Chapter 1 History of Surgery
It remains a rhetorical question whether an understanding of surgical history is important to the maturation and continued education and training of a surgeon. Conversely, it is hardly necessary to dwell on the heuristic value that an appreciation of history provides in developing adjunctive humanistic, literary, and philosophic tastes. Clearly, the study of medicine is a lifelong learning process that should be an enjoyable and rewarding experience. For a surgeon, the study of surgical history can contribute toward making this educational effort more pleasurable and can provide constant invigoration. Tracing the evolution of what one does on a daily basis and understanding it from a historical perspective become enviable goals. In reality, there is no way to separate present-day surgery and one’s own clinical practice from the experience of all surgeons and all the years that have gone before. For budding surgeons, it is a magnificent adventure to appreciate what they are currently learning within the context of past and present cultural, economic, political, and social institutions. Active physicians will find that the study of the profession—dealing, as it rightly must, with all aspects of the human condition—affords an excellent opportunity to approach current clinical concepts in ways not previously appreciated.
In studying our profession’s past, it is certainly easier to relate to the history of so-called modern surgery over the past 100 or so years than to the seemingly primitive practices of previous periods because the closer to the present, the more likely it is that surgical practices will resemble current practices. Nonetheless, writing the history of modern surgery is in many respects more difficult than describing the development of surgery before the late 19th century. One significant reason for this difficulty is the ever-increasing pace of scientific development in conjunction with unrelenting fragmentation (i.e., specialization and subspecialization) within the profession. The craft of surgery is in constant flux and, the more rapid the change, the more difficult it is to obtain a satisfactory historical perspective. Only the lengthy passage of time permits a truly valid historical analysis.
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. 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. They managed to ligate major arteries for common and accessible aneurysms and made heroic attempts to excise external tumors. Some individuals focused on the treatment of anal fistulas, hernias, cataracts, and bladder stones. Inept attempts at reduction of incarcerated and strangulated hernias were made and, hesitatingly, rather rudimentary colostomies or ileostomies were created by simply incising the skin over an expanding intra-abdominal mass, which represented the end stage of a long-standing intestinal obstruction. Compound fractures of the limbs, with attendant sepsis, remained mostly unmanageable, with staggering morbidity being a likely surgical outcome. Although a few bold surgeons endeavored to incise the abdomen in the hope of dividing obstructing bands and adhesions, abdominal and other types of intrabody surgery were almost unknown.
Despite it all, including an ignorance of anesthesia and antisepsis tempered with the not uncommon result of the patient suffering from or succumbing to the effects of a surgical operation (or both), surgery was long considered an important and medically valid therapy. This seeming paradox, in view of the terrifying nature of surgical intervention, its limited technical scope, and its damning consequences before the development of modern conditions, is explained by the simple fact that surgical procedures were usually performed only for external difficulties that required an objective anatomic diagnosis. Surgeons or followers of the surgical cause saw what needed to be fixed (e.g., abscesses, broken bones, bulging tumors, cataracts, hernias) and would treat the problem in as rational a manner as the times permitted. Conversely, the physician was forced to render subjective care for disease processes that were neither visible nor understood. After all, it is a difficult task to treat the symptoms of illnesses such as arthritis, asthma, heart failure, and diabetes, to name but a few, if there is no scientific understanding or internal knowledge of what constitutes their basic pathologic and physiologic underpinnings.
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. Because this reorientation of internal medicine occurred within a relatively short time and brought about such dramatic results in the classification, diagnosis, and treatment of disease, the rapid ascent of mid-19th century internal medicine might seem more impressive than the agonizingly slow, but steady, advance of surgery. In a seeming contradiction of mid-19th century scientific and social reality, 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 until the discovery of anesthesia in 1846 and an understanding and acceptance of the need for surgical antisepsis and asepsis during the 1870s and 1880s. Still, surgeons never needed a diagnostic and pathologic revolution in the manner of the physician. Despite the imperfection of their scientific knowledge, the pre–modern era surgeon did cure with some technical confidence.
That the gradual evolution of surgery was superseded in the 1880s and 1890s by the rapid introduction of startling new technical advances was based on a simple culminating axiom—the four fundamental clinical prerequisites that were required before a surgical operation could ever be considered a truly viable therapeutic procedure had finally been identified and understood:
The first two prerequisites were essentially solved in the 16th century, but the latter two would not be fully resolved until the ending decades of the 19th century. In turn, the ascent of 20th century scientific surgery would unify the profession and allow what had always been an art and craft to become a learned vocation. Standardized postgraduate surgical education and training programs could be established to help produce a cadre of scientifically knowledgeable physicians. Moreover, in a final snub to an unscientific past, newly established basic surgical research laboratories offered the means of proving or disproving the latest theories while providing a testing ground for bold and exciting clinical breakthroughs.
Few individuals have had an influence on the history of surgery as overwhelmingly as that of the Brussels-born Andreas Vesalius (1514-1564; Fig. 1-1). As professor of anatomy and surgery in Padua, Italy, Vesalius taught that human anatomy could be learned only through the study of structures revealed by human dissection. In particular, his great anatomic treatise, De Humani Corporis Fabrica Libri Septem (1543), provided fuller and more detailed descriptions of human anatomy than any of his illustrious predecessors. 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. Even more radical was Vesalius’ blunt assertion that anatomic dissection must be completed by physician-surgeons themselves—a direct renunciation of the long-standing doctrine that dissection was a grisly and loathsome task to be performed by a diener-like individual while the perched physician-surgeon lectured by reading from an orthodox anatomic text from on high. This principle of hands-on education would remain Vesalius’ most important and long-lasting contribution to the teaching of anatomy. Vesalius’ Latin literae scriptae ensured its accessibility to the most well-known physicians and scientists of the day. Latin was the language of the intelligentsia and the Fabrica became instantly popular, so it was only natural that over the next 2 centuries, the work would go through numerous adaptations, editions, and revisions, although always remaining an authoritative anatomic text.
The position of Ambroise Paré (1510-1590) in the evolution of surgery remains of supreme importance (Fig. 1-2). He played the major role in reinvigorating and updating Renaissance surgery and represents severing of the final link between surgical thought and techniques of the ancients and the push toward more modern eras. From 1536 until just before his death, Paré was engaged as an army surgeon, during which time he accompanied different French armies on their military expeditions, or was performing surgery in civilian practice in Paris. Although other surgeons made similar observations about the difficulties and nonsensical aspects of using boiling oil as a means of cauterizing fresh gunshot wounds, Paré’s use of a less irritating emollient of egg yolk, rose oil, and turpentine brought him lasting fame and glory. His ability to articulate such a finding in a number of textbooks, all written in the vernacular, allowed his writings to reach more than just the educated elite. Among Paré’s important corollary observations was that when 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 or with hot oleum. Described in his Dix Livres de la Chirurgie avec le Magasin des Instruments Necessaires à Icelle (1564), the free or cut end of a blood vessel was doubly ligated and the ligature was allowed to remain undisturbed in situ until, as a result of local suppuration, it was cast off. Paré humbly attributed his success with patients to God, as noted in his famous motto, “Je le pansay. Dieu le guérit,”—that is, “I treated him. God cured him.”
Although it would be another 3 centuries before the third desideratum, that of anesthesia, was discovered, much of the scientific understanding concerning efforts to relieve discomfort secondary to surgical operations was based on the 18th century work of England’s premier surgical scientist, John Hunter (1728-1793; Fig. 1-3). Considered one of the most influential surgeons of all time, his endeavors stand out because of the prolificacy of his written word and the quality of his research, especially in using experimental animal surgery as a way to understand the pathophysiologic basis of surgical diseases. Most impressively, Hunter relied little on the theories of past authorities but rather on personal observations, with his fundamental pathologic studies first described in the renowned textbook A Treatise on the Blood, Inflammation, and Gun-Shot Wounds (1794). Ultimately, his voluminous research and clinical work resulted in a collection of more than 13,000 specimens, which became one of his most important legacies to the world of surgery. It represented a unique warehousing of separate organ systems, with comparisons of these systems—from the simplest animal or plant to humans—demonstrating the interaction of structure and function. For decades, Hunter’s collection, housed in England’s Royal College of Surgeons, remained the outstanding museum of comparative anatomy and pathology in the world, until a World War II Nazi bombing attack of London created a conflagration that destroyed most of Hunter’s assemblage.
Since time immemorial, the inability of surgeons to complete pain-free operations had been among the most terrifying of medical problems. In the preanesthetic era, surgeons were forced to be more concerned about the speed with which an operation was completed than with the clinical efficacy of their dissection. In a similar vein, patients refused or delayed surgical procedures for as long as possible to avoid the personal horror of experiencing the surgeon’s knife. Analgesic, narcotic, and soporific agents such as hashish, mandrake, and opium had been used for thousands of years. However, the systematic operative invasion of body cavities and the inevitable progression of surgical history could not occur until an effective means of rendering a patient insensitive to pain was developed.
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 and so-called laughing gas parties and ether frolics were in vogue, especially in America. Young people were amusing themselves with the pleasant side effects of these compounds as itinerant so-called professors of chemistry traveled to hamlets, towns, and cities to lecture on and demonstrate the exhilarating effects of these new gases. 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 T.G. Morton (1819-1868), a Boston dentist, persuaded John Collins Warren (1778-1856), professor of surgery at the Massachusetts General Hospital, to let him administer sulfuric ether to a surgical patient from whom Warren went on to remove a small, congenital vascular tumor of the neck painlessly. After the operation, Warren, greatly impressed with the new discovery, uttered his famous words, “Gentlemen, this is no humbug.”
Few medical discoveries have been so readily accepted as inhalational anesthesia. News of the momentous event spread rapidly throughout the United States and Europe, and a new era in the history of surgery had begun. Within a few months after the first public demonstration in Boston, ether was used in hospitals throughout the world. Yet, no matter how much it contributed to the relief of pain during surgical operations and decreased the surgeon’s angst, the discovery did not immediately further the scope of elective surgery. Such technical triumphs awaited the recognition and acceptance of antisepsis and asepsis. Anesthesia helped make the illusion of surgical cures more seductive, but it could not bring forth the final prerequisite—all-important hygienic reforms.
Still, by the mid-19th century, both physicians and patients were coming to hold surgery in relatively high regard for its pragmatic appeal, technologic virtuosity, and unambiguously measurable results. After all, surgery appeared a mystical craft to some. To be allowed to consensually cut into another human’s body, to gaze at the depth of that person’s suffering, and to excise the demon of disease seemed an awesome responsibility. It was this very mysticism, however, long associated with religious overtones, that so fascinated the public and their own feared but inevitable date with a surgeon’s knife. Surgeons had finally begun to view themselves as combining art and nature, essentially assisting nature in its continual process of destruction and rebuilding. This regard for the natural would spring from the eventual, although preternaturally slow, understanding and use of Joseph Lister’s (1827-1912) techniques (Fig. 1-4).
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. There was no arguing that the deadening of pain permitted a surgical operation to be conducted in a more efficacious manner. Haste was no longer of prime concern. However, if anesthesia had never been conceived, a surgical procedure could still be performed, albeit with much difficulty. Such was not the case with listerism. Without antisepsis and asepsis, major surgical operations more than likely ended in death rather than just pain. Clearly, surgery needed both anesthesia and antisepsis, but in terms of overall importance, antisepsis proved to be of greater singular impact.
In the long evolution of world surgery, the contributions of several individuals stand out as being preeminent. Lister, an English surgeon, can be placed on such a select list because of his monumental efforts to introduce systematic, scientifically based antisepsis in the treatment of wounds and the performance of surgical operations. He pragmatically applied others’ research into fermentation and microorganisms to the world of surgery by devising a means of preventing surgical infection and securing its adoption by a skeptical profession.
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 and, after experimenting with zinc chloride and the sulfites, decided on carbolic acid. By 1865, Lister was instilling pure carbolic acid into wounds and onto dressings. He would eventually make numerous modifications in the technique of dressings, manner of applying and retaining them, and choice of antiseptic solutions of varying concentrations. Although the carbolic acid spray remains the best remembered of his many contributions, it was eventually abandoned in favor of other germicidal substances. Lister not only used carbolic acid in the wound and on dressings but also went so far as to spray it into the atmosphere around the operative field and table. He did not emphasize hand scrubbing but merely dipped his fingers into a solution of phenol and corrosive sublimate. Lister was incorrectly convinced that scrubbing created crevices in the palms of the hands where bacteria would proliferate. 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 created by previously contaminated silk ligatures. Lister evolved a carbolized catgut suture that was better than any previously produced. He was able to cut the ends of the ligature short, thereby closing the wound tightly and eliminating the necessity of bringing the ends of the suture out through the incision, a surgical practice that had persisted since the days of Paré.
The acceptance of listerism was an uneven and distinctly slow process, for many reasons. First, the various procedural changes that Lister made during the evolution of his methodology created confusion. Second, listerism, as a technical exercise, was complicated by the use of carbolic acid, an unpleasant and time-consuming nuisance. Third, various early attempts to use antisepsis in surgery had proved abject failures, with many leading surgeons unable to replicate Lister’s generally good results. Finally, and most importantly, acceptance of listerism depended entirely on an understanding and ultimate recognition of the veracity of the germ theory, a hypothesis that many practical-minded surgeons were loath to accept.
As a professional group, German-speaking surgeons would be the first to grasp the importance of bacteriology and the germ theory. Consequently, they were among the earliest to expand on Lister’s message of antisepsis, with his spray being discarded in favor of boiling and use of 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. By the mid-1890s, less clumsy aseptic techniques had found their way into most European surgical amphitheaters and were approaching total acceptance by American surgeons. Any lingering doubts about the validity and significance of the momentous concepts that Lister had put forth were eliminated on the battlefields of World War I. There, the importance of just plain antisepsis became an invaluable lesson for scalpel bearers, whereas the exigencies of the battlefield helped bring about the final maturation and equitable standing of surgery and surgeons within the worldwide medical community.
Especially prominent among other late 19th century discoveries that had an enormous impact on the evolution of surgery was research conducted by Wilhelm Roentgen (1845-1923), which led to his 1895 elucidation of x-rays. Having grown interested in the phosphorescence from metallic salts that were exposed to light, 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 9 feet away. This strange effect continued after the current was turned off. He found that the screen had been painted with a phosphorescent substance. Proceeding with full experimental vigor, Roentgen soon realized that there were invisible rays capable of passing through solid objects made of wood, metal, and other materials. Most significantly, 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. In a short time, numerous applications were developed as surgeons rapidly applied the new discovery to the diagnosis and location of fractures and dislocations and the removal of foreign bodies.
By the late 1890s, the interactions of political, scientific, socioeconomic, and technical factors set the stage for what would become a spectacular showcasing of surgery’s newfound prestige and accomplishments. Surgeons were finally wearing antiseptic-looking white coats. Patients and tables were draped in white, and basins for bathing instruments in bichloride solution abounded. Suddenly, all was clean and tidy, with conduct of the surgical operation no longer a haphazard affair. This reformation would be successful not because surgeons had fundamentally changed but because medicine and its relationship to scientific inquiry had been irrevocably altered. Sectarianism and quackery, the consequences of earlier medical dogmatism, would no longer be tenable within the confines of scientific truth.
With all four fundamental clinical prerequisites in place by the turn of the century, highlighted by the emerging clinical triumphs of various English surgeons, including Robert Tait (1845-1899), William Macewen (1848-1924), and Frederick Treves (1853-1923); German-speaking surgeons, including Theodor Billroth (1829-1894; Fig. 1-5), Theodor Kocher (1841-1917; Fig. 1-6), Friedrich Trendelenburg (1844-1924), and Johann von Mikulicz-Radecki (1850-1905); French surgeons, including Jules Peán (1830-1898), Just Lucas-Championière (1843-1913), and Marin-Theodore Tuffiér (1857-1929); Italian surgeons, most notably Eduardo Bassini (1844-1924) and Antonio Ceci (1852-1920); and several American surgeons, exemplified by William Williams Keen (1837-1932), Nicholas Senn (1844-1908), and John Benjamin Murphy (1857-1916), scalpel wielders had essentially explored all cavities of the human body. Nonetheless, surgeons retained a lingering sense of professional and social discomfort and continued to be pejoratively described by nouveau scientific physicians as nonthinkers who worked in little more than an inferior and crude manual craft.
It was becoming increasingly evident that research models, theoretical concepts, and valid clinical applications would be necessary to demonstrate the scientific basis of surgery to a wary public. The effort to devise new operative methods called for an even greater reliance on experimental surgery and its absolute encouragement by all concerned parties. Most importantly, a scientific basis for therapeutic surgical recommendations—consisting of empirical data, collected and analyzed according to nationally and internationally accepted rules and set apart from individual authoritative assumptions—would have to be developed. In contrast to previously unexplainable doctrines, scientific research would triumph as the final arbiter between valid and invalid surgical therapies.
In turn, surgeons had no choice but to allay society’s fear of the surgical unknown by presenting surgery as an accepted part of a newly established medical armamentarium. This would not be an easy task. The immediate consequences of surgical operations, such as discomfort and associated complications, were often of more concern to patients than the positive knowledge that an operation could eliminate potentially devastating disease processes. Accordingly, the most consequential achievement by surgeons during the early 20th century was ensuring the social acceptability of surgery as a legitimate scientific endeavor and the surgical operation as a therapeutic necessity.
William Stewart Halsted (1852-1922), more than any other surgeon, set the scientific tone for this most important period in surgical history (Fig. 1-7). He moved surgery from the melodramatics of the 19th-century operating theater to the starkness and sterility of the modern operating room, commingled with the privacy and soberness of the research laboratory. As professor of surgery at the newly opened Johns Hopkins Hospital and School of Medicine, Halsted proved to be a complex personality, but the impact of this aloof and reticent man would become widespread. 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. Halsted proved, to an often leery profession and public, that an unambiguous sequence could be constructed from the laboratory of basic surgical research to the clinical operating room. Most importantly, for surgery’s own self-respect, he demonstrated during this turn of the century renaissance in medical education that departments of surgery could command a faculty whose stature was equal in importance and prestige to that of other more academic or research-oriented fields, such as anatomy, bacteriology, biochemistry, internal medicine, pathology, and physiology.
As a single individual, Halsted developed and disseminated a different system of surgery so characteristic that it was termed a school of surgery. More to the point, Halsted’s methods revolutionized the world of surgery and earned his work the epithet “halstedian principles,” which remains a widely acknowledged and accepted scientific imprimatur. Halsted subordinated technical brilliance and speed of dissection to a meticulous and safe, albeit sometimes slow performance. As a direct result, Halsted’s effort did much to bring about surgery’s self-sustaining transformation from therapeutic subservience to clinical necessity.
Despite his demeanor as a professional recluse, Halsted’s clinical and research achievements were overwhelming in number and scope. His residency system of training surgeons was not merely the first such program of its type—it was unique in its primary purpose. Above all other concerns, Halsted desired to establish a school of surgery that would eventually disseminate throughout the surgical world the principles and attributes that he considered sound and proper. His aim was to train able surgical teachers, not merely competent operating surgeons. There is little doubt that Halsted achieved his stated goal of producing “not only surgeons but surgeons of the highest type, men who will stimulate the first youth of our country to study surgery and to devote their energies and their lives to raising the standards of surgical science.” So fundamental were his contributions that without them, surgery might never have fully developed and could have remained mired in a quasiprofessional state.
The heroic and dangerous nature of surgery seemed appealing in less scientifically sophisticated times, but now surgeons were courted for personal attributes beyond their unmitigated technical boldness. A trend toward hospital-based surgery was increasingly evident, in equal parts resulting from new, technically demanding operations and modern hospital physical structures within which surgeons could work more effectively. The increasing complexity and effectiveness of aseptic surgery, diagnostic necessity of the x-ray and clinical laboratory, convenience of 24-hour nursing, and availability of capable surgical residents living within a hospital were making the hospital operating room the most plausible and convenient place for a surgical operation to be performed.
It was obvious to both hospital superintendents and the whole of medicine that acute care institutions were becoming a necessity, more for the surgeon than for the physician. As a consequence, increasing numbers of hospitals went to great lengths to supply their surgical staffs with the finest facilities in which to complete operations. For centuries, surgical operations had been performed under the illumination of sunlight, candles, or both. Now, however, electric lights installed in operating rooms offered a far more reliable and unwavering source of illumination. Surgery became a more proficient craft because surgical operations could be completed on stormy summer mornings, as well as on wet winter afternoons.