Demystifying the Saga of Surgery

A throwback on how the life saving skill has evolved over the ages!

Excerpts from the book.- ‘ The Gentle Tyrant’,  authored by  Dr. M.S. Venkatraman

It sounds strange but it is true that a good surgeon cuts to heal.  It is said that a surgeon who is good at his job, has the “eyes of an eagle, the heart of a lion and the fingers of a lady.”  The State of Tamil Nadu can boast of great surgeons like Dr. Pandalai, Dr.Rangachari and Dr.Mohan Rau, to mention a few.  But they came into the field after surgery had become an art.

The evolution of surgery is interesting.  Man has relied upon the surgeon to cure some of his illnesses since the pre-historic days.  There is evidence of surgery being performed nearly 5,000 years ago as recorded in the Edwin Smith Papyrus (meaning paper) and the Eben Papyrus.

There are ancient Egyptian documents referring to the period of about 3,000 B.C.  The impression that illnesses were due to supernatural forces made the priests take to the profession of being physicians also.  May be a healer of the mind could heal the body as well.

Witch doctors still work among some of the African tribes today. The Edwin Smith Papyrus and the Eben papyrus refer to the making of holes in the skull of ailing patients.  “Trephining”, as it was called, was done with the purpose of letting the evil spirits within the skull out. Incidentally, similar trephined skulls have been found in Central and South America, which had been performed by the Maya and Inca tribes in the 7th to 9th A.D.

Role of Hippocrates

Hippocrates of Greece is regarded as the father of medicine.  Apart from setting the guidelines on how to practice the art of medicine, he established the norms in the practice of medicine, its discipline and ethics.  Hippocrates also described some surgical procedure like setting right fractures and dislocations.

He realized the importance of the role of war in the development of surgery. He rightly stated:  “War is the only proper school of surgery.”  Nearly 2,500 years later, this became very real.  The two world wars, the Vietnam and Korean wars, reinforced this observation and contributed a lot towards advancement in surgery, though at the cost of enormous human suffering.

In the Indian subcontinent, Sushruta, a surgeon of the 5th century A.D., performed and described operations like removal of stones and suturing of the intestines, after administration of painkillers which included Hyoscyamus and Cannabis Indica.  He described surgical procedures to salvage a baby by caesarian section after the mother had died.

Pic courtesy: US News Health

In those days, highway robbers and women who misbehaved were punished by cutting off their noses.  Sushruta described in surgical procedure to reconstruct the nose using the skin from the forehead, known today the world over as the Indian technique of Rhinoplasty.

China had developed acupuncture, and Roman medicine was highlighted by the work of a surgeon named Celsus.  He described surgery for stones in the bladder, cataract removal  and caesarian section.

In Europe, surgery was not a very popular profession yet. It was looked down upon.  In the days prior to the discovery of anaesthesia, speed was the criterion in surgery.  The patient was pinned down after being given a stiff dose of rum along with opium, cannabis or hyoscyamus.  There were people to time the surgery with a watch as though it were a race, to find out who was capable of performing surgery fastest.

Amputation used to be carried in less than a minute.  One surgeon prided himself in doing a surgery inside the skull, in just seven minutes.  Stone in the bladder was a common ailment and there were surgeons styled lithotomists who used to remove the stones, some in just 10 seconds. It may be mentioned that Lousis XIV, Emperor of France, suffered from a stone in the bladder.

There were some lithotomists who would hide a stone in the pocket and dramatically produce it after surgery to give the impression that it had been removed from the patient.  They would collect the fees and disappear only to reappear the next day to repeat the trick in the next town.

The myth about a ‘good’ surgeon:

Surgeons then used to practise going about with their instruments in their coat pockets.  The coats were nearly always blood-stained and the more stained the better was the impression about the surgeon.  It had become a status symbol.  They were not aware that this was the greatest source of sepsis.  Chamberlein, an obstetrician, who discovered the forceps to deliver a baby, always used to carry the forceps hidden inside the folds of his coat lest somebody discover the nature of the forceps.

Though wars had contributed to surgery, bullet injuries caused during battle were often treated by cauterizing the wound with carbolic acid with devastating effect.  This could lead to severe destruction of tissues.

A French surgeon, Ambrose Pare, was the first to end this nefarious practice.  He treated the wounds by dressing them without application of cautery and the wound healed well and faster. His humility was there for all to see, when at the height of his popularity, he said. “I treat the patients.  God heals them.”  It was Florence Nightingale who added that feminine touch of compassion and made nursing a profession of grace and dignity.

Pic courtesy: Coastnow

Yet, the surgeons were looked down upon. There were not a part of the Royal College of Physicians.  The surgeons were referred to as Misters and not Doctors (even today the Fellows of the Royal College of Surgeons on their own prefer to be referred to as Misters).  The surgeons were tied up with the barbers till the late 19th century, possibly because both earned their livelihood by cutting!

Infection invariably occurred in the wounds after surgery and the patient would be ill. He would be ill till the pus made its way out.

During the renaissance period, science also marched ahead in rapid strides along with art.  Leonardo da Vinci studied anatomy for the sake of art.  Michelangelo was another artist who expounded human anatomy again for art.  A breakthrough in dissecting the human body was made by Vesalius, a surgeon-anatomist of Padua, Italy. The craze for dissection assumed serious proportions. Body-snatching from the graves became a popular pastime of some of the criminals of the 18th century.  The bodies were sold to anatomists for dissection.

Three major breakthroughs occurred about this time. Louis Pasteur discovered in 1857 that infection was due to germs.  It was in 1683, 200 years earlier, that Leeuwenhock, a lens grinder, discovered for the first time these germs under the microscope.

He was amazed at the sight of these germs and called them animalcules.  In 1846 Semmelweiss recognized the importance of cleanliness to avoid such an occurrence of infection by just washing of hands after attending toe ach case. His work has however not given due recognition and tragically he ended up in a mental asylum.

Discoveries in the field of surgery:

William Harvey established the role of the heart and circulation of blood in the in the body.  Surgeons were now undergoing a metamorphosis to become scientists. In England, the Barber-Surgeons company which was formed in 1540 was dissolved and the surgeons broke free in 1745. the Royal College of Surgeons was formed in course of time. John Hunter, Billroth, Kocher were some of th earlier pioneer surgeons who had become innovative in developing surgical techniques.

At this stage, two great discoveries changed the concept of surgery. Morton demonstrated that ether could make a patient unconscious and he could be operated upon. The Massachusetts General Hospital still remembers and honours Morton by inviting the visitors to the Ehter hall.

Laughing gas (nitrous oxide) was another anaesthetic agent which became very popular, and because of the euphoria it created, a number of doctors got addicted to it. Laughing gas parties were not uncommon.  The art of anaesthesia has made great strides since.

Anaesthetic techniques had become so safe and reliable that surgery lasting 24 hours are now being performed with no risk. Of course other factors such as maintaining the fluid level in the body, the salt levels and monitoring throughout the surgical procedure contributed a lot towards making surgery safe.

surgery in summer

The other major improvements was the recognition of the need for cleanliness and antisepsis.  This was stressed by Joseph Lister, who performed surgery after spraying carbolic acid in the operation theatre.  Infection after surgery dropped to very low levels.

Allergy to carbolic acid made Halstead, another famous surgeon at Baltimore, introduce the usage of gloves during surgery, since his staff nurse, an efficient assistant, developed allergy Gloves became part of the armamentarium in the theatre.  The romantic side of the story was that the nurse would later become Mrs.Halstead!

Blood transfusions, antibiotics and the quality of anaesthesia have all changed the picture much. Antibiotics have given an enormous boost towards the prevention of infection, till recently the biggest killer in the post-operative period.  Today with all the sophisticated electronic instruments available in the theatre to monitor the patient’s blood pressure, pulse, temperature, oxygen level in he blood, electro-cardiogram etc., surgery has become quite safe.  It may be safer to have surgery in such a theatre than crossing the Mount Road during peak hours!

Where the surgeons dreaded to wield a knife upon a patient a hundred years ago, today organs like the brain and heart, are being operated upon with ease.

Destructive surgery has been replaced by constructive surgery.  Surgery to reduce fat, surgery to change the shape of the nose and surgery to correct baldness are being commonly done today.  Cosmetic surgery, a surgery of luxury, has come to existence.

Organs like kidney, liver and the heart are being replaced.  Artificial organs are round the corner.  Surgery for transplantation of organs from animals like baboons and pigs has started, with its own problems of ethics.  Surgery is being performed for birth defects when the baby is still inside the protective cavity of the uterus.

The saga of surgery goes on.  It has played no small role in curing patients who had no hope whatsoever till recently as 50 years ago.