History is simply not dead past. It is like a great teacher whose teachings continue to influence his students long after he is no more. Knowing history is to know genesis and evolution of life, society and human behavior. Tracing the sequential development in any sphere of life leads to intellectual understanding of various parallels and often seemingly bizarre processes in an orderly and mature manner. Such a reconstruction of past events helps in many ways. It paves the way for selection of one particular line of thinking out of various diverse lines of pursuing a goal. It helps in tutoring oneself about conducting research in a chosen field in a more scientific way. You choose to learn either from your own mistakes or from others’ experiences. A great surgeon has succinctly put it “learn from others’ mistakes because you will never live long to commit all the mistakes yourself”. It also reveals mysteries of nature unfolding themselves before curious minds. All these influence positively one's ability, enthusiasm, and behavior for scientific study of mankind, culture, religion, human life, and diseases. It might be apt to say that history leads to the progressive path to future.
Medicine in particular is a field of science where history plays a key role in understanding the exact pathophysiological processes underlying a disease and how the currently accepted treatment practices have come about. This also gives an opportunity to appreciate the commanding work done by our forefathers and to pay our respects and tribute to them. They also become our role models and enthuse us to emulate them in order to achieve higher goals in pursuance of excellence.
SURGERY IN ANCIENT AND MEDIEVAL TIMES
We learn through Ayurveda and other Indian surgical treatises written by ancient Indian surgeon Sushruta and others that surgical science was quite advanced in the ancient Indian times around 4 to 8 hundred years Before Christ. However, little is available in the written text form to document about different operations. Therefore much of the written or documented form of surgical history goes back to only around 250 years and much of it was developed in the European and American parts of the globe.
In the Middle Ages, surgery had little scientific basis and empirical application of unproven treatments was the routine. As the darkness of the middle ages descended, medical care in Europe was delivered by monks, barbers and poorly trained and self-qualified surgeons. In Britain, monks and barbers were free to practice surgical therapy without any formal training or supervision. Surgical therapy consisted primarily of amputations, laparotomies, scarification, leeching and drainage of abscess. In order to protect the society against the inept practitioners of surgery, an organized Guild of Surgeons was formed in 1423 by the Surgeon to Henry the V. In 1540, King Henry the VIII formed the company of barber-surgeons of England. Three great surgeons, Ambroise Paré, John Hunter and Joseph Lister, during this period, laid the foundation of the modern surgery through their observations and the spirit of experimentation.
Ambroise Paré
Ambroise Paré (Fig. 1.1) was a French army surgeon who introduced the use of ligatures to control hemorrhage in battlefield. He introduced the concept of controlled experimentation by treating two soldiers with similar looking wounds lying in the same tent. The first soldier's wound was managed by the standard therapy of cauterizing with boiling hot-oil.
The second soldier's wound was managed by debridement, cleansing and application of clean dressing without boiling oil. The next morning the soldier, in whom oil was not used, had improved significantly; whereas the one treated by hot-oil developed marked systemic symptoms with fever, tachycardia and disorientation. When he was praised for the good outcome of this new approach of not using boiling oil in the battlefield wound, Paré very humbly replied, “I treated him, God cured him.”
John Hunter
John Hunter (Fig. 1.2) contributed significantly through both clinical and laboratory experiments and is considered the founder of scientific surgery. He also studied the field of comparative anatomy and natural history. Hunter was a great thinking-surgeon of his time. He thought about clinical questions and converted these questions into the experiments and then into operations. John Hunter was born in 1728 near Glasgow. Hunter worked as an apprentice in London with his brother William. He was taught by Pott and Cheselden. He had an insatiable scientific curiosity and enthusiasm for experimental approach. His dissections and experiments are preserved as a time capsule at the Royal College of Surgeons in London. John Hunter studied the concept of transplantation and vascular growth; he transplanted the spur of a cock to the comb on the head of another cock. He also performed the first xenograft transplant by placing a human tooth in the comb of a cock. Both these transplants were successful without rejection. He later injected the blood vessels to demonstrate neovascularization of the transplanted organs. Thus, he was perhaps the first surgeon to have studied the phenomena of angiogenesis.
He ligated the artery of a deer and showed that the antler velvet lost its warmth and the arterial pulsations. A week later, warmth returned with restoration of blood flow. Hunter suggested that the stimulus of necessity led the smaller channels to increase and do the work of the larger blood vessels. Based on these studies he operated on a 45-year-old coachman with a popliteal artery aneurysm and performed the famous 'Hunterian ligation.'
John Hunter established the concept of experimental surgery by using animals to develop surgical techniques prior to their application on human beings. Hunter's observations are preserved in 4 books; these are The Natural History of Teeth (1771), A Treatise on the Venereal Disease (1786), Observations on Certain Parts of the Animal Oeconomy (1786), and A Treatise on Blood, Inflammation and Gun Shot Wounds (1794). Hunter died in 1793.
Lord Joseph Lister
Joseph Lister (Fig. 1.3) was born in 1827 in Scotland. He obtained a university education and joined as a house surgeon to the great master surgeon James Syme and at the young age of 33, he was appointed Professor of Surgery at the University of Glasgow. He performed experiments and clinical observations on tissue viability, involuntary muscle fibers, inflammation, gangrene and coagulation.
He observed many infections on the wards and performed experiments on infected surgical wounds. Before Lister's discovery, nearly all wounds used to become infected and suppurate. In compound fractures of the leg, the standard of care was amputation because these wounds, as a rule, became festered. In 1865, Lister heard of experiments of Louis Pasteur about germs. Lister got convinced that wound infections in surgical patients were caused by minute organisms or germs. In the Scottish city of Carlisle, carbolic acid was used to treat the sewage. Lister therefore chose carbolic acid to treat the surgical wounds. On March 12, 1865, he began his first clinical studies using carbolic acid soaked dressings on a compound fracture of the leg of a young boy called James. When the dressing was removed, instead of usual festering and suppuration, a clean healing wound was observed heralding the era of antisepsis. By experiments he showed that if arterial ligation is performed by silk ligatures, instead of catgut, the infection and hemorrhage could be reduced. He developed methods of sterilizing the operating theater using vaporized carbolic acid. He was successful in reducing the surgical mortality in the Royal Infirmary of Edinburgh from 45 to 1.8 percent by the year 1879.
HISTORY OF MODERN SURGERY
History of modern surgery actually begins towards the latter decades of the 19th century, when the surgeon truly emerged as a specialist and it was not until the first part of the 20th century that surgery could be considered as an important specialty of medicine as a whole. Four major advancements in related disciplines helped tremendously in making surgery a truly scientific, effective, safe, and acceptable way of treating patients. These include: (i) knowledge of human anatomy, (ii) discovery of anesthesia in 1846, (iii) intraoperative hemostasis, and (iv) concepts of asepsis.
Human Anatomy
An indepth understanding of human anatomy is key to precise surgical procedures and their successful outcome. Brussels-born Andreas Vesalius (1514–1564) (Fig. 1.4) was a Professor of Anatomy and Surgery at Padua, Italy. Vesalius emphasized the importance of human dissection and proclaimed that human anatomy could be learned only through the study of structures revealed by human dissection. Most importantly, Vesalius corrected errors in traditional anatomic teachings propagated 13 centuries earlier by Greek and Roman authorities, whose findings were based on animal rather than human dissection. Furthermore, Vesalius asserted that surgeons themselves must perform anatomic dissection. This principle of hands-on education would remain Vesalius's most long lasting contribution to the teaching of anatomy. His great anatomic treatise, De Humani Corporis Fabrica Libri (1543), provided a detailed description of the human anatomy.
As a student of surgery, none of us can forget the masterly description of minutest detail of human anatomy by Henry Grey. He was an ardent disciple and a great learner and believed in the importance of human anatomy. Besides being credited with many important anatomical findings, while working in the Hammersmith Hospital, London, his major contribution has been the authoritative and extensive Textbook of Human Anatomy, the best available resource of human anatomy.
Hemostasis in Surgery
Surgeon is best identified with a scalpel-blade and surgery, to most people, means bloody mess. In fact, one of the major concerns has been that of achieving hemostasis during surgery.
Ambroise Pare's (1510–1590) position in the evolution of surgery remains of supreme importance. From 1536 Paré was either engaged as an army surgeon, accompanying different French armies on their military expeditions, or performing surgery in civilian practice in Paris. Among Pare's important observations was that in performing an amputation, it was more efficacious to ligate individual blood vessels than to attempt to control hemorrhage by means of mass ligation of tissue. He described in his Dix Livers de la Chirurgie avec le Magasin des Instruments Necessaries a lcelle (1564), that the free or cut end of a blood vessel was doubly ligated and the ligature was allowed to remain undisturbed in situ until, as the result of local suppuration, it was cast off.
Development of Anesthesia
As anatomic knowledge and surgical techniques improved, the search for safe methods to prevent pain became more pressing. By the early 1830s, chloroform, ether, and nitrous oxide had been discovered. It soon became evident to various physicians and dentists that the “pain-relieving” qualities of ether and nitrous oxide could be applicable to surgical operations and tooth extraction. On October 16, 1846, William TG Morton (1819–1868), a Boston dentist, pursuaded John Collins Warren (1778–1856), Professor of Surgery at Massachusetts General Hospital, to let him administer sulfuric ether to a surgical patient from whom Warren went on to painlessly remove a small, congenital vascular tumor of the neck. Within a few months after the first public demonstration in Boston, ether was used in hospitals throughout the world. The development of anesthesia is further discussed in Chapter 13: Anesthesia.
Concepts of Asepsis
The recognition of antisepsis and asepsis was a significant event in the evolution of surgery. Often, major surgical operations ended in death due to uncontrolled infection. Joseph Lister (1827–1912), an English surgeon, introduced systematic, scientifically-based antisepsis in the treatment of wounds and the performance of surgical operations. By 1865, Lister used pure carbolic acid into wounds and onto dressings. He also sprayed it in the atmosphere around the operative field and table. A second important advance by Lister was the development of sterile, absorbable sutures. He believed that much of the deep suppuration found in wounds was due to previously contaminated silk ligatures. He used to cut the ends of the ligature short; thereby closing the wound tightly, and thus eliminated the necessity of bringing the ends of the suture out through the incision, a surgical practice that had persisted since the days of Paré.
German-surgeons were the first to grasp the importance of bacteriology and the germ theory. They propagated Lister's theory of antisepsis. Carbolic acid spray was replaced by boiling and use of the autoclave for instruments. The availability of heat sterilization was a landmark event and led to the availability of sterile aprons, drapes, instruments, and sutures. Similarly, the use of facemasks, gloves, hats and operating gowns also evolved naturally.
EVOLUTION OF SCIENTIFIC METHODS IN SURGERY DURING THE 19TH AND 20TH CENTURY
William Stewart Halsted (1852–1922) (Fig. 1.5) set the scientific tone for this most important period in surgical history. He introduced the modern operating “theater”. He introduced the “new” surgery, based on anatomic, pathologic, and physiologic principles and employing animal experimentation. Halsted's clinical and research achievements were overwhelming in number and scope. He also introduced the “Residency” scheme of training surgeons.
This was not merely the first such program of its kind; it was unique in the sense that its aim was to train able surgical teachers, not merely competent operating surgeons.
DEVELOPMENT OF SURGERY IN THE MODERN TIMES
It was an exciting era for surgeons, with important clinical advances made both in the operating room and in the basic science laboratory.
Major surgical feats, which took place in the modern era, are arranged chronologically below:
- 1921: Successful ligation of the abdominal aorta for aneurysmal disease by George Vaughan (1859–1948).
- 1923: Section of the mitral valve for mitral stenosis by Elliott Cutler (1888–1947).
- 1924: Cholecystography by Evarts Graham (1883–1957) and Warren Cole (1898–1990).
- 1928: Electrocoagulation in neurosurgery by Harvey Cushing (1869–1939).
- 1931: Flanged nail for pinning a fracture of the neck of the femur by Marius Smith-Petersen (1886–1953).
- 1933: Successful removal of an entire lung for cancer by Evarts Graham.
- 1935: Pancreaticoduodenectomy for cancer of the pancreas by Allen Oldfather Whipple (1881–1963).
- 1935: Implanted pectoral muscle into the pericardium and attached a pedicled omental graft to the surface of the heart, thus providing collateral circulation to the organ by Claude Beck (1894–1971).
- 1935: Splanchnic resection for hypertension by Max Peet (1885–1949).
- 1936: Prefrontal lobotomy as a means of treatment for various mental illnesses by Freeman (1895–1972).
- 1939: Successful ligation of a patent arterial duct by Robert Gross (1905–1988).
- 1943: Vagotomy for peptic ulcer by Lester Dragstedt (1893–1976).
- 1944: Resection of a saccular aneurysm of the thoracic aorta by John Alexander (1891–1954).
- 1945: Resection for coarctation of the aorta with direct anastomosis of the remaining end by Robert Gross (1905–1988).
With such a wide variety of technically possible surgical operations, it had clearly become impossible for any single surgeon to master all the manual skills combined with the pathophysiologic knowledge necessary to perform such cases. Therefore, by mid-20th century, a strong movement toward specialization had gathered momentum with numerous surgeons restricting their practice to one specialized field. This paved the way to sub (super)-specialization of various surgical disciplines.
Abdominal Surgery
Gastric Surgery
In the time of Hippocrates, gastric injuries used to prove fatal for want of any definite treatment. In his time, opening of the abdominal cavity was unima-ginable.
In 1877, Theodor Billroth (Fig. 1.6) successfully closed a gastric fistula and called the operation gastrorrhaphy. On January 29, 1881, in Vienna, Billroth successfully carried out excision of pylorus for a pyloric tumor and performed an end-to-end gastroduodenostomy. Four years later, on January 15, 1885 Billroth carried out resection of a pyloric tumor and a gastroenterostomy. This became a standard procedure for tumors with gastric outlet obstruction. Billroth had a profound impact on gastric surgery and it is a tribute to his surgical genius that we still perform the same surgical procedures even today. In 1880, Mikulicz had carried out an operation for perforated gastric ulcer. Although the patient died soon after the operation this became the standard procedure for surgical treatment for gastric perforation. The first successful pyloroplasty was carried out in 1887. Schlatter carried out the first successful total gastric resection in 1897 in Zurich. He anastomosed the distal esophagus with the jejunum end-to-side.
Surgery of the Gallbladder and the Biliary System
The treatment of cholecystitis and cholelithiasis remained in the hands of the physicians for a very long time. Johannes Fabricius was the first surgeon to remove gallbladder stones in 1618. Courvoisier (Fig. 1.7) (of Courvoisier's law) and Langenbuch established that the gallbladder could be ligated without any untoward effects. In 1799, Morgagni reported lithotomy for gallbladder stones. The first cholecystostomy was performed by Boobs on July 16, 1867 in USA. Kocher (of Kocher's forceps fame) performed an operation for gallbladder empyema. Langenbuch performed the first successful cholecystectomy in 1882.
Cholecystoenterostomy using small bowels was done by Monastyrski in 1887 and Kappeler in the same year. In 1904 Montprofit published his procedure of cholecystoenterostomy using small bowel and Roux's anastomosis. With these procedures surgery of the gallbladder and the biliary tree became well-established; but further improvements followed with better radiological demonstration of the gallbladder and biliary system and with the development of choledochoscope. Laparoscopic cholecystectomy was first performed by P Mouret in France in 1987 (see later).
Surgery of the Pancreas
Probably the existence of pancreas was not known in the times of Hippocrates. Galen considered the pancreas a cushion for the stomach against the vertebral column. Further description of the pancreas was made by Vesal (1514–1564), Falloppio (1523–1562) and Bauhin (1560–1624).
George Wirsung discovered one of the pancreatic ducts and Santorini (1724), discovered the other duct. Kuhne isolated trypsin in 1877 and demonstrated the importance of pancreatic secretion as an important digestive juice. Mering and Minkowski showed in 1890 that after experimental extirpation of pancreas, diabetes mellitus ensued. Langerhans demonstrated the special cells in the pancreas in 1869 (Islets of Langerhans). Tschassownikow recognized their importance as the endocrine component of pancreas.
Surgery for Chronic Pancreatitis
In 1904, Payr made an incision of the pancreatic capsule in a patient with chronic pancreatitis. In 1936 Mallet-Guy recommended excision of the tail of the pancreas for chronic pancreatitis. Child and Fry recommended the subtotal resection of the pancreas for chronic pancretitis in 1962 and 1965. Puestow performed the first lateral pancreaticojejunostomy, which has become a standard procedure since then.
In cases of pancreatitis involving the head of the pancreas duodenopancreatectomy was recommended by Warren (1961) and Whipple (1964).
In 1921, the first cystogastrostomy was performed by Jedlicka and Kerschner successfully performed cystojejunostomy in 1929 for a pancreatic psuedocyst.
Surgery for Pancreatic Tumor
The first successful excision of a pancreatic tumor was done by Trendelenburg (1882), who resected the tail of the pancreas for a spindle cell sarcoma. Total pancreatic resection of the pancreas was carried out by Franke on May 1, 1900. Whipple (Fig. 1.8), in 1935, performed the most popular and still widely performed Whipple's procedure for pancreatic head tumor. Zollinger and Ellison in 1955 described gastrinomas and Wilson and Ellison in 1966 recommended total gastrectomy for such tumors.
Surgery of the Intestines
The major problem facing surgeons during the ancient period and even upto 18th century was perforating bowel injuries resulting in peritonitis, which proved fatal in vast majority of cases. It was considered almost impossible to repair injured and perforated intestines. However, in ancient India, Sushruta had described the repair of intestine using large ant-heads. Ants were allowed to bite on the edges of the two segments of intestine, which needed anastomosis. The ants were decapitated next leaving behind the head attached to intestine. (The ants’ claws serve as natural staples). This was the first form of a natural stapling.
Abu Kassim (1000 BC) derived suture materials from animal intestines with which he closed bowel wounds. This was the first demonstration of use of a biological material for suturing and ultimately paved the way for development of absorbable catgut sutures. Use of silk sutures was introduced in the 12th century, but the management of intestinal perforations remained unsatisfactory. It was not clear to the surgeons of that time how an anastomosis of the intestines should be done and which side would stick easily, the serosa or the mucosa. In 1826 the French surgeon Lembert introduced interrupted-suture techniques through the serosa and muscularis inverting the margins of the intestines. Although, the patient died of peritonitis, the anastomosis did not leak. This method gradually became accepted.
Diversion colostomy in intestinal injury was first performed by Paracelsus (1536). With further development, terminal colostomies were accepted management of patients after trauma or in cases of carcinoma of the rectum in the 18th century. The use of ileostomies and cecostomies in the management of ulcerative colitis and tuberculosis was established in the 19th century. With better methods of performing anastomosis of the intestines, resection and end -to -end anastomosis of the intestines was possible, which enabled surgeons of the 19th century to resect tumors from the colon and, later, further improvements of surgical techniques made it possible to remove the tumors of the rectum.
Appendicitis occupies a special place in surgical practice. It is one disease, which seems most simple to diagnose and to treat; yet it often baffles the most experienced of surgeons. Aretaus described an appendicular mass in the year 100 BC. The appendix was first described by Carpi, an anatomist in Bologna. The recognition of appendicitis was first made in the 18th century. Later Parkinson (1812) gave a clinical account of fatal perforated appendix in a child. Louyer-Villermay was the first to establish the relationship between peritonitis in the right iliac fossa and inflammation of the appendix in 1824. The first incision and drainage of an appendicular abscess was done by Hancock, in 1848. The planned appendectomy was done by Synmonds in 1883. Despite enormous advances in surgical practice and modern investigative tools, acute appendicitis humbles the most experienced surgeon even today.
Surgery of Herniae
Abdominal herniation was recognized and described during the time of Papyrus Ebers (1555 BC). Hippocrates (460–375 BC) (Fig. 1.9) described cases of umblical herniae, which caused pain, nausea and vomiting. Celsus (25 BC-45 AD) recommended the surgical closure of umbilical hernia after reduction. Later, in the 7th century, Paulus of Aegina described 'operation and reduction' of umbilical herniae. The procedure consisted of application of sutures to close the defect.
Celsus also described and treated inguinal herniae through reduction and operation of incision of the skin over the herniated gut. With the development and improvement of anesthesia it became possible to operate and repair herniae in the 19th century. Dupuytren (1828), Foux (1830) and Lawrence (1852) reported series of operations of incarcerated inguinal herniae in babies and small children. The idea of strengthening of the inguinal wall was introduced by Bassini in 1884 and published in 1890, which is still a standard procedure.
Thoracic Surgery
One of the most feared complications of thoracic trauma was pneumothorax, which was well known for the last 2000 years. Although, from the 13th to the 17th century sporadic cases of resection of lung tissue were reported (Rolando of Salerno in 13th century and Hildanus in 17th century) the first successful treatment of pneumothorax was only possible in the beginning of the 19th century. Empyema thoracis has been a disease of surgical interest, which was treated by drainage in the Middle ages. Bilau in 1875 introduced the underwater seal drainage for empyema thoracis. The ability to change an open pneumothorax to a closed pneumothorax became a lifesaver in the first World War, although with the development of aseptic techniques and some understanding of the pathophysiology of the chest cavity, it was possible to resect parts of the lung infected with tuberculosis (Block, 1881). The first resection of a lung for tuberculosis was done by Tuffier in 1891. Nevertheless, for many years therapeutic pneumothorax (Plombing and thoracoplasty) was the mainstay of tuberculosis treatment. The early part of the 20th century saw the introduction of lobectomy, pneumonectomy and segment resections for malignant diseases of the lung and lately lung transplantation for a variety of conditions.
The first important milestone in cardiology was the discovery of the blood circulation by Harvey in 1628. This enabled doctors of the 17th century, Auenbrugger (1722–1809), Corvisart (1755–1821), Laennec (1781–1826) and Skoda (1805–1881) to make improvements in the diagnosis of cardiac ailments.
Laparoscopic Surgery
The word laparoscopy is derived from the Greek laparos, meaning, “flank,” and scope meaning “an instrument for observation”. It is a term that is used to describe the procedure where peritoneal contents are examined with an endoscope. The introduction of the technique into the field of general surgery has been a relatively recent development. Frankfurt-born physician Phillip Bozzini successfully visualized the human urethra in 1805. Bozzini was also able to view the urinary bladder and to visualize stones and neoplasms. Throughout the mid-1800s, several scientists attempted to construct endoscope-like instruments.
Laproscopy for examining the peritoneal cavity was first attempted on live dogs in 1901 by George Kelling, a surgeon from Dresdon who called this procedure celioscopy. Hans Christian Jakobaeus popularized the technique in humans. His technique involved the use of a trocar to establish pneumoperitoneum.11Like Kelling, Jakobaeus also used a cystoscope to examine the peritoneal contents. Zollikofer in 1924 wrote about the benefit of utilizing carbon dioxide to obtain pneumoperitoneum. Between 1929 and 1959, Kalk published extensively on laparoscopy and is considered by many to be the father of modern laparoscopy. In 1938, the Hungarian physician Janos Veress designed a modification of the spring-needle. This needle design is still being used today to initiate pneumoperitoneum for laparoscopic procedures.
One of the most important developments of this era occurred in 1952 when the French scientists Fourestier, Gladu, and Valmiere literally revolutionized the technique of laparoscopy with their cold light fiberglass illumination. Kurt Semm, a German gynecologist, designed an automatic insufflation device in 1977. This piece of equipment had the ability to monitor both gas flow and intra-abdominal pressure. He also developed thermocoagulation for use during laparoscopic procedure, instruments such as hooked scissors, an irrigation-aspiration device, and the morcellator. In 1983, Semm performed the first laparoscopic appendectomy.
Despite these technological advances, laparoscopy did not gain acceptance in the field of general surgery during the early years of its development. It was not until after 1986, following the development of a video-computer chip that allowed the magnification and projection of images onto television screens, that the techniques of laparoscopic surgery truly became integrated into the discipline of general surgery.
French surgeon Mouret performed the first laparoscopic cholecystectomy on a human patient in 1987. The laparoscopic cholecystectomy is now considered standard therapy for routine gallbladder removal and is considered the procedure, which has established the usefulness and safety of laparoscopic surgery. Laparoscopic surgery has changed the field of general surgery more dramatically and more rapidly than any other surgical milestone (see later).
INDIAN CONTRIBUTION TO THE PRACTICE OF SURGERY
In the golden era of ancient civilizations, the art of medical practice reached its zenith in India. The two main leaders in their own domains were Charaka in medicine and Sushruta in surgery.
No treatise on surgery can be complete without the inclusion of masterly description of various surgical procedures described by the great ancient Indian surgeon Sushruta. It was a remarkable feat to device and perform various surgical operations at a time when there was no formal knowledge of human anatomy, disease pathophysiology and surgical concepts. In his historical chronicle Whipple stated, “All in all, Sushruta must be considered the greatest surgeon of the premedieval period.”
The Era of Sushruta
Most scholars of ancient Indology have placed Sushruta in the period of between 600 and 800 BC. Sushruta (Fig. 1.10), an accomplished surgeon and philosopher, but, above all a great teacher, compiled a monumental treatise in surgery, the Sushruta Samhita, which is the earliest text for the systematic teaching of surgery. The Sushruta Samhita was first translated from Sanskrit into Arabic by Abil Saibial in the eighth century AD. It was later translated into Latin, German and English.
Sushruta indexed five principal sections in the Samhita, including (i) Sustrasthana or the primary principles consisting of 46 chapters detailing the basic foundation of medical sciences, technical nomenclature and pharmacological classifications; (ii) Nidana containing 16 chapters elaborating the pathological concepts of disease; (iii) Sarirasthana consisting of 10 chapters on human anatomy; (iv) Chikitsasthanam containing 34 chapters on the medical and surgical treatment of various disease processes; and (v) Kalpasthana consisting of 8 chapters on toxicology.
Figs 1.11A to D: Instruments designed by Sushruta based on the birds and animals: (A) Crow -faced forceps. (B) Butcher-bird faced forceps. (C) Crocodile-faced forceps and (D) Jackal-faced forceps (based on instruments displayed at National Museum of Science, New Delhi and Dr Sakti Das :(Sushruta, the Pioneer Urologist of Antiquity; Jorunal of Urology, Vol-165, May 2001)
Sushruta asserted that surgery was the foremost branch of medicine and succinctly stated, “All hold this tantrum to be the most important of all the other branches of the Ayurveda in as much as instantaneous actions can be produced with the help of such appliances as surgical operation, external applications of alkalis cauterization, etc. (Figs 1.11A to D) and secondly as it contains all that can be found in the other branches of the science of medicine as well, with the superior advantage of producing instantaneous effect. Hence, it is the highest in value of all the medical Tantras.”
SURGEONS AND THE NOBEL PRIZE
It may seem incongruous that surgeons, with their very workmen like focus on practical solutions to common problems, would draw accolades from the august world of scientists and academics but the surgical specialties have produced 9 Noble Prize winners in ‘Medical Science’. The reasons for this success are derived from the attributes cultivated in every generation of surgeons; these are: care for the sick, scientific curiosity, concentrated activity and commitment to excellence. These 9 surgeons are starting from Emil Theodore Kocher in 1909, Allvar Gullstrand, Alexis Carrel, Robert Barany, Frederick G Banting, Walter R Hess, Werner O Forssman, Charles B Huggins, and Joseph E Murray (Figs 1.12A to I). Despite their pursuits of distinctly different interests in different countries all these surgeons share the essential attributes that is to define the profession. Their careers were concerned with solving human problems and the puzzles of nature (Table 1.1).
- Emil Theodore Kocher: Emil Theodore Kocher was born in Bern, Switzerland on August 25, 1841 and graduated from Medical College University of Berne in 1865. He visited clinics of Billroth in Vienna, Lister in Edinburgh, and Pasteur in Paris. He returned to Berne in 1866 and was appointed Professor in 1872. He wrote articles on subjects such as orthopedics, gastrointestinal and biliary tract surgery, techniques of abscess management, trauma and repair of inguinal hernia. He wrote a textbook of surgery in 1892. Kocher performed more than 9000 thyroidectomies with less than 1 percent mortality (this was the era without proper anesthesia, blood transfusion and antibiotics). He described the features of postoperative hypothyroidism and termed it cachexia strumibriva. He was awarded with a Noble Prize in 1909 for his work on the physiology, pathology and surgery of diseases of the thyroid. He died on July 27, 1917 at the age of 75. Kocher's name goes in every 14operation theater by his famous maneuvers like Kocher's technique of mobilizing duodenum, the subcostal Kocher's incision for cholecystectomy the transverse Kocher's incision for thyroidectomy and Kocher's reduction of dislocated shoulder.
- Allvar Gullstrand: Allvar Gullstrand was born in Copenhagen on June 5, 1862. He graduated in medicine from University of Uppsala in 1888. Largely self-educated in mathematics and physics, Gullstrand theorized the geometric abnormality in the cornea which formed the basis for the distortion of light in patients with astigmatism. Gullstrand developed an operation for the treatment of symblepharon and designed slit-lamp and modern ophthalmoscope. Gullstrand was awarded Noble Prize in 1911 for his work on dioptrics and visual accommodation. His remarkable achievements were derived from a focused application of mathematics and physics to the clinical world.
- Alexis Carrel: Alexis Carrel was born near Lyons, France, on June 28, 1873 and graduated from University of Lyons in 1900. In 1902, Carrel published his first article on the anastomosis of blood vessels. He recognized that the key to success in vascular surgery lies in delicate and meticulous operative technique. He constructed the vascular anastomosis by three equidistant retaining sutures so placed that when pulled resulted in triangulation of the vessel lumen and the artery could be dilated and edges could be brought in a straight line, which are simply sutured. This technique is even followed today for vascular surgery. Carrel was awarded Noble Prize in 1912 for his work on vascular suturing and transplantation of blood vessels and organs. During World War II, he developed a wound cleansing solution of sodium hydrochlorite with the famed British chemist Henry Dakin (Dakin's solution).
- Robert Barany: Robert Barany was born in Vienna, Austria on April 22, 1876 and graduated with a doctorate in medicine in 1900. He was trained in surgery in the famous Vienna General Hospital. He developed interest in urology and otology. Barany observed that patients developed nystagmus and dizziness on irrigation of the auditory canal and theorized that temperature changes in the vestibular canal resulted in perception of body movement. During the World War I, Barany was sent to organize a military surgical unit where he managed wartime neurosurgical injuries, which included the primary closure of debrided spinal wounds. Barany was captured by the Russian army in 1915 and interred a prisoner of war in Turkistan. It was here that he received the news that his work on vestibular apparatus had won the 1914 Nobel Prize in medicine. He was released in 1916 to return to Vienna where he was accused by his colleagues of plagiarism. Fully exonerated of these acquisitions, Barany moved to Sweden at the University of Uppsala where he died in 1936.
- Frederick G Banting: Frederick G Banting was born on November 14, 1891 in a small town near Toronto, Canada. His parents were hardworking farmers who wanted him to become a Methodist minister. Much to his father's dismay, Banting enrolled in University of Toronto's medical school in 1912. During the World War I, Banting enlisted with the Medical Corps of the Royal Canadian Army and left England. He served in France and was decorated with the Military Cross. He sustained serious injury to his right arm and returned to Toronto in 1919, where he completed his training in orthopedic surgery. There, he developed a keen interest in physiology of diabetes mellitus and pancreas. He thought that the endocrine function of pancreas could be better studied if the exocrine function was somehow removed. He approached Prof. MacLeod, Professor of physiology at University of Toronto with his research proposal. After much resistance, MacLeod, ultimately, allowed him to work in his laboratory with his student Charles H Best. Banting and Best proceeded with a series of experiments that involved ligation of the pancreatic duct and induction of exocrine atrophy. They found that the extract of this atrophic pancreas reversed the diabetic coma.In January 1922, a preparation of this extract was used to treat a young boy with diabetic ketoacidosis at Toronto Children Hospital. The Noble Prize was awarded in 1923 to Banting and MacLeod for discovery of insulin. The decision of the Noble committee to exclude Best deeply wounded Banting's sense of fairness. He shared half of his prize money with Best. With the Noble 15Prize money he went onto establish the Banting Research Foundation and Banting Institute at the University of Toronto. Then came World War II, which led Banting to rejoin the military and to perform war related research. He developed a high-pressure flight outfit to protect the pilots during high gravitational force maneuvers. While testing this device on his way to England, Charles Banting died in an aeroplane crash.
- Walter R Hess: Walter R Hess was born in Switzerland on March 17, 1881. After passing out from University of Zurich in 1905, he entered in a residency programme in ophthalmology. Later, he performed experiments on hemodynamic and blood viscosity and autonomic control of circulation. He served as a field surgeon in the Imperial German Army during World War I. He became Chairman of the department of physiology in Zurich. He performed detailed animal studies to map the functional organization of the brain. He studied an area of midbrain, what is now known as diencephalon. Hess was awarded Noble Prize in 1949.
- Werner Theodore Otto Forssmann: Werner O Forssmann was born on August 29, 1904 in Berlin Germany and graduated in medicine from Fredrick Wilhelm University in 1928. After many experiments on cadavers he performed the first intravenous catheterization of human heart on himself in 1929. He made a cut-down upon a vein in his left arm and threaded a well oiled ureteral catheter towards the heart. He then walked through the hospital to the radiology department where an X-ray was taken to prove the location of the catheter in the right heart. Forssmann completed his training as an urologist and served as an Army Surgeon during World War II. Forssmann's contribution to development of heart catheterization was recognized by the Noble committee, who awarded Noble Prize in 1956. The modern practice of cardiology and critical care thus became indebted to an urologist and his daring experiment.
- Charles B Huggins: Charles was a urologist born in Halifax, Canada on September 22, 1901. He received his BA from Acadia University in Nova Scotia. Huggins earned his medical degree from Harvard University in 1924 and joined University of Chicago in 1927. He studied physiology of prostate gland and found that prostatic secretion was regulated by androgens and estrogens. Huggins demonstrated that bilateral orchidectomy or estrogens could lead to a decrease in serum level of acid phosphatase, a marker of metastatic prostatic cancer. Huggins later applied this line of reasoning to his research on endocrine regulation of breast cancer. Ovariectomy and adrenalectomy was advocated as endocrine therapies for advanced breast cancer. His discoveries on hormonal treatment of prostate cancer won him his share of 1966 Noble Prize for physiology and medicine.
- Joseph E Murray: Joseph P Murray is the most recently honored surgeon by a Noble Prize. He shared the 1990 award with E Donnall Thomas for discoveries in the field of organ and cell transplantation. The first successful human kidney transplant was carried out between identical twins in a daring operation performed by Murray on December 23, 1954.
The reasoning and preparation that was necessary, along with the unwavering conviction, that a procedure of this magnitude would work, and the confidence that his technical skills would measure upto the challenge combined to personify the essence of the surgical ideal.
Murray was born on April 1, 1919 in Milford Massachusetts and graduated from Harvard Medical School in 1943. His surgical internship at the Peter Brent Brigham Hospital in Boston was interrupted by service with the United States Army as a first Lieutenant. He trained himself as a plastic surgeon while attending to the wounded and burn soldiers of the World War II. After the War, Murray completed his residency in Boston and went on for training in head and neck and plastic surgery at Memorial Sloan Kettering Hospital. He returned to Boston to take the post in the department of surgery at Brigham Hospital. This hospital had a dialysis unit and was involved in treatment of a large number of patients with end-stage renal disease.
Murray began a series of animal experiments to develop the technique of transplantation and also inducing tolerance for the new organ. From his experiments and that of his colleague who had shown that cadaver kidney would inevitably fail, 16he concluded that transplantation would become feasible if the host's immunological barriers were eliminated.
The ultimate test of his hypothesis took place in 1954 involved a patient Richard Herric, with renal failure, and had his identical twin brother who was willing to donate kidney. The first transplant operation was successful and the patient went on to live 8 more years, marrying the recovery room nurse and fathering two children.
The lessons we learn from these nine Noble Laureates is that they were all active participants in patient care. Their research was meticulous, yet to the point. They neither distracted nor isolated themselves from their social responsibilities. These surgeons concentrated their skills and efforts to a technical problem or a biological puzzle. Seven of them served their country during the time of war to care for sick and wounded. Their scientific endeavors were characterized by an intellectual curiosity that respected neither the boundaries imposed by their formal training nor the limits placed around them by their colleagues. Bridges were built across specialties, in between labs and the bedside. The speed and direction of the future progress in modern science in surgery will be linked not only to the efforts of the individual but also to the retained values of the profession. Hence, very importantly, history of surgery is not just dead past.
SUGGESTED READINGS
- David C Sabiston Jr: Textbook of Surgery—The Biological Basis of Modern Surgical Practice (14th edn). WB Saunders Company, United States of America, 1991.
- Dhawan IK, Khanduri P, Anantakrishnan N: Textbook of Surgery for Undergraduates. BI Churchill Livingstone, New Delhi 1994.
- Harold Ellis: History of Surgery. Greenwich Medical Media Limited, London, 2001.