Lecture №1 Historical aspects of surgery (core)

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A findings of archeologists and medical writings (such as papyrus) are only the source of knowledge about ancient medicine. The prehistorical humans, using the most rudimentary surgical instruments were able to remove splinters, pierce boils or blisters, treat burns and excise traumatized tissues, bore open a human skull

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3700 BC Some of earliest sources described wound care using fresh meat, honey, and lint stressing importance of giving the rest for injured extremity. They used primitive bandages to mummification of bodies lying the basis for future more definitive wound treatment.

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2250 BC Babilonian physicians were able to open purulent cavities with bronze knives. Wound irrigation was accomplished using the honey, milk, and plane water. They were able to close wounds using animal hair or tendons. In the code of Hammurabi the Babylonian law provided severe penalties for the surgeons whose operations were unsuccessful. The code of Hammurabi is shown.

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600 BC Chinese used a wine and bread at the care of a wound. Cosmetic surgery and anesthesia using inhaled opium or auto-suggestion were attempted in China.

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Ancient India has a rich medical history. Ancient physicians described more than 100 surgical instruments, including scalpels, lancets, scarifies, saws, trocars and needles. They used maggot therapy (fly larva) to treat wounds, successfully performed cesarean sections, tooth extractions, etc. Widely renowned for skills in

plastic surgery, introduction of skin pedicled flaps, etc.

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They used maggot therapy to treat wounds

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1500-1300 BC Greek civilization is considered as most ancient and influencing one. It gifted the world with the word "surgery" hyros (hand)- and urge (action). At the picture the Good Asclepius treats a patient.

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Approximately 400 years B. C. first systematic description of wounds, dislocations, fractures, and their treatment was done by Hippocrates. First definitive explanation of bandaging and dressing. It was him who introduced the term "desmurgy" desmos - connecting, urge -action.

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The Corpus Hippocraticum was the collection of knowledge of ancient Greek civilization precisely describing different types of wounds, ulcers, injuries, fractions, and their treatment.

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900-800 BC. From the Homeric poems, the Illiad and the Odyssey that was written roughly 800-700 B.C. (tells about Troy war ) is given realistic description of battle wounds, arrow and slingshot injuries and their treatment, etc. At the picture Hector treats Potrocl

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The vase shows wound care (it was built contemporary to Hippocrates). At that time they were able to make incisions of purulent wounds, tumors, hemorrhoids, stones, amputations, venesections (bloodletting), or coagulation of bleeding vessel. There were stressed an importance of good conditions to wound drainage and use of boiled water managing the wound.

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Many attention was paid for treatment of fractures and dislocations. Methods of shoulder dislocation therapy are still used. Very logic reduction of displaced spinal vertebra using special construction is shown. Two sticks are used to distort the spine and the lever is used to reduce vertebra

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One of the most prominent Roman authorities is Aurelius Cornelius Celsus. He was the encyclopedist of the early first century A. D. Celsus "De medicine" is the oldest important medical document after the "Corpus Hippocraticum" It provides cumulative knowledge of Roman medicine and surgery. At first he described classical picture of inflammation, etc.

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One of the most famous physicians of the Roman period in second century A. D. (129-199) was Galen. His views dominated European medicine for almost 15 centuries, until the time of Renaissance. He considered that disease was caused by the humors - yellow bile, black bile, blood and phlegm (although it was described earlier by Hippocrates). Rases was Persian doctor who at first invented primitive cast.

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1125 AD The French university was opened. Doctors of Medieval time used the same approach at treatment as 1000 years ago or even more shocking. Surgery of the Middle Ages was provided predominantly by itinerant and barber surgeons.

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Lack of knowledge and ban of surgery by church were most important obstacles. Anatomy was still shaded, autopsy for education aim was permitted only twice a year. The picture shows cardiovascular and muscular systems of those time.

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The procedure of bloodletting is shown which was frequently used during period between 400 BC till XIX century. At the beginning the procedure was a common part of treatment accomplished by surgeons (latter during medieval time was done by barbers).

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Hemostasis by means of heat metal was commonly used to cauterize wounds (control of bleeding)

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1338 AD Invention of gunpowder, thirst gunshot wounds. 1400 At a French army the wine was used to irrigate wounds and spider's web to stop bleeding treating the gun wound

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During the Renaissance, surgery did slowly begin to regain a higher social position. Most prominent physicians and anatomists were Vesalius, Fabricius, William Harvey, and Paracelsus. Classification of wounds dated by 1517 year

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1536 Paracelsus. Considered a pus in the wound as a negative event, comparing it with the rotted apple justifying necrectomy as a part of treatment. He blamed bloodletting procedure.

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1543 An anatomy presented by Vesalius broke former views at Galen's human structure. Created by him practical anatomy atlas for students at those time was most accurate and complete. Anatomy of muscular and venous system is shown. But still achievements were not used fully.

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1536-1545 Ambroise Pare introduced dressing soaked by rose oil and egg yolk instead of former wound treatment with boiling oil. He described a debridement (French word) of gunshot wound (not only incision but excision of necrotic tissues also), ligation of vessels, etc. Blamed presence of a pus at the wound.

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1597 The method of Italian plasty using migrating flap was introduced. Presented picture shows device to stabilize the hand during transfer of the arm's skin at the nose.

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Military time were considered to be the real opportunity for practice and innovations in surgery. New influx of knowledge was done by Napoleon wars. 1794-1814 Jean Larrey as a doctor performed more than 200 amputations daily, stressed an importance of extremities immobilization.

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Former Immobilization was usually done using wooden boards. 1851-1855 Flemish surgeon Matise invented plaster cast. Since those time the modern type has not gain a lot of differences.

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During the nineteenth century the surgeon emerged as a specialist and a respected medical practitioner. But at the first half of century the scope of surgery remained limited. Surgeons treated only simple fractures, dislocations and g y pabscesses and performed amputations technically perfect but with high mortality rate. They managed to ligate major arteries for common and accessible aneurysms and made attempts to excise external tumors, but the abdominal surgery was virtually unknown.

There were numerous obstacles to the advance of surgery. Pain, infection, hemorrhage and shock were four of the most difficult to overcome.

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Narcotic and analgesics agents such as hashish, opium, alcoholic beverages, mandrake root, or even reduction of blood flow to the brain to diminish sensibility had been used for thousands of years to alleviate human pain. 1831 there were introduced three main anesthetics: ether, nitrous oxide, and chloroform, but without practical application. Picture shows the common aim of analgesic.

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The effective use of general anesthesia can be precisely dated to the 1840s. William Morton successfully used ether. It became obvious that these substances could be applicable to surgical operations. First successful surgery of vascular tumor under ether anesthesia was done 1846 by Jon Warren

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Portraits of Morton and others. They gifted the narcosis to humans, 1842,

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Devices for anesthetic delivery offered by Pirogov (left), and offered by Morton (right) with latter invention of endotracheal root, etc.

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Thousands of years a different materials were used as a dressing mostly lint and canvases. Purulent complications (accumulation of pus) were common after even perfectly performed surgery. Results of such operations were commonly disappointing. If a patient was fortunate there was a slow healing process to recovery. And relation to pus in the wound was unequivocal. Here dressing materials are h d h i f C l ill XIXshown used at the time from Celsus till XIX century.

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1847-1848 Second crucial step was an introduction of antisepsis as part of wound treatment. Fillip Shimmelvaise (Hungary surgeon) is at the picture. He introduced disinfection of hands before taking the birth care;

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Louis Pasteur (at left) had found responsible for fermentation microorganisms and developed a germ theory of disease. He showed that the pus formation and inflammation were caused by living, multiplying matter. Jousef Lister (English surgeon, at right) continued his research from practical point of view.

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1867 Introduction of gauze soaked by carbolic acid. 1870 Listers conception was that everything that was in contact with wound must be sterile (hand washing, wound and instrument irrigation, air spraying). He introduced a new suture material known as a catgut (cat's gut) absorbed by tissues in several weeks.

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1870-80 An antiseptic conception had already developed. Special operating rooms, dressing rooms, their separation, clean and dirty areas, shaving, cleaning, and other rules were invented.

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Aseptic conception was the necessity of sterilization of instruments using physical methods

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1876 Johnson was inspired by Listers works and had started manufacturing dressing materials. Nowadays his company is one of the most renowned.

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Guillaume Dupuytren was one of the most trained French surgeons who introduced intestinal suture, wrote a manual of operative surgery, etc.

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In American surgery great contributions for development of surgery were done by Mc Burney (in honor for this surgeon the point of maximal tenderness was named, and now bearing his name) and Murphy (who described the symptoms of acute cholecystitis).

Kocher sign

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1874 German surgeon Kirsh had introduced a split-thickness skin graft, special stainless wires (treatment of fractures), etc. Theodor Billroth, Esmarch 1879 (introduction of tourniquet to stop bleeding and special device for wound irrigation), Mikulicz, Volkmann, Bergmann are the famous surgeons who made great contributions in the history of German abdominal surgery.

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First stapes in neurosurgery were done by Harvey Cushing. He introduced the practice of sphygmomanometry into the operating room (beginning of the monitoring during surgical operation). 1895 instruments used to cutting and exploration of tissues

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1836-1840 Pirogov (left) at the period of Russian-Turkey war 1865-66 were done most practical achievements. New methods of gunshot wound management, amputations, separation of clean and infected patients, etc.Vishnevskiy (right) offered many methods of infiltration anesthesia, active wound care, etc.

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Mechnikov (left) had found cell phagocytosis 1882-83 Sclifosovsky (right) accomplished comparison of carbolic acid and iodine (their antiseptic efficacy)

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1878-80 Robert Koch at first described a specific microorganisms (different species like mycobacterium tuberculosis, staph, etc.) responsible for different forms of infection.

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1883-84 Kocher (representatives of German school) His surgical treatment of goiter, earned Kocher to Nobel Prize in 1909, the first time it was awarded to a surgeon. He also made attention to the understanding role of the thyroid gland in the body's metabolism.

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1905 William Halsted, an American surgeon, made numerous important contributions to surgical technique and teaching. He introduced the use of rubber gloves into the surgery, developed improved methods for operating on hernias and cancer of the breast. He took part in the establishing the "surgical residency system", new program of education provided systematic way of young surgeons training.

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The discovery of X-rays by Roentgen in 1895. Primary used to bones and tissues within a few years the use of rays was expanded and include physiologic studies such as those of swallowing and intestinal motion.

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Organ transplantation. Alexis Carrel at period of 1902 till 1912 overcame the problem of blood supply of transplanted organ. New method of blood vessels reconnection by means of end-to-end suture was proposed by Carrel. In honor to that he was awarded the Nobel Prize in 1912.

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The story of modern chemotherapy connected with works of the British pathologist Alexander Fleming. At 1928 he had discovered that culture of penicillium was able to suppress multiplication of staph. Also he had found inhibiting agent and called it lysozyme.Latter was invented first antibiotic starting antibacterial era.

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One of the prime contributors to the field of cardio-vascular surgery has been Michael DeBaky. In 1934 he first described a roller pump for extracorporeal circulation. After this he became a leader in the field of direct surgery for the treatment of thoracic and abdominal aneurysms including complicated resection of lesions of the aortic arch. He was the first to perform carotid endarterectomy in 1953 and the use of saphenous vein bypass graft for coronary arteries.

A i lA cariopulmonary

bypass machine

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Virtual surgeon and virtual surgery computer forecast of results before and after surgery are not in future.

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