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|"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 (400 B.C.)|
MYTHOLOGY AND MIDDLE AGES ( Click below to see appropriate section )
Albucasis, an Arab, was born in Spain in the tenth century. In ancient Arabic medicine he has been hailed as an outstanding physician and an able surgeon. With special instruments devised by him, he removed polyps and tonsils; he frequently used branding iron and cautery in his surgical practice. He also described obstetric instruments.
Roger Frugardi of Salerno wrote the first Western book on Surgery in the year 1170. He prescribed oral administration of seaweed ashes for goitre, not unlike the present day iodine therapy. His surgical skill was exhibited in his technique in suturing severed intestines together over an elderwood tube or an animal trachea.
Theodoric de Lucea (1205-1248) postulated scrupulous cleanliness in surgical procedures as the basis of success.
Lanfrane, an Italian by birth, was educated in Milan: he subsequently moved to Paris and settled down in practice as a surgeon. He spread the Italian gospel of "healing wounds by first intention" some time in 1295.
In England, John of Arderne (1307-1390) established himself as a reputed surgeon and later by 1376 became the pioneer proctologist. He wrote a treatise on Fistula-in-ano and the use of rectal injections. He described his famous operation for haemorrhoids - the excision of the thrombosed vein. He also advised rectal examination to differentiate between fistula-in-ano and anal cancer; the latter having a stony hard feel to the examining finger.
Guy de Chauliac (1300- 1367), a renowned French surgeon, in his book "Chirurgia magna" stipulated the qualities of a good surgeon. To quote : " A good surgeon should be acquainted with liberal studies, with medicine and above all with anatomy; he should be courteous; bold in security, pious and merciful, not greedy of gain, but looking for his fee in moderation, according to the extent of his services". These lines hold as true today as they did 600 years ago.
Paracelsus, was the adopted name or nom de plume of Aureolus Theophrastus Bombastus von Hohenheim. Born in Switzerland in 1493 of a physician - father and a hospital superintendent- mother, Paracelsus was exposed to medicine right from childhood. He spent his youth wandering from one university to another in France, Italy and Germany learning bits and pieces of chemistry, alchemy and astrology. He returned to Basel in 1527 and was appointed city physician. Here, Paracelsus discarded the traditional clothes of the physician of the 16th century (a wig and a scarlet coat) and wore conventional clothes. Further, he taught his students and wrote his prescriptions in German and not in Latin as was the prevailing practice . This was unacceptable to the so-called experts and they denounced Paracelsus. In disgust, Paracelsus burned he books of Galen and Avicenna - thereby making permanent enemies and forcing him to leave the city for good. He was the first person to describe miner's lung or pneumoconiosis, the relationship between goitre and cretinism, the difference between mental retardation and insanity and to use sulphur and antimony as drugs. Paracelsus died in 1541.
Among those who also contributed to the study of anatomy was Leonardo da Vinci [ 1452-1515 ]. He is, of course known to the world as the painter of the famous Mona Lisa which is in The Louvre, Paris. He dissected thirty corpses and made remarkable pencil drawings of this findings. He was among the first people to contradict Galen - he drew what he saw with his own eyes and not what Galenic theory stated. Since he did not publish his works, there was little impact on medical science.
Ambroise Pare (1510-1590), a field surgeon became an outstanding surgeon of the sixteenth century and indeed, one of the greatest of all time. He wrote extensively on gun shot wounds and published a treatise in 1545. He advocated the use of ligatures to control bleeding and a limited use of cautery in amputation. He is well known for showing that a mixture of eggs, oil of roses and turpentine gave better results than boiling oil in gun-powder wounds - a serendipitous discovery made due to the lack of oil. It is said that on the battle field Pare was considered equivalent to 10,000 men because soldiers believed that with Pare around, their chance of survival was the greatest. He was a "Barber surgeon" but his skill and achievements were better than the so-called surgeons of those days. He was grudgingly admitted to the College de St Come despite the fact that he did not know Latin. Pare abolished the common procedure of castration during herniotomy and also invented the artery forceps. He is thus considered the 'Father of Surgery'. Pare is best known for his statement " I dressed him, God cured him " , a statement that shows the humility of the man and serves as a lesson to surgeons of all ages.
In the 16th century the name of Andreas Vesalius (1514-1564 ) stands supreme. He was a Belgian by birth and spent most of his time in Italy studying anatomy and contributing to the subject by his personal observations. It may not be an exaggeration to state that the practice of modern medicine or allopathy really began with this man. Vesalius , after completing his studies at Louvain, and later at Paris went to Padua which was then one of the leading medical schools in the world. By careful observation and performing dissections himself, Vesalius realized that a lot of Galenic anatomy was wrong. In Basle, in 1543, he published his De Humani Corporis Fabrica and changed the face of anatomy. It will interest readers to know that 1543 was also the year that Nicolas Copernicus published his seminal work De Revolutionibus Orbium Celestium in which he demolished the Ptolemic theory that the earth was the centre of the universe. Thus, two of the most important and influential works in science were published in the same year. In his book, Vesalius pointed out over 200 errors in the Galenic teachings. He also stated that his book was merely a reference book for his students - in order to learn anatomy, they would have to perform dissections themselves. Vesalius later became court physician to Charles V and later to Phillip II of Spain.
With the discovery of the gun powder in the fifteenth century and the use of the explosives in war weapons, extensive soft tissue injuries and fractures of bones became quite common. The nature and severity of wounds called for dexterity on the part of the medical personnel and ingenuity for improvisation. In fact war-time was a boon for surgeons with skill and intelligence.
In the seventeenth century in England, surgery was in the hands of "Barber surgeons". They carried out both simple procedures like pulling out a painful tooth as well as a complicated operation such as amputation of the leg. For anaesthesia, they made the patient unconscious by giving him a knock on the head with wooden hammer. During the eighteenth century several British men of medicine contributed to the advancement of surgery. Only a few of these are mentioned here due to limitations of space.
Percival Pott (1713 -1788) was famous for his treatise on wounds, Fractures and dislocations and less known for his work on Hydrocele and Cataract. Sir Percival himself had a fallon London Bridge and fractured his tibia [ Note that this is not Pott's fracture ]. The story goes that Pott refused to be treated at his own hospital, St.Bartholomew's , saying that the only good surgeon there had injured himself and was not in a position to heal others. He used the door of the nearest house as a splint and went to Guy's Hospital for treatment. Pott however, is remembered for other things: his description of tuberculosis of the spine (Pott's spine) and more importantly his observation of carcinoma of the scrotum in chinney sweeps. Pott realised that this devastating disease was caused by the soot remaining in contact with the skin (the young boys had to climb naked into the chimneys) and described a simple cure - a daily bath. This not only marks the beginning of concept of occupational disease, but also of preventive medicine. Two hundred years later, the age of specialisation has termed this field preventive oncology.
John Hunter (1728-1793), the brother of the anatomist and obstetrician William Hunter, was a great surgeon and an experimentalist. It is said that it is he who found surgery a mechanical art and left it an experimental science. He proved the existence of collateral circulation by his experiments on antlers of deer and made studies in Comparative Anatomy, Botany and Zoology. Hunter, in 1767, inoculated himself on his forearm with what he believed to be gonococcal pus to prove that syphilis and gonorrhea were the same disease. His deductions were fallacious as the man from whom he extracted the pus had both the diseases. His experiment, however showed the contagious nature of the disease. Hunter, as a result, is reported to have suffered from a syphilitic affliction of the blood vessels for the rest of his life. In fact, he suffered from angina pectoris in his later years and always said " My life is in the hands of any rascal who chooses to annoy and tease me " . Nevertheless this experiment led to the use of the term "Hunterian chancre". Hunter died precisely as he had predicted - he collapsed after a heated discussion with someone, in a pub.
Astley Paston Cooper (1768-1841) was a student of John Hunter. He had a passion for anatomy which brought him in touch with body snatchers through whom he obtained bodies for dissections. He made London the surgical centre of the world in the early nineteenth century. He was the first to ligate the abdominal aorta. He successfully excised a lesion in 1820, probably a sebaceous cyst from the head of King George IV, for which he was awarded a Baronetcy. The anatomy student would have heard of his name in the ligaments of Cooper in the breast.
More or less at this point of time the use of Ether and Chloroform as anaesthetics turned out to be a milestone in the development of complicated surgery. With the improvement of the technique of prolonged anaesthesis, surgeons resorted to more complicated techniques, as the duration of the surgical operation was not any more an important factor. However, deaths due to post-operative infections continued to be a major obstacle.
James Syme (1799-1870) was born in Edinburgh. He made several contributions to the surgical literature including the Symes Amputation for the ankle joint. In 1823, in Great Britain he was the first to perform a hip disarticulation. He was also probably the first European surgeon to adopt ether anaesthesia and later, Lister's antiseptic technique. Joseph Lister , his house-surgeon- and later, his son- in- law , derived a lot of inspiration from his illustrious teacher.
James Paget (1814-1899) is associated with two conditions, Paget's disease of the nipple and Paget's disease of bones.
It is said that the history of surgery may be divided into 2 parts - before and after Lister. Lord Joseph Lister (1827-1912) was a multifaceted individual. In the early part of his career he described two distinct muscles in the iris of the eye, the dilator and the sphincter, and also muscles attached to hair follicles. Contraction of these elevated the hair, resutlting in goose skin appearance.In Glasgow, as a Professor of surgery, Lister pondered over the fact that while simple fracures usually healed without problems, most compound fractures got infected and led to the patient's death. A professor of chemistry named Thomas Anderson put him on the right track by introducing him to the papers of Louis Pasteur. Pasteur had just shown that grape juice when exposed to air fermented, due to the presence of some agent that fell from the air, leading to the formation of wine. Extrapolating from this concept, Lister thought of the possibility of a similar agent falling into the open wounds of a compound fracture and leading to the infection.
During his dialogues with others on this topic, Lister earned that the use of carbolic acid (phenol) had destroyed the stench of the sewers in Carlisle. He then decided to experiment with carbolic acid on a patient with a compound fracture. The first patient died. However, his second patient survived - practically a miracle in those days- and antiseptic surgery was born. Lister in a letter to his father in June 1866 wrote that he had discovered " one of the 10 most important things that have ever happened to the human race". He published his paper in the Lancet in March 1867 and later read it a British Medical Association meeting - and was scoffed at. He also used the 'donkey spray' with which carbolic acid was sprayed over the field of the operation in order to destroy the microbes from the air during surgery. Lister stuck to his beliefs - and propogated them strongly. Two events took place that aided him greatly. First, he successly drained an abscess for Queen Victoria - using his antiseptic technique. Later, In the Franco - Prussian war, surgeons made use of Lister's antiseptic surgery - and saw a decrease in the incidence of hospital gangrene. Lister also invented the sinus forceps, aortic tourniquet, wire-needle and catgut ligature. In 1897, he was elevated to the peerage as Lord Lister for his surgical achievements.
A mention must be made of Lord Lister's wife, Agnes. She typified the saying " Behind every successful man, there is a woman". Agnes not only supported her husband throughout in his beliefs [ which were then controversial ] but directly played an important role in his work. It was she who translated Pasteur's work from French into English for the benefit of her husband.
In Germany, Christian Albert Theodor Billroth (1829-1894) was making a name for himself through his surgical skill, particularly of the gastro-intestinal tract. He, for the first time resected the oesophagus and also performed the first laryngectomy. In 1881, he performed the first resection of the Pylorus for cancer. Besides his professional achievements, he was also an excellent painist and a great friend and admirer of Johannes Brahms.
Theodore Kocher (1841-1917), a Swiss surgeon, was the first to surgically excise the thyroid gland as a means of treating goitre, which was cosmetically disfiguring. Kocher was the first surgeon to be awarded the Nobel Prize in surgery [ in 1909 ], an award he richly deserved.
Paul Broca (1824-1880) was a multifaceted individual who was a neurosurgeon, orthopaedic surgeon, neurologist and anthropologist. He described the area 44a, also called Broca's area, which is the centre for articulate speech and was the first to use a trephine to draina brain abscess. He established scientific societies and built up a medical museum and even became a senator in his later life. Ironically, this pioneer of neurological sciences died of a burst aneurysm in the brain.
American surgeons have contributed in no small way to our knowledge of surgery. William Steward Halsted ( 1852-1922) has already been mentioned [ in the chapter on Nurses ] as being responsible for the introduction of gloves. He also performed the Radical Mastectomy as a treatment for carcinoma of the breast, an operation called " the Halsted" in his honour. Finally, it was he who first used Cocaine as a local anaesthetic. Unfortunately, he also became a life-long addict to the same substance. The Mayo family is known throughout the world for their surgical skill. The father, William Worell (1819-1911) founded the Mayo Clinic in Rochester, Minnesota while his sons Charles Horace ( 1861- 1939) and William James ( 1865-1939 ) founed the Mayo Foundation for Medical Education and Research. Charles was renowned for his thyroid surgery and William, for his gastric surgery.
At this time, Harvey Cushing (1869-1939) was making news as a neurosurgeon. He published his observations on the role of the Pituitary and sexual infantilism, which was further supported by experimental work. His classic publication on "The Pituitary body and its Disorders" in 1912 is a masterpiece of meticulous observations and their correlations. He was a prolific writer and published interesting papers on history of medicine including a biography of his great teacher entitled "Life of Sir William Osler". Walter Dandy [ 1886-1946 ] , also an American neurosurgeon was responsible for introducing pneumoencephalography as well as surgery for prolapsed intervertebral discs, arteriovenous malformations and intracranial aneurysms. Sir Victor Horsley was the first to operate on spinal cord tumours and for epilepsy.
The Nobel Prize in medicine is awarded to persons making a significant achievement or advance in that field. It would be fitting to conclude this chapter by mentioning the surgeons who have won this coveted prize. They are Theodore Kocher (1909 - for his contributions ot thyroid surgery and physiology), Allvar Gullstrand (1911- for his work on dioptrics, the science of refracted light of the eye), Alexis Carrel (1912- for vascular surgery and organ transplantation), Robert Barany (1916 - for physiology and pathology of the Vestibular apparatus), Werner Forssmann (1956- for his contribution to cardiac catheterization), Charles Huggins (1966 - for hormonal manipulation of prostatic carcinoma as a means of palliating or curing patients) and Joseph Murray (1990 - for renal transplantation). Other surgeons who have won the Prize for non-surgical work are Sir Frederick Banting, Sir Alexander Fleming ( he had received his Primary FRCS in 1909) and Walter Hess (1949- for research on the interbrain).
The renowned seats of learning of ancient Indian medicine were Kashi ( Varanasi / Banaras) in the East and Taxila (Taksasila) in the West. Sushruta was the teacher of surgery at Kashi while Atreya taught medicine and surgery at Taxila. The Dayanand Ayurvedic College was established in Jullundar in 1898, Takmil-Ut-Tib College in Lucknow in 1902 and National Homeopathic Medical College in Lucknow in 1921. With the Moghul invasion of India, Unani medicine was introduced and the first school of Unani medicine was established in Delhi during the reign of Akbar. By 1990 , there were 11 schools of Unani medicine, 131 colleges of Homeopathic medicine, and 83 of Ayurvedic medicine. There are over 460,000 practitioners of traditional Indian medicine in India today.
With the arrival of the Portuguese, Western medicine was introduced into India ( Vasco da Gama arrived at Calicut in May 1498 ). There were European physicians in the courts of Shah Alam, Haider Ali, Tipu Sultan and Maharaja Ranjit Singh. The first medical schools of Western medicine were established by the English in Madras and Calcutta in 1835 and in Bombay in 1845 as well as by the Portuguese at Mandovi in Goa in 1842. Earlier, in 1703, a rudimentary course in medicine was conducted at the Royal Hospital in Goa. Since then, the number of such schools/colleges in India has been growing steadily. By the end of 1989 there were 125 such institutions with over 14,000 new graduates every year.
The first Indian woman to graduate in Western medicine is believed to be Anandibai Joshi of Pune, in the year 1886. She was the first Brahmin student from Poona (Pune). She took her training in the United States of America in "The Woman's Medical College", Philadelphia and completed her M.D. in 1886. She was greatly encouraged by her husband Gopalrao , a clerk in the postal department who stronly advocated women's education. Soon after her return to India, she was appointed as a physician in charge of the female ward of the Albert Edward Hospital at Kolhapur . ( The present Civil Hospital in Kolhapur was formerly known as Albert Edward Hospital ). She however died of tuberculosis at the age of 22 years in 1887. Her distant cousin Pandita Ramabai, the poetess and a social worker was invited by the Dean of the college to attend the graduation ceremony of Anandibai. Pandita Ramabai wrote about Anandibai in her book " High caste Hindu woman ". Sharayu Bhatia in her book "The Firsts- Life Sketches of Medical Women in India ' writes that Anandibai Joshi was the first Indian woman graduate trained abroad.
The first four men to qualify in Western medicine from the Calcutta Medical College in 1838 were Uma Karan Set, Dwarka Nath Gupta, Raj Kristo Dey and Nobin Chander Mitter.The first batch of students admitted in the Grant Medical College, Bombay, in 1845, were awarded the diploma "Graduates of Grant Medical College," (G.G.M.C.) in 1851. They were Bhau Daji Lad Parsekar, Sebastian A.D'Carvalho, Atmaram Pandurang Tarkhad, Paul Frances Gomes, Merwanjee Sorabji, Burjorji Dorabji, Anant Chundroba Dukle and J.C. Lisboa. Information about students of Madras Medical College was not available in books referred to nor could it be obtained from the institution concerned.
Subsequently, surgery made rapid strides in the latter half of the nineteenth century and the early part of the twentieth century, consistent with rapid advances in basic sciences. As a result, specialization in surgery was envisaged and introduced to improve the quality of surgical practice. The most outstanding surgical achievement in the latter half of the twentieth century is 'transplant surgery'.
Attempts at transplant of the skin were made by Sushruta. In 303 A.D. the twin brothers, Cosmos and Damian, physicians of Arab origin, amputated the leg of a Caucasian and attempted to graft in its place the leg of a recently deceased Moor. John Hunter successfully transplanted the spur on the cock's comb. With this was reborn the concept of transplants of tissues and organs. In 1905, organ transplant was attempted by Alexis Carrel, a French surgeon - an autotransplant of a dog kidney. Although the attempt was unsuccessful, he was awarded the Nobel prize in medicine in 1912 for this experiment. The first heart transplant was performed by Christian Barnard of South Africa in the Groot Shuur Hospital, Cape Town, on 3rd December, 1967. In India, the first heart transplant was attempted at the King Edward VIII Memorial Hospital, Bombay on 16th February, 1968 by the late Prafulla Kumar Sen, who was then the Professor and Head of the department of Cardio-thoracic Surgery. The first successful heart transplant in India was performed by P Venugopal at the AIIMS in 1994. Other organ transplants are being undertaken such as that of kidney, lung, bone marrow etc. The first kidney transplant at K.E.M. Hospital, Bombay was attempted in 1966. The first successful renal transplant in India was performed at Christian Medical college, Vellore in 1977 by Mohan Rau. Bone marrow transplants are the only transplants that do not fall within the purveiw of the surgeon. The first bone marrow transplant in India was done by a team of doctors at the Tata Memorial Hospital in 1983. The patient, Vandana Kadam, who then had acute myeloid leukaemia is still alive and well. Subsequently, the Christian Medical College, Vellore and the AIIMS have started bone marrow transplants.
The modern age or post modern age of surgery is synonymous with Minimal Access Surgery. Also known as key hole surgery, laparoscopy, endoscopy etc. Laparoscopic Cholecystectomy was the land mark operation that led to a change of mindset and approach to surgery as is outlined in our next section.
Bhatia, Maj. Gen.S.L.: Surgery in Ancient India - A Lecture: Personal communication
Kothare, S.N.: Surgery in Ancient and Medieval Times St. John's Medical College, Jour. Med.: 4: 64, 1991
Starzl, T.E.: personal reflections in Transplantation, The Surgical Clinics North America, 58: 8/9, 1978,
Sabiston, Jr. D.C.: text Book of Surgery, " The Development of Surgery" By G.H. Brieger, publisher, W.B. Saunders Cp., Philadephia, London, Toronto, Tokyo, 12th edition, 1981.
Sagan, Carl. Broca's Brain. Coronet books, Hodder and Stoughton, Great Britain, 1980.
Alsop, G. F. : History of the Woman's Medical College, Philadelphia, Pennsylvania, 1850-1950 A.D. : Philadelphia, London, Montreal, 1950
Directory of medical colleges in India: Government of India Press, Nasik, 1978.
Goyal, K. : Binnys Directory of Medical College in India : Ed.8, Binnys Publishing House, 86 U.B. Jawahar Nagar, Delhi - 110 007, 1990
India-1976: Publication Division, Ministry of Information and Broadcasting, Government of India, 1976
Jaggi, O P. Medical Education and Research. Vol 13, 1979. Publisher Atmaram and sons, Delhi.
Talwalkar, NG. Men and memorabilia of Grant Medical College and JJ Group of Hospitals. The Research Society, JJ Group of Hospitals and Grant Medical College, Bombay 400 008, 1995
History of surgery can be divided into three eras ( click on the following for further reading):