A short history of surgery

Prof. Harold Ellis CBE MCh FRCS

There is no doubt that the first surgeons were the men and women who bound up the lacerations, contusions, fractures, impalements and eviscerations to which man has been subject since appearing on Earth. Since man is the most vicious of all creatures, many of these injuries were inflicted by man upon man. Indeed, the battlefield has always been a training ground for surgery. Right up to the 15th century, surgeons dealing with trauma were surprisingly efficient. They knew their limitations—they could splint fractures, reduce dislocations and bind up lacerations, but were only too aware that open wounds of the skull, chest and abdomen were lethal and were best left alone, as were wounds involving major blood vessels or spinal injuries with paralysis. They observed that wounds would usually discharge yellow pus for a time; indeed this was regarded as a good prognostic sign and was labelled ‘laudable pus’.

The 15th century heralded a new and dreaded pathology—the gunshot wound. These injuries would stink, swell and bubble with gas. There was profound systemic toxicity and a high mortality. Of course, we now know that this was the result of clostridial infection of wounds with extensive anaerobic tissue damage caused by shot and shell. The surgeons of those times were shrewd clinical observers but surmised that these malign effects were due to gunpowder acting as a poison, for it was not until centuries later that the bacterial basis of wound infection became evident. At that period the remedy was to destroy the poison with boiling oil or cautery. Boiling oil was the more popular since it was advocated by the Italian surgeon Giovanni da Vigo (1460–1525), the author of the standard text of the day, Practica In Arte Chirurgica Compendiosa. These treatments not only produced intense pain but also made matters worse by increasing tissue necrosis.

The first scientific departure from this barbaric treatment was by the great French military surgeon Ambroise Paré (1510–1590) who, while still a young man, revolutionised the treatment of wounds by using only simple dressings, abandoning cautery and introducing ligatures to control haemorrhage. He established that his results were much better than could be achieved by the old methods.

Ignorance of the basic sciences behind the practice of surgery was slowly overcome. The publications of The Fabric of the Human Body in 1543 by Andreas Vesalius (1514–1564) and of The Motion of the Heart by William Harvey (1578–1657) in 1628 were two notable landmarks.

Surgical progress, however, was still limited by two major obstacles. First, the agony of the knife: patients would only undergo an operation to relieve intolerable suffering (for example from a gangrenous limb, a bladder stone or a strangulated rupture) and, of course, the surgeon needed to operate at lightning speed. Second, there was the inevitability of suppuration, with its prolonged disability and high mortality, often as high as 50% after amputation. Amazingly, both these barriers were overcome in the same couple of decades.

In 1846, William Morton (1819–1868), a dentist working in Boston, Massachusetts, introduced ether as a general anaesthetic. This was followed a year later by chloroform, employed by James Young Simpson (1811–1870) in Edinburgh, mainly in midwifery. These agents were taken up with immense enthusiasm across the world in a matter of weeks.

The work of the French chemist Louis Pasteur (1822–1895) demonstrated the link between wound suppuration and microbes. This led Joseph Lister (1827–1912), then a young professor of surgery in Edinburgh, to perform the first operation under sterile conditions in 1865. This was treatment of a compound tibial fracture in which crude carbolic acid was used as an antiseptic. The development of antiseptic surgery and, later, modern aseptic surgery progressed from there.

So at last, in the 1870s, the scene was set for the coming enormous advances in every branch of surgery whose breadth and successes form the basis of this book.

Approaches to surgical problems

Principal mechanisms of surgical disease

Surgical patients present with disorders resulting from inherited abnormalities, environmental factors or combinations in varying proportions. These are summarised in Box 1.1, as a useful ‘first principles’ framework or aide-mémoire upon which to construct a differential diagnosis. This is useful when clinical features do not immediately point to a diagnosis. This approach is known as the ‘surgical sieve’; however, it is not a substitute for logical thought based on the clinical findings.