Introduction to Surgery

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Slide 1 :

Introduction to Surgery Dr. Roman Pathak Dali University

Slide 2 :

19th Century Rise of Surgery Early 19th century surgery Introduction of Antisepsis Introduction of Anesthesia Rise of the Hospital Role of Civil War Industrialization Professional issues

Slide 3 :

Pre-1800 Surgery Traditionally distinct from physicians Surgery is derived from Greek words for work and hand

Slide 4 :

Surgeons vs Physicians Surgeons Barber-surgeon Guild Often illiterate Apprenticeship Mister Tool central Physicians Physician Guilds More intellectual Attended University Doctor Eschewed use of tools

Slide 5 :

Barber-surgeon Lucas van Leydan The Surgeon and the Peasant 1524 Depicts barber-surgeon

Slide 6 :

Early 19th Century Surgery Surgery was dreaded Patients avoided surgery; pain Mortality was high 19% amputations prior to 1850 Primarily wound treatment Lancing boils Draining abscesses Suturing injuries

Slide 7 :

Surface wound treatments

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Tools of the trade 1846 scarifier 1863 cupping set

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Infection Post-surgical infection so common that pus felt to be sign of healing “Laudable Pus” Gangrene common Stench

Slide 10 :

Surgery and Pain Made surgery more difficult Delayed treatment Patients allowed wounds and tumors to grow and fester Notion of consent was different Drugs like opium, hemp, hashish, whiskey Unpredictable, unsafe Speed essential

Slide 11 :

Surgery and Pain “In case of amputation, it was the custom to bring the patient into the operating room and place him upon the table. [The surgeon] would stand with his hands behind his back and would say to the patient, “Will you have your leg off, or will you not have it off?” If the patient lost courage and said, “No,” he had decided not to have the leg amputated, he was at once carried back to his bed in the ward. If, however, he said, “Yes,” he was immediately taken firmly in hand by a number of strong assistants and the operation went on regardless of whatever he might say thereafter. If his courage failed him after this crucial moment, it was too late and no attention was paid to his cries of protest. It was found to be the only practicable method by which an operation could be performed under the gruesome conditions which prevailed before the advent of anesthesia.”

Slide 12 :

Surgery and Speed Surgeon was a “clock-driven gladiator” Minimize shock and pain Speed at the price of tissue damage

Slide 13 :

19th C Surgery Street clothes Bare hands Unclean and reused instruments Assistants were medical students and junior doctors Often performed at home

Slide 14 :

Anesthesia Horace Wells Dentist Reported use of Nitrous Oxide 1844

Slide 15 :

Anesthesia William E Clarke ether Crawford Long MD 1842 Georgia surgeon Ether

Slide 16 :

WT Morton and MGH WT Morton, dentist October 1846 1st public demonstration of ether Mass General Hospital Not 1st surgical use of ether

Slide 17 :

Demonstration of ether in the Ether Dome, October 16, 1846

Slide 18 :

Chloroform 1847 James Young Simpson

Slide 19 :

Effect of anesthesia on surgery # operations increased Mortality increased Risk assoc’d w/ anesthetics Explosion Underanesthetized and overanesthetized Decreased patient fear Surgery lasted longer

Slide 20 :

Effect of anesthesia on surgery Not adopted immediately or universally Restricted in military Too expensive for charity patients Questioned on moral grounds Obstetrical anesthesia Socio-economic and racial disparities

Slide 21 :

Impact of the Civil War

Slide 22 :

Amputation, c. 1863

Slide 23 :

Impact of Civil War Important training ground Exposure to injuries and infections Value of hospitals

Slide 24 :

Rise of Hospitals During 19th C most surgery performed in the home Mortality 3-5x higher in hospitals Hospitals for charity cases Social stigma

Slide 25 :

Rise of hospitals 1800: 2 hospitals Pennsylvania Hosp New York Hospital 1821: Mass General Hospital #3 1873: 178 hospitals 1909: 4359 hospitals

Slide 26 :

Forces contributing to rise of hospitals Professional Nurses/ anesthetists/ orderlies available Location for teaching/ learning Immigration Urbanization Lack of extended families Poverty/ expense of health care Technology and surgical equipment available

Slide 27 :

Bellevue Hospital, 1880s

Slide 28 :

Infection Post-surgical infection rises in 19thc Crowded hospitals Infection in hospitals Increase in traumatic injuries Hospitalism Gangrene, erysipelas, pyema Associated with large, old buildings Led to new hospital design w/ ventilation and more space

Slide 29 :

Bellevue, 1860

Slide 30 :

Pennsylvania Hospital, 1911

Slide 31 :

Infection control Ignaz Semmelweis 1847 experiments w/ washing hands & instruments in chlorine solution to prevent childbed fever Publishes in 1860 Impact ignored

Slide 32 :

Louis Pasteur French chemist 1857 and 1860 Demonstrated that fermentation is caused by a living organism (not a chemical reaction) Refuted spontaneous generation Louis Pasteur

Slide 33 :

Antisepsis and Joseph Lister British Surgeon Influence: Pasteur Pus/ infection caused by microbes in air 1867 introduces Antisepsis Carbolic acid Rinse hands and instruments

Slide 34 :

Antiseptic Surgery Antiseptic Surgery, 1882

Slide 35 :

Antisepsis Coincides with heightened public interest in cleanliness and hygiene Erratically adopted, especially in America Solution caustic Many physicians opposed germ theory By 1880s, generally though not uniformly adopted Lister didn’t wash his hands; operated in street clothes

Slide 36 :

Robert Koch

Slide 37 :

Robert Koch 1843-1910, German 1876: discovers anthrax 1882: mycobacterium tuberculosis Demonstrates bacteria have specific etiological relationship to disease

Slide 38 :

Robert Koch, cont’d Made bacteriology clinically applicable refined culture and dye techniques Koch’s postulates Experimental process showing organism A causes disease B

Slide 39 :

Koch’s Postulates, 1882 Organism must be present in all cases of the diseased condition but not in healthy animals Organism must be isolated and grown in pure culture Culture must induce disease experimentally Organism can be reisolated from experimental infection

Slide 40 :

Impact of Germ Theory Idea of disease specificity Allowed possibility of equating disease with an organism Reclassification of disease Dynamic conception of disease

Slide 41 :

Impact of Germ Theory Belief that medicine could fight disease, improve public health provided scientific rationale for public health/hygiene efforts Shifted attention from internal organs to external invaders ironically reinforced prejudices about “outsiders”

Slide 42 :

Impact cont’d Provided theoretical foundation for diagnosis and therapy Specific therapy for infectious diseases Search for vaccines, antitoxins, “magic bullets”

Slide 43 :

Asepsis Introduced by Ernst von Bergmann in 1877 Recognition that hands, body, instruments were more likely source of infection than air Led to sterilization, cleaning patient, handwashing, eventually gloves and masks By 1890s most hospitals used autoclaves However, many surgeries still performed in homes

Slide 44 :

Hayes Agnew, 1886

Slide 45 :

The Agnew Clinic, 1889 (Thomas Eakins)

Slide 46 :

Hahnemann Hospital, 1899

Slide 47 :

1901

Slide 48 :

Mobile, 1904

Slide 49 :

Women’s Medical College, 1903

Slide 50 :

Blossoming of Surgery By 1870s and 1880s surgeons can operate on head, chest, and abdomen 1886: 1st successful appendectomy 1886: MGH abdominal surgery ward Abdomen now available to surgeons 1880s and 90s: Physiological Surgery Conserved tissues, preserved anatomy, careful dissection Compare to slash and speed model

Slide 51 :

Increase in operations MGH 1841-1845: 37 operations/ year 1847-1851: 98 operations/ year 1898: 3700 operations Surgery in 1900 Safer Less painful More invasive Less infection risk

Slide 52 :

“The Century of the Surgeon” 1870-1970 Explosion in surgical techniques New areas of the body accessible Attention to detail and tissue

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