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Working With Their Hands: A Brief History of Surgery

Surgical Techniques of the Ancients

The word surgery is derived from the Greek words for ‘work’ and ‘hand’. Throughout history, the status of surgery within medicine has been on of flux, although for the most part up until the modern era it was ranked below the work of the more ‘learned’ physicians.
Three themes have dominated the history of surgery:
1) The relation of surgery (including its structure, status and values) to the broader field of medicine has not always been easy;
2) Elective procedures have become more frequent through time and are now the result of complex choices; and
3) The dangerous technologies of war have led to improved surgical techniques that have then found peacetime applications.
In neolithic times humans practiced splints for setting fractures, and trephination (possibly to relieve headaches, stop seizures, or help those who lost consciousness after receiving a blow to the head).
Papyrus scrolls from ancient Egypt detail surgical operations such as trephination and circumcision.
In the Greek and Roman era surgery was dangerous and seldom performed. Wounds, however, were dressed with wine, beer, myrrh and rust in the hope of helping healing. Also the wars (and gladiatorial combats) of these eras led to surgery in the army. Here cautery (the searing of wounds with hot metal instruments) was widely practiced—and would be throughout the Middle Ages. The Romans also improved surgical and dental tools using copper to make scalpels and forceps for pulling teeth.

Wall Painting of Surgery in Hellenistic Greece [Image to Left]

Roman-era Surgery on Wounded Gladiator [Image to Right]

Medieval Surgery

During the Middle Ages a few surgeons rose to prominence—perhaps the most famous was Henri de Mondeville in the early 14th century. In his writings he emphasized anatomy and described techniques to dress wounds, relieve pain and staunch bleeding—including the use of a tight band around a limb that was to be amputated. Another surgeon from the same era, Guy de Chauliac, also recognized the importance of anatomy, but only as it dealt with wounds, factures, tumors, hernias, ulcers and cataracts.
Most medieval surgeons and physicians accepted the traditional belief in laudable pus and devised poultices to encourage its formation.
Ambroise Paré in the sixteenth century, wrote many treaties on surgery—most of which contained a ‘wound man’ with commentaries on how to manage each type of injury. His works proved technical details on amputation, the treatment of fractures, and elective procedures such as trephination. To ensure wide circulation of his views, Paré wrote in vernacular language rather than in Latin. One of his most commonly recommended treatments was cauterization of wounds using cautery irons.

Medieval Surgery on a Skull, from Northern Italy [Above]; and a Medieval Operation on a Liver [Image to Right]

Early Modern Surgeries

One of the first common surgeries of the early modern era was the treatment of cataracts in the eyes (called couching). The procedure involved inserting a needle into the eye at the edge of the cornea to push the clouded lens down and out of the way. By the early 1700s, lenses were not longer simply pushed down, but actually removed during surgery.
Cutting to remove bladder stones, or perineal lithotomy, was quite common during the 17th and 18th centuries, perhaps due to dietary problems.
During the Renaissance some plastic procedures were performed to correct hare lip deformities and basic rhinoplasty. Some experimental procedures were performed in which skin from the upper arm was transplanted onto a damaged nose.
Operations to repair missing noses were of great importance in the 17th century due to the spread of syphilis throughout Europe.
By the 18th century, the traditional stigmas attached to surgeons were slowly eroding as their craft (and new techniques and instruments) were held in higher regard by the educated elites.

Surgical Procedure on a Skull, Early 17th Century [Above]; and History of Neurosurgery (1666 edition) [Image to Right]

The Professionalization of Surgeons

In 1518, the internist doctors of England formed the Royal College of Physicians to control licensing and the practice of medicine. In 1540, barber-surgeons were granted a charter by Henry VIII to form their own guild. This charter protected their right to practice and granted them autonomy over licensing and discipline. In the other European countries the incorporation of surgeons also took place separate from physicians. By the late 18th century, surgeons comprised a range of medical practitioners, from the village barber to an aristocratic elite, but their practical apprenticeship in training continued. These professional organizations created a hierarchy and an environment in which specialties would later develop.
Until the mid 19th century, physicians were routinely mocked for being impractical, bookish, and generally ineffectual. Their university-based education was considered stagnant. Surgeons on the other hand maintained separate schools where they taught by apprenticeship on living patients and by dissection of cadavers. In France, surgeons continued to reject the university establishment which had been allied with the monarchy. After the Revolution of 1789 the revised Paris Medical School combined surgical education into its curriculum.

Barber Treating a Patient’s Foot, 17th Century, Europe [Above]; and King Henry VIII Presenting Royal Charter to Barbers Surgeons of London, 1540 [Below]

The Founding of Some of the Earliest Professional Organizations of Surgeons

Year Founded	Organization
1505	Seal of Cause granted to barbers and Surgeons of Edinburgh
1521	Licence by examination of the surgeon-in-chief, Portugal
1540	United Company of Barber Surgeons of London
1603	Academia dei Lincei, Rome
1694	Revival of Collège St. Côme in Paris
1731	Académie de Chirurgie, Paris
1736	School of Surgery, the precursor of the Royal Academy of Surgery in Copenhagen, Denmark
1760	Royal College of Surgery, Barcelona, Spain
1787	Royal College of Surgery of San Carlos, Madrid, Spain
1800	Royal College of Surgery, London
1920	Royal College of Physicians and Surgeons of Canada

Relieving the Pain: ‘Modern’ Anesthesia

Alcohol, opium and bleeding had traditionally been used to relieve pain during surgery. The best relief for a person undergoing surgery was rapid loss of consciousness, caused either by the analgesia or by the procedure itself. Surgeons had to work quickly and accurately.
Anesthetic gases would transform surgery. Its earliest advocates, however, were not surgeons or physicians—instead they were chemists and dentists. Nitrous oxide (often referred to as ‘laughing gas’) was known in the late 18th century, and was often used at social gathering were it was sniffed to produce inebriation. In 1799, the English chemist Humphrey Davy experimented with a combination of nitrous oxide and oxygen in both animals and humans and he argued that it could be used to relieve pain in surgery. Nitrous oxide was also used by the dentist Horace Wells in the mid 1800s when he conducted public demonstrations of ‘painless’ tooth extractions. Chloroform was introduced into surgical practice in 1847 by the Scottish doctor James Young Simpson who recommended it for obstetrical procedures.
Controversy, however, swirled around all forms of anesthesia in this period due in part to the dangers of gaseous explosions, deaths of patients (largely a result however of their serious conditions and the complicated surgeries), as well as the ‘morals’ and ‘dangers’ of using the gases.
Once anesthesia became accepted, however, longer and more complicated operations became possible for the first time in history.

Ether Being Used During an Operation in Boston, c. 1890s [Above]; Chloroform Inhaler, late 19th Century [Image to Right]

Preventing Infection: Development of Antisepsis

In 1847 Ignaz Semmelweis introduced the washing of hands and instruments in a chlorine-water solution to prevent fevers, but he did not publish this finding until 1860. In 1867 the Scottish surgeon Joseph Lister announced the results of his experiments with carbolic acid in open fractures—in this Lister stated that such treatment would prevent infections from bacteria, thereby allying himself with the new ideas of Pasteur.
Lister’s views circulated widely, but ‘germ theory’ was still not universally accepted. Some doctors agreed to splash antisceptics into wounds or spray them into the air to kill germs, but still maintained that surgical wounds were inherently clean.
Rubber gloves were patented in 1878 and gradually entered surgical procedures.
The leading advocates for antisepsis in Canada were the surgeons Thomas Roddick of Montreal and Archibald Malloch of Hamilton. It was not until the late 19th century, however, that their views became the norm in hospitals and medical schools.
Lister’s post-amputation death rates with and without antiseptics in surgery:

Joseph Lister (1827-1912)

Years	Total Cases	Lived	Died	Mortality %
1864-1866	35	19	16	45.7 without antiseptics
1867-1879	40	34	6	15.0 with antiseptics

Warfare & Battlefield Surgery

The many wars of the 19th century had a tremendous impact on the development of surgery as surgeons not only had to cope with thousands of wounded, but also new injuries caused by much deadlier weapons (including the melee ball, massive artillery bombardments with shrapnel wounds, and by the end of the century maxim guns). During the US Civil War (as had been the case during the Napoleonic Wars) the most common treatment for wounds was amputation! Often camp surgeons performed 100s of amputations after a battle.
The horrors of the battle of Solferrino in 1859 led to the Swiss businessman and philanthropist, Jean Dunant, to found the International Red Cross in 1863. This body established the Geneva Convention in 1864 to guarantee neutrality to both wounded soldiers and their attendants.
The brutal injuries of World War I (both from guns and gas attacks) led to developments in the treatment of burns and plastic surgery. In World War II, experiments with thin skin grafts and remodelling techniques in England helped repair many scarring injuries. Also blood transfusion, which had been first tried in 1917, became quite common during the second great war. This technology meant that more complicated surgeries (such as cardiovascular) could be developed in the post-war era. It was not until WWII, however, that disease no longer claimed lives than battlefield injuries.

Wounded Soldier and Battlefield Surgeon, 15th Century Europe [Image to Right]; and Field Hospital, Union Army during the American Civil War (1861-1865) [Below]

The Costs of Surgery
(Financial, Cultural & Scientific)

In North America there are two competing models for providing medical care. In the United States, private health care dominates—a system in which those with money can afford health insurance even if they cannot afford the operation itself. However, the result is a two-tiered system in which many have inadequate or no coverage. In Canada our higher taxes cover the high costs, yet complicated procedures are available only in major urban centres. Also to control costs, elective surgery is rationed, not by the patient’s ability to pay, but by delay. The high costs of surgery are also criticized by those who believe that funds would be better spent on prevention and epidemiology (public health).
Cost-benefit analyses have been performed on the effectiveness of tonsillectomy—a procedure that until the early 1960s was practiced on approximately 1/3 of all children in North America. While the rates of the operation have been declining many suggest that the procedure is still over-utilized. The geographic discrepancies in the utilization of procedures such as coronary bypass and hysterectomies also lead epidemiologists to explore how economic factors can relate to indications for surgery.
Breast cancer accounts for approximately 10% of all female deaths in North America, and the surgical procedure of mastecomy has a lengthy history (common since the 17th/18th centuries). In the 1970s, however, epidemiological surveys suggested that while radical mastecomy may prevent local recurrence, it could not be correlated with increased survival—the result has been a shift to simple mastecomy combined with chemotherapy. Surgeons and their craft are now at the apex of the medical hierarchy. The traditions of manual dexterity and technical innovation (now including microsurgery and lasers) has not vanished, but only increased. Now surgeons, however, must deal with new challenges posed by economics, as well as ethical and epidemiological concerns.

Surgical Amputation of a Limb, mid 1700s