A very brief history of surgery

By James Wright, MD, MPH

When confronted with the prospect of their child having an operation, many parents are understandably concerned. Surgery is a serious undertaking and it does carry risks. However, they might take some solace in the fact that their family is experiencing this in modern times.

Surgeons are highly trained, highly skilled, and have often specialized -- meaning they have maximum experience and knowledge about the types of surgery they perform. Millions of surgeries are performed every year without incident saving countless lives. This was not always the case. The incredible success of modern surgery is built on a difficult past of trial and painful error

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Operating in the dark

The first known surgical procedures occur long before people had any real knowledge about the inner workings of the body. Evidence of trephination, the drilling or scraping of holes into the skull to expose the brain, is found as early as the Neolithic era about 10,000 years ago. These operations continue to this day, though not for the same reasons; it is suspected that curing mental illness and seizures were the original purposes for the surgery, these days trepanation is done to allow for access to the brain to perform another operation.

About 3500 years ago, the first surgical texts appear. Many civilizations, including the Egyptians, Indians, Chinese, and Greeks, performed surgeries varying from the simple, such as stitching a wound, to the complex, such as a caesarian section. The procedures were commonly carried out by priests rather than physicians who mostly restricted themselves to administering medicines and advice.

How successful these operations were is not known exactly, but consider some of the major obstacles facing patient and surgeon. Anesthetics, if used at all, were probably equivalent to asking the patient to drink a bottle of scotch before lying down on the operating table. And once a surgeon started cutting, the typical method to control bleeding was cauterization: sealing blood vessels with extreme heat.  Think ‘small branding iron’. Although this worked in an immediate sense, the technique was painful and destructive to surrounding tissues, often causing addition problems. Moreover, while some cultures understood that cleanliness was a good idea, post operative infections took the lives of many following a ‘successful’ operation.   

Ignorance, pain, infection, and bleeding

In addition to the problems of pain, bleeding, and infection, there was at least one more big obstacle to successful surgery:  sheer ignorance of the inner structures and functions of the body. Through much of European history at least, learning anatomy was a criminal enterprise. Until the 14^th century, most anatomy texts were not much better than stick drawings or were actually of dog anatomy. The only way to learn anatomy was to obtain bodies – which was considered sacrilegious. But around this time, anatomists at the university in Bologna got permission to dissect bodies (often executed criminals), and began a systematic investigation into body structures and function. They brought in artists, including Leonardo and Michelangelo, who created detailed drawings which were then reproduced into much better medical texts.

Medical and surgical knowledge and skill grew. Previous discoveries made by Arabic scholars were taught and incorporated into the new science. Despite this, physicians still did not do surgeries.  This was left to trained surgeons if the patient was lucky or by barbers. In fact, just about anyone could hang a shingle on their door and call themselves a surgeon. It was not until the problems of bleeding, infection, and pain relief were conquered that the two disciplines joined in a formal manner.

Although tying off blood vessels was not entirely new, this technique was greatly improved by, among others, Napoleon’s battlefield surgeons. As a consequence, bleeding could be much better controlled, especially in non-battlefield conditions. British surgeons began the modern era of anesthesia in the mid 1800’s with the introduction of ether and chloroform. Over time, different substances and procedures made anesthesia more safe and effective. One consequence of pain-free surgery was more procedures being performed. However since the problems of infection had yet to be adequately dealt with, the surgical success rate remained grim.

The march of science is almost never a straight line. Running parallel to these improvements to medicine and surgery were all forms of quackery such as bloodletting with leeches, and basic knowledge about the body was still lacking. Not until the mid 1600’s was it generally accepted that the pumping heart circulated blood around the body. More importantly, understanding the cause of infection and taking steps to prevent it wasn’t even begun to be successfully addressed until the mid 1800’s. The impetus for that discovery was sparked by the habits of midwives, who were more apt to wash their hands than medical students, and was confirmed with the invention of the microscope and the insights it provided to the likes of Louis Pasteur and others.

Modern surgery

Addressing, and in many cases solving the problems of pain, bleeding and infection brings us to the modern era of surgery where surgical techniques were developed and enhanced. Surgery improved as it was formalized as a branch of medicine and was systematically taught and studied at universities. Additionally, many advances can be attributed to the work of battlefield surgeons, who, with an abundance of desperate patients, could attempt things that had never been tried before. But it wasn’t just soldiers and those suffering from trauma who benefited.

In the early 1960’s 80% of infants born with a ‘complete transposition of the great arteries’, a defect that causes the blood to be pumped backwards through the heart and lungs, did not survive their first birthday. However, Dr. William Mustard, working at Toronto’s Hospital for Sick Children, pioneered a new surgery that rerouted the blood. This development led to about 80% of these patients living past their 20^{th8/sup> birthday.}

Since the 60’s, modern medicine has seen everything from artificial hearts to organ and tissue transplants, from laparoscopy to robotic surgery.  With these developments and many more, the number of different types of operations performed has increased but more importantly, so has the success rate.  Moreover, because knowledge of the structures and the function on the different systems in the body has advanced incredibly in the last 100 years let alone thousands, surgeons also have a much better idea of when not to operate.  Evidence now guides the practice of surgery.

In other words, modern parents can not only take solace that their child is having surgery during an era of great surgical skill and knowledge but also in the fact that their child’s surgery is not being performed unnecessarily. 

, FRCSC