as the words were quite simple,
and the subject and writing were striking.
So here is the tome that I've written for you,
it's been more than a minuscule chore.
And if when you're through, you don't like it, don't tell me,
or I will be hurt to the core.
The major texts of surgery, written for students and physicians, are usually upwards of two thousand pages and filled with complex medical vocabulary, and this makes it all but impossible for the layman to understand the procedures and the bases for surgical practice. It is my intent to give a simplified but comprehensive presentation of surgery for the general populace.
The objectives will be to offer information and guidance to patients and family about the most common surgical procedures, which physicians have often failed to make sufficiently clear to those whom they are treating.
This is not a textbook for surgeons or students, but a guide for all individuals who want to understand the basics of surgery. While the focus will be primarily on what is called general surgery, I will also include sections on the most common sub-specialties, such as Vascular (dealing with blood vessels), Cardiac (heart surgery), Pediatrics, Orthopedics, Neurosurgery (Brain and spinal cord) and several others.
I am not interested in giving you only a reference text, but in presenting you with a pleasant read about the past, present and future of surgery, hopefully in such a way that it is not just filed away on a shelf, only to be used when one has a surgical problem or question. A study of the human body, its function, failings, and surgical correction can be fascinating, even exciting, when set forth in the appropriate way. I hope this book will let you marvel at the beauty, the complexity, and the ability of the human body to be repaired in the hands of the trained physician, and perhaps when you finish you may glean some of the fascination and excitement I have found in my day in and day out experience as a practicing surgeon.
Chapter 2
HISTORY OF SURGICAL PROCEDURES
When Will and Ariel Durant wrote their Story of Civilization
In thousands of pages and eleven large books, 'twas a massive publication
But using my art of brevity, I'll write this medical history, as I should,
And only use eight pages...’cause, damn’ I'm really good!
Let us look through a mythical telescope back to the earliest days of creation and see what we can conjure up about the ability of primordial creatures to take care of themselves. Imagine some slimy thing crawling across the ocean floor, getting bitten by another slimy thing or somehow becoming injured. Our little creature had two outlooks: dying or somehow repairing the damage and surviving, albeit probably for a shorter period of time. Now we can postulate that the repair took place, most assuredly without conscious understanding by Mr. Slime, either by secretion of some internal healing substance or by an instinctual reaction by the organism which caused it to repair the injury. Sound farfetched? Well, maybe, but this same process is going on millions and millions of years later throughout the animal kingdom of today. Creatures have some inherent ability to heal themselves without conscious awareness, and this type of healing has led to the eventual development of present day medicine and surgery. Big step in reasoning, you may say. Possibly, but it leads us to that day millions of years ago when man first became able to reason, even at the most fundamental level.
When a “lower” species was cut or injured, it depended on the body to heal itself. Blood flowed from a wound until the blood vessel went into spasm and allowed the coagulation system to form a clot. Then one day a primordial humanoid found he could stem the flow of blood by applying pressure to the bleeding site...and surgery was born! He then showed his discovery to his cohabitants, who showed it to their offspring, and so on through the ages.
The beast of the forest that injured itself and developed an abscess, somehow knew through instinct to chew upon the area until it opened and drained. Drainage, even today, is the treatment of an abscess or locked in infection. But it took the conscious intellectual human mind to look at the abscess on a limb and know that it must be poked with a sharp stick in order to drain and allow him to survive.
And because man could not understand the reasoning behind his sickness he probably attributed it to spirits, spells (put upon him by other people, animals or demons), or the unknown and thereby began to perform incantations along with his early surgical and medical exploits. So now let us put away this mythical scope and jump to the dawn of civilization. We know that, in ancient Peru, France, and Britain, human skulls have been discovered showing that trephining or trepanning was done, which consisted of making a one- to three-inch hole in the skull. This apparently allowed evil humors to get out, and scientists examining the skulls say that the “patient” often lived long after the procedure! This practice may still exist among some primitive peoples of the world. So we can look at aboriginal or South American tribal cultures and possibly see what the prehistoric or primitive man used for healing. This included vegetable drugs, binding wounds and removing foreign objects (such as sticks or arrows!), and also included charms, talismans and incantations. A great deal of early medicine was done by the “medicine men” and witch doctors with much of the result being the effect of fear or belief, such as we see in placebo effects even today.
Now, in reviewing medical and surgical history, there are great gaps highlighted by the masters of each age, usually individuals who collected the history of medicine to that date and wrote it down as their own treatise. Surgical care progressed very slowly over the early millennia and over the last several centuries. To give you a brief background of historical highlights is to give you the names of the individuals who made these compilations in the early periods and to note the innovators and geniuses of the last five hundred years who made the sentinel achievements whereby medicine and surgery took giant steps forward.
Let us start with the invention of writing and the information found on clay tablets, which we call the Code of Hammurabi, apparently written by a Babylonian king 3800 years ago. One such pillar tablet is preserved in the Louvre Museum in Paris and gives rules about treatment and also the punishment of physicians whose patients die in the course of treatment —they would have their hands cut off! (Fortunately, our rules are somewhat less severe today.) And in ancient Babylon the sick were placed in the street for anyone to offer help or information about treatment (the first curbside consultations!). Sacrifice and incantation was a major part of medicine.
Moving on to ancient Egypt we find the name Imhotep, a chief minister of King Zoser, who not only designed the pyramid but was an early “healer” and became immortalized as the Egyptian God of Healing. The Edwin Smith and Ebers Papyri discovered in the eighteen hundreds in Egypt, gave voluminous information about treatment, incantations, and notably a long treatise on the care of wounds and battle injuries.
In India we find ancient writings, two to four thousand years old, about a medical system called Ayurveda, mostly spiritual; this was followed from 800 B.C. through the first millennium A.D. by the more advanced ideas of two individuals, Caraka (an internist) and Susruta (a surgeon) with writings about wounds, tumors, and abscesses as well as medical diseases. Early Hindu surgeons drained abscesses, removed simple tumors and did crude treatment of fractures and sewing up of wounds.
In China, the culture extends back several thousand years with traditional Chinese Medicine and its dualistic theory of the Yin (female, dark and passive the earth) and the Yang (male, light and active the heavens) principles. The human body was made up of five elements (fire, water, earth, metal and wood) and these, with balances between yin and yang, determined health or illness. The Chinese described tying off (ligation) of arteries,
