said the body consisted of five organs: heart, lungs, liver, kidney and spleen. We all have heard about acupuncture; the Chinese also used hydrotherapy (i.e., cold baths for fever) and had a great pharmacopoeia of herbal medicines, many of which are still used today, such as castor oil, camphor, and iron for anemia.
Western Medicine progressed slowly over several thousand years from Early Greece with Asculapius slowly drifting away from the supernatural. By the fourth century B.C., Hippocrates, often called the father of medicine, had written his “Aphorisms” (the best known being the first: “Ars Longa, Vita Brevis Art is long and life short”) with many descriptions of observations and diagnosis, but only the most basic in the way of surgical intervention. He left us the famous Hippocratic Oath, which has been stated by graduating medical students for many years. I include it for you to peruse, since it is universally known about, but rarely seen.
“I swear by Apollo the Physician, and Asclepius, and Health and Allheal, and all the gods and goddesses...to reckon him who taught me this Art equally dear to me as my parents, to share my substance with him, and to relieve his necessities if required; to look upon his offspring in the same footing as my own brothers, and to teach them this art, if they shall wish to learn it, without fee or stipulation, and that by precept, lecture, and every other mode of instruction, I will impart a knowledge of the Art to my own sons, and to those of my teachers, and to disciples bound by a stipulation and oath according to the law of medicine, but to none others. I will follow that system of regimen which, according to my ability and judgment, I consider for the benefit of my patients, and abstain from whatever is deleterious and mischievous. I will give no deadly medicine to anyone if asked, nor suggest any such counsel; and in like manner I will not give to a woman a pessary to produce abortion... Into whatever houses I enter, I will go into them for the benefit of the sick, and will abstain from every voluntary act of mischief and corruption; and, further from the seduction of females and males, of freemen and slaves. Whatever, in connection with my professional practice or not in connection with it, I see or hear, in the life of men which ought not to be spoken of abroad, I will not divulge, as reckoning that all should be kept secret.”
Another Greek, Galen, in the first century A.D. postulated an entire body of medicine, much of it false, which was to be followed, essentially unchallenged, for fifteen hundred years. He stressed the importance of anatomy but, since dissection was forbidden, the anatomy of the day was often poorly conceived or completely in error.
The Muslim empire produced the genius of the Persian, Rhazes, who wrote many texts and actually distinguished between measles and smallpox. He was later followed by another Persian, Avicenna, who wrote the “Canon of Medicine.” But as much as these tomes expounded on diagnosis and medications, there was a surprising paucity of knowledge in the area of surgery.
You may ask “Why?” and the answer is actually quite simple. A good basis for surgery depends on a firm knowledge of accurate human anatomy. Up to this point, dissections were carried out on animals or on parts of human beings; the anatomical knowledge was often based on centuries-old texts, which were often incorrect or flights of fancy of the author. During the late fourteenth and fifteenth centuries new anatomy texts appeared and were much more complete than those we had seen for two thousand years. In 1543 Andreas Vesalius published his “De Humani Corporis Fabrica” (On the Structure of the Human Body), which was based on careful human dissection, and the diagrams are, for the most part, as accurate as anatomical treatises of today. His work was followed by a host of books on anatomy and physiology, and this may well be considered the beginning of modern surgery. Within the next one hundred years there was an explosion of scientific and cultural advancement with the likes of the genius philosopher Rene Descartes (“I think, therefore I am.”), Isaac Newton (Laws of Physics—remember the apple falling on his head?), Galileo (the telescope), Robert Hooke and Anton Leeuwenhoek (the discovery and use of the microscope), and the great discovery and publication of “De Motu Cordis” on the circulation of blood and the function of the heart by William Harvey (1628).
Surgery then took great strides forward when the physician could understand the anatomy and some physiology, and attempt to correct its problems. Likewise, there were advances in the parallel field of medicine, such as Edward Jenner's description of Smallpox inoculation in 1796, Johannes Muller's description of physiology or how things work in the 1830s, and the description of the bacterial cause of disease by Semmelweiss (child bed fever—women dying of infection after being examined by physicians with dirty hands) and Robert Koch (who discovered the organism that causes tuberculosis).
The most famous contribution to surgery and its advancement came with the discovery of anesthesia by several individuals, including Crawford Long, Horace Wells, and William Morton (who first demonstrated a painless operation at the Massachusetts General Hospital in 1846). Nitrous oxide, ether, and chloroform became the drugs of choice and led to the advancement of more complex surgery. In the end of the nineteenth century, Conrad Roentgen's discovery of Xrays led to the opening of new horizons in the field of diagnostics.
With the twentieth century came the development of chemotherapy for syphilis by Paul Ehrlich, followed soon by the discovery of Sulfonamide and the discovery and use of Penicillin by Alexander Fleming in 1928, and its purification and widespread use at Oxford by Howard Florey and Ernest Chain, ten years later.
Liberated from the time-warped problems of pain and infection, and armed with a host of new techniques, surgery came of age in the twentieth century. I won't go into much detail about the advances, but suffice it to say that because of the two World Wars, medicine and surgery were “forced” to make great strides, including immunological advances and a whole host of support technologies including the invention of plastics and inert metals which could be used in surgery. Advances in technique, that started during the last decade of the nineteenth century by such surgical giants as the Viennese Theodor Billroth (abdominal surgery, including ulcer surgery on the stomach) and William Halsted (the radical mastectomy), propelled surgery into the twentieth century and the development of neurosurgery by Harvey Cushing, and thoracic surgery (removal of part or all of a lung) by Harold Brunn, Rudolph Nissen, and Evarts Graham. By 1944, John Garlock in New York City was able to successfully remove an entire esophagus for cancer using part of the colon as an interposition “graft.” In the early 1920s and 30s surgeons began operating on the heart, but successes were rare and true cardiac surgery didn't start until the 1940s with the early development of extracorporeal circulation—first in animals, then in humans—by John Gibbon Jr. Soon it was possible to put the heart completely at rest, stopping the “beating,” and allowing surgeons to remove and replace damaged heart valves and bypass blocked coronary arteries. Alexis Carrel had perfected the suturing of blood vessels back in 1905, and vascular surgery has made great strides since that time. This led to experimentation with organ transplantation, and victories over rejection came with greater understanding of immunology and immunosuppression. In 1967 the world was made aware of the first heart transplant by Christian Barnard in South Africa, a procedure that has now become routine and standard at medical centers throughout the world.
This has been a very brief outline of four thousand years of medical and surgical history, and we should be happy that we live at a time when most of the pain and suffering of surgical intervention has been all but relieved. Let us move on now to understand more about the training that these physicians have in preparation for taking the patient into consultation and the scalpel in hand.
Chapter 3
EDUCATING THE SURGEON
In thirteen hundred and forty two
To become a doctor, there was little to do.
Climb a hill, raise your arms in a humble position
Yell once and dance and...you're a physician.
The training today is much more intense,
The course
