From Brutal Craft to Modern Miracle: A History of Surgery

Early Surgery: A Brutal Craft

• Surgery in the past was a brutal craft, far removed from the modern, skilled practice it is today.
• Baby Travis Long undergoes a major operation at Boston Children's Hospital to correct malformed heart vessels.
• Modern surgery is a team effort involving anesthetists, technicians, and specialist nurses.
• Surgeons of the past took great risks, learning through failure and defying conventional wisdom.

The Operating Theater of the 1830s

• Operating Room setting:
  • Porters held patients down instead of anesthesia.
  • Students and visitors watched operations.
  • Sawdust covered the floor to absorb blood and vomit.
  • No ventilation or plumbing.
  • Surgeons washed hands only at the end of the day.
  • Surgeons wore blood-stained frock coats, symbolizing seniority.
• Speed was crucial due to the lack of anesthesia.
• Surgeons needed nerves of steel to operate on screaming, struggling patients.
• Many aspiring surgeons couldn't handle the gruesome reality.

The Surgeon's Origins

• Surgery was initially a brutal craft learned through apprenticeship.
• Surgeons were often barbers, using sharpened instruments.
• Surgeons were distinct from physicians and not considered doctors (hence "Mister" in British surgery).
• The term "surgeon" comes from the Greek word for hands.
• Physicians (often clerics) avoided getting blood on their hands.
• Surgeons were manual workers assisting physicians.

Military Surgery: The Road to Respectability

• Battlefield injuries forced surgeons to expand their skills.
• War wounds, even minor ones, were extremely dangerous due to infection.
• Amputation was a common solution to prevent infection.
• The correct way to finish the operation was to dip the stump in boiling oil or cauterize wounds with hot irons.
• Amboise Pare, a 16th-century military surgeon, accidentally discovered that boiling oil was not the best treatment.
  • He ran out of oil and used a bland mixture of egg yolks instead.
  • Patients treated with the mixture fared better than those treated with boiling oil.
• Pare's humane approach improved the calling's brutality, gaining him recognition.

Amputation in the 1830s (A Gruesome Demonstration)

• Tourniquet applied to the thigh or pressure on the femoral artery.
• Assistants held the patient down.
• Quick sweeps with a knife to create skin flaps.
• Saw used to amputate the leg.
• Amputated leg thrown into sawdust.
• Thirty seconds was a good time for amputation.
• Even if the patient survived the surgery, infection or bleeding could be fatal.
• This scene represented the best scientific surgery had to offer 150 years ago.

Limited Surgical Repertoire

• Few patients submitted to surgery due to the agony.
• Common operations included Cesarean sections and cutting for bladder stones.
• Bladder stones were common and caused terrible pain.
• Cutting for stones was done without anesthesia and had a high mortality rate.
• Cesarean sections were performed without anesthesia.
• Originally, Cesarean sections were performed on dead mothers to save the fetus.
• Cesarean sections with survival of both mother and fetus were terrifying procedures.

Barriers to Surgical Advancement

• Three main barriers to be overcome:
  • Control of blood loss
  • Elimination of surgical infection
  • Conquest of pain
• Methods to assuage pain:
  • Brandy to get patients drunk
  • Laudanum to induce dizziness
  • Hypnotism and mesmerism
  • Alcohol, morphia, and other heavy drugs
  • Boxers to knock people out before operations (16th century)
  • Military surgeons had soldiers bite a bullet during amputation.

Ephraim McDowell's Ovariotomy (1809)

• Ephraim McDowell performed an ovariotomy in Danville, Kentucky.
• Patient: Mrs. Jane Todd Crawford, suffering from a large ovarian tumor.
• Mrs. Crawford traveled 60 miles on horseback to reach McDowell.
• An angry crowd threatened McDowell if the patient died.
• McDowell made a nine-inch incision and removed 15 pounds of gelatinous substance and a 7.5-pound sac.
  • $incision = 9 inches$
  • $tumor = 15 pounds$
  • $sac = 7.5 pounds$
• The operation lasted 25 minutes without anesthesia.
• Mrs. Crawford lived to 78 years old.
• Her suffering could have been reduced with nitrous oxide, researched nine years prior by Humphrey Davy.
• Davy's book went unnoticed by surgeons due to its obscure title.

The Discovery of Anesthesia

• Nitrous oxide (laughing gas) and ether were inhaled for fun.
• Dentist William Morton realized ether's pain-killing effects.
• Morton demonstrated ether anesthesia at Massachusetts General Hospital during an operation by Professor John Warren.
• Gilbert Abbott, a young boy, underwent a minor operation with ether anesthesia.
• Morton administered ether using a simple glass sphere with a sponge.
• Abbott felt no pain during the cyst removal.
• Warren declared, "Gentlemen, this is no humbug."
• October 1846 is a significant date in the history of medicine.
  • Before: Screams and cries in the operating theater.
  • After: Peace and quiet of modern surgery.

Early Adoption of Anesthesia

• Warren used anesthesia in major operations.
• Report in The Lancet (London) brought it to Robert Liston's attention.
• Liston, a senior surgeon at University College Hospital, was known for his speed and strength.
  • Fastest amputation time: 28 seconds (also removed assistant's fingers and patient's testicle).
• Liston used ether anesthesia for an amputation on Frederick Churchill.
• Liston called it a "Yankee dodge" to render men insensible.
• The amputation took 28 seconds.
• Churchill initially rejected the procedure but was carried away.
• Liston declared that the "Yankee dodge beats mesmerism hollow."

Chloroform

• Ether was effective but unpleasant.
• James Young Simpson, an Edinburgh obstetrician, experimented with new chemical substances.
• Simpson and his friends tried chloroform and found it far stronger and better than ether.
• Chloroform was first used on a patient giving birth to a girl, who was named Anesthesia.
• Chloroform had drawbacks, including sudden unexpected deaths.
• Patients stopped breathing when given too much chloroform.
• Most anesthetists returned to ether, which remained the leading anesthetic for a century.

The Impact of Anesthesia

• Surgeons quickly adopted anesthesia, realizing it relieved pain and provided more time.
• James Syme of Edinburgh used the extra time to perform more complex procedures.
• Syme demonstrated that diseased bone could be pared away and the joint reconstructed instead of amputating the entire limb.

The Problem of Infection

• Anesthesia exposed the second major barrier to surgical advance: infection.
• Surgeons were familiar with sepsis, putrefaction, and hospital gangrene.
• Mortality rates could reach 100%, leading to hospital closures or burning.
• The cause was unknown and attributed to miasma (vapors).
• The miasma was actually bacteria on the surgeon's hands.
• Simple operations could lead to gangrene and streptococcus infection.
• Surgeons went from filthy dissecting rooms to operating theaters without cleaning up.
• The concept of bacteria and germ theory was not understood.

Lister and Antiseptic Surgery

• The period between ether discovery and Lister's work was a "black period" of surgery due to terrible results.
• Chemist Pasteur discovered bacteria and their role in spreading disease.
• Joseph Lister, professor of surgery in Glasgow, sought to poison the bacteria.
• Lister used carbolic acid (phenol) to kill microbes, inspired by its use in sewage works.
• Crucial experiment: James Greenlees, a child with a compound fracture, was treated with phenol instead of amputation.
• The wound healed without infection.
• Lister collected 11 compound fractures, with 9 patients walking out of the hospital with intact limbs.
• Lister's operating room used a damp mist of carbolic produced by a spray pump to combat airborne bacteria.

Resistance to Lister's Ideas

• The carbolic regime was not quickly adopted due to doubts about its necessity.
• Carbolic acid could damage tissue.
• Some surgeons thought it harmed patients.
• America was slow to adopt the techniques.
• A conservative faction resisted change.

Halsted and Surgical Gloves

• William Halsted of Baltimore adopted Lister's ideas.
• Halsted's nurse, Caroline Hampton, was allergic to carbolic acid.
• Halsted contacted Goodyear Rubber Company to make her rubber gloves.
• Halsted and Hampton married the following year.
• These were the first surgical gloves, initially to protect the nurse's hands.
• Later, gloves were universally adopted to protect patients from the surgeon's hands.

Koch and Aseptic Technique

• Robert Koch identified bacteria species and their role in wound infection.
• Koch proved that bacteria from surgeons' hands caused fever and death.
• Harmful organisms had to be prevented from reaching the patient's wound.
• Boiling was far more effective than carbolic acid.
• The focus shifted from antisepsis (killing existing infections) to asepsis (creating a sterile field).
• Aseptic technique involves masks, gowns, and sterile equipment.

Changes in the Surgical Environment

• Surgeons were slow to change their ways.
• Operations gradually moved from wards to designated hospital rooms.
• Special operating room clothes became standard.
• Large amphitheaters with audiences in everyday clothes increased infection risk, but they were needed for demonstration.
• Theaters disappeared as surgery became less exciting (patients survived more often).
• Holsted's operating room used gloves as an aseptic precaution.
• Surgeons wore hats due to hair being a source of bacteria.
• Masks were adopted, first by surgeons, then by everyone in the operating room.

Sterilization Techniques

• New technology backed up changes in the surgical environment.
• Systems developed for sterilizing everything contacting the patient's wound.
• The steam autoclave was the best method.
• Instruments could also be sterilized by soaking in chemicals or using gas ovens with bactericidal fumes.

The Era of Surgical Expansion

• Surgeons began opening the abdomen more frequently.
• Heroic operations became widespread.
• Sometimes successful, but sometimes encountering a mysterious problem: shock.

The Enigma of Shock

• Shock was recognized during the Civil War.
• Stonewall Jackson's symptoms were described as a classic example of shock.
  • Pale, gasping, poor circulation.
• Initially, shock was considered a psychological response to injury.
• It's due to blood loss which causes blood volume to drop below a critical point.
• Surgeons were unsure how much blood was being lost.
• There was no way to replace lost blood.

Early Blood Transfusions

• The first blood transfusion was from animals to humans (lambs) in 1667 by Richard Lower.
• The idea was abandoned after a French doctor was sued for a patient's death.
• The first human-to-human transfusion was in 1818 by Guy's Hospital.
• Some transfusions were successful, but many were disastrous due to incompatible blood types.
• Karl Landsteiner explained blood groups in 1900, discovering that red cells from one group could be damaged by the serum of another.
• Compatibility testing became possible.
• Crude early transfusions connected donor and patient by a tube.
• Syringes were used to draw and inject known amounts of blood.
  • $Known amount of Blood$

Blood Transfusions in World War I

• The First World War created a need for blood transfusions.
• Sodium citrate was used as an anti-clotting chemical, allowing blood to be stored for later transfusion.
• Direct methods were no longer necessary.
• After death, blood could be kept for several days.
• Thousands of transfusions were given.
• By the early 1930s, people donated blood freely through the Red Cross as a patriotic duty.

Overcoming Barriers and Specialization

• Pain, infection, and blood loss could be overcome by expert surgeons.
• Surgeons began to specialize.
• Harvey Cushing specialized in brain surgery, despite high mortality rates (70%).
• Cushing controlled bleeding with artery clamps and used a toothed wire to saw through the skull.
• He used diathermy to seal blood vessels and monitored blood pressure.
• Cushing transformed brain surgery outcomes.

Cushing's Techniques and Operating Room

• Cushing's brain surgery technique was highly respected.
• Two colleagues filmed his 2000th operation, a pituitary gland tumor removal.
• Aseptic techniques were strictly observed.
• Operations were often performed in complete silence to minimize infection risk.
• The operating rooms at the Brigham Hospital were open and pleasant.
• Cushing used local anesthetic to keep the patient unaware.
• Cushing reduced the death rate following brain tumor surgery from 70% to 4%.
  • $Initial = 70$
  • $Final = 4$

World War II: A Catalyst for Change

• Ordinary surgery was transformed in even small hospitals during WWII.
• Large numbers of wounded led to the development of penicillin to kill bacteria inside the body.
• Postoperative infection became less menacing.
• Blood transfusion services rapidly expanded.
• Blood could be safely stored for weeks.
• Blood transfusion went from "guild of the gallon" to large-volume transfusions (2-5 liters).

Anesthesia Advancements

• A crash program trained anesthetists to staff emergency hospitals.
• Shortage of blood and inexperienced anesthetists at Pearl Harbor led to high mortality rates due to the use of Pentothal, which lowers the blood pressure of patients in shock.
• Lessons were learned, and anesthetists specialized after the war.
• Drugs like ether came under attack.
• Ether anesthesia saturated body tissues, causing long recovery times.
• Ether irritated the lungs which increases the likelihood of pneumonia if coupled with abdominal operations.

Muscle Relaxants and Curare

• New specialists questioned the need to saturate patients with ether.
• Muscle relaxation required large doses of ether.
• Curare, a muscle relaxant from the Amazon jungle, was introduced in the 1940s, and enabled anesthetists to achieve effective muscle realaxation while minimizing general anesthesia levels and risks..
• Curare paralyzed muscles, but anesthetists could manage breathing.
• Only light anesthesia was needed with curare, minimizing damaging effects.
• Recovery was almost immediate.
• Modern anesthesia, antisepsis, blood transfusion, and antibiotics transformed surgery.

The Golden Age of Surgery

• A gruesome and dangerous craft became a respected branch of medicine in about 100 years.
• Surgery entered its golden age, penetrating previously forbidden territory like the heart.
• At Boston Children's Hospital, baby Travis's heart was successfully reconstructed after 5 hours of surgery.
• Next time on Nova, the pioneers of heart surgery.

The Pioneers of Cardiac Surgery

• Cardiac surgery required enormous self-confidence and risk-taking.
• Some surgeons connected sick children to parents acting as human heart-lung machines.
• Said of one surgeon that his name would go down in history as the first surgeon who ever developed an operation with a 200% mortality.
• Next time on NOVA, Into the heart.