel Prize
— Another important advance was the creation of
portable X-ray machines/ mobile x-ray stations
(Oct. 1914)
— Marie Curie
— Another major advance was that it became
possible to store blood; this saved many lives.

Little Curie
20th Century
• Surgery could be considered to have achieved
the status of a Bona fide profession
 MODERN ERA
• Highlighted by educational reforms in its medical
schools, Halstedʼs redefinition of surgical residency
programs, and the growth of surgical specialties, the
stage was set for the blossoming of scientific surgery

• Progress in surgical instrumentation and surgical

techniques went hand in hand.

• Surgical 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.
• domain of surgery had become so well established that the
professionʼs foundation of basic operative procedures was
already completed
• As a consequence, there were few technical surgical mysteries
left. What surgery now needed to sustain its continued growth
was the ability to diagnose surgical diseases at an earlier stage,
locate malignant growths while they remained small, and have
more effective postoperative treatment so that patients could
survive ever more technically complex operations

— exemplified by the introduction of cholecystography in 1924 by

Evarts Graham (1883-1957) and Warren Cole (1898-1990)
— It was an exciting era for surgeons, with important clinical
advances being made in the operating room and basic science
laboratory.
— Among the most notable highlights were the introduction in 1935
of pancreaticoduodenectomy for cancer of the pancreas by Allen
Oldfather Whipple (1881-1963
— a report in 1943 on vagotomy for the operative treatment of
peptic ulcer disease by Lester Dragstedt
Allen Goldfather Whipple
(1881 – 1963)

• Among the most notable

highlights were the
introduction in 1935 of:
• Pancreaticoduodenectomy
for pancreatic cancer
Max Peet (1885 – 1949)
• Specialized in the
subtemporal section of
the Trigeminal nerve for
Tic Douloureux and
bilateral
supradiaphragmatic
sympathectomy for HPN
Harvey Williams Cushing
(1869 – 1939)

• Introduced
electrocoagulation in
neurosurgery in 1928
• 1st to describe Cushing’s
Disease
• Father of Neurosurgery
• With Ernest Sachs
• BP as VS
— Frank Lahey (1880-1953) stressed the importance of
identifying the recurrent laryngeal nerve during
thecourse of thyroid surgery

— Owen Wangensteen (1898-1981) successfully

decompressed mechanical bowel obstructions by using
a newly devised suction apparatus in 1932

— George Vaughan (1859-1948) successfully ligated the

abdominal aorta for aneurysmal disease in 1921

— Max Peet (1885-1949) presented splanchnic resection

for hypertension in 1935

— Walter Dandy (1886-1946) performed intracranial

section of various cranial nerves in the 1920s
• Walter Freeman (1895-1972) described prefrontal
lobotomy as a means of treating various mental
illnesses in 1936

• Harvey Cushing (1869-1939) introduced

electrocoagulation in neurosurgery in 1928

• Vilray Blair (1871-1955) and James Brown (1899-

1971) popularized the use of split-skin grafts to cover
large areas of granulating wounds

• • Earl Padgett (1893-1946) devised an operative

dermatome that allowed calibration of the thickness of
skin grafts in 1939.
• With such a wide variety of technically complex
surgical operations now possible, it had clearly
become impossible for any single surgeon to master
all the manual skills and pathophysiologic knowledge
necessary to perform such cases

• Therefore, by the middle of the century, a

consolidation of professional power inherent in the
movement toward specialization, with numerous
individuals restricting their surgical practice to one
highly structured field, had become among the most
significant and dominating events in 20th century
surgery
 Dwight Harken (1910-1993)
— Removed bullets and
shrapnels from the heart with
no signal fatality
— Innovator in heart surgery
— Correct mitral stenosis
— Cardiac implant, 1st Internal
pacemaker
— introduced the concept of the
intensive care unit (1951)
 John Gibbon (1903-1973)
— Invented the heart - lung
machine

— 1st successful open heart

operation in 1953
— paved the way for all future
cardiac surgery, including
procedures for correction of
congenital heart defects,
repair of heart valves,
revascularization operations,
and heart transplantation
Heart - Lung
Machine
 Michael DeBakey(1908 – 2008)
• He pioneered the use of Dacron
grafts to replace or repair blood
vessels
• invented the roller pump
• developed ventricular assist devices
• was among the first to perform
• a coronary artery bypass
• carotid endarterectomy,
• demonstrated the link between
cigarette smoking and lung cancer
• created an early version of what
became the mobile army surgical
hospital or MASH unit
 Other Highlights in the 20th Century
§ Hermann Pfannenstiel described his technique for a
suprapubic surgical incision
§ William Mayo presented his results on partial gastrectomy
One of the founders of Mayo Clinic
§ John Finney authored a paper on a new method of
gastroduodenostomy -- Authored Worked under William Halsted
a paper on a new method of gastroduodenostomy
- Founder and 1st President of the American College of Surgeons (ACS

§ Jose Goyanes (1906) used vein grafts to restore arterial

flow
§ Charles Huggins found that antiandrogenic treatment
consisting of orchiectomy, or giving of estrogen could
produce long term regression in patients with advance
prostate cancer
Laparoscopic Surgery
Minimally invasive surgery
/Key hole surgery
 History of laparoscopy
• Georg Kelling, of Dresden, Saxony, performed the first
laparoscopic procedure on dogs (1902)
• Hans Christian Jacobaeus of Sweden, reported the first
laparoscopic operation on humans (1910)
• Patrick Steptoe from England, started to perform
laparoscopic procedures in the operating room under
sterile conditions (1980)
• The first solid state camera was introduced and this was
the start of 'video-laparoscopyʼ (1982)
• Phillipe Mouret performed the first video-laparoscopic
cholecystectomy in Lyons, France. (1987)
Single Incision Laparoscopic Surgery (SILS)
Natural Orifice Transluminal Endoscopic
Surgery (N.O.T.E.S)
Robotic Surgery
Mobile Army Surgical Hospital
M.A.S.H
 Present Day
Its all about TECHNOLOGY
 Present Day
Is technology always good?
Not Really.....