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19th Century Rise of Surgery . Early 19th century surgeryIntroduction of AntisepsisIntroduction of AnesthesiaRise of the HospitalRole of Civil WarIndustrializationProfessional issues. Pre-1800 Surgery. . Traditionally distinct from physiciansSurgery is derived from Greek words for work and hand.
The History of Surgery

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1. The History of Surgery Hughes Evans History of Medicine

3. Pre-1800 Surgery Traditionally distinct from physicians Surgery is derived from Greek words for work and hand

4. Surgeons vs Physicians Surgeons Barber-surgeon Guild Often illiterate Apprenticeship Mister Tool central Physicians Physician Guilds More intellectual Attended University Doctor Eschewed use of tools

5. Barber-surgeon Lucas van Leydan The Surgeon and the Peasant 1524 Depicts barber-surgeon

6. Early 19th Century Surgery Surgery was dreaded Patients avoided surgery; pain Mortality was high 19% amputations prior to 1850 Primarily wound treatment Lancing boils Draining abscesses Suturing injuries

7. Surface wound treatments

8. Tools of the trade 1846 scarifier 1863 cupping set

9. Infection Post-surgical infection so common that pus felt to be sign of healing ?Laudable Pus? Gangrene common Stench

10. Surgery and Pain Made surgery more difficult Delayed treatment Patients allowed wounds and tumors to grow and fester Notion of consent was different Drugs like opium, hemp, hashish, whiskey Unpredictable, unsafe Speed essential

11. Surgery and Pain ?In case of amputation, it was the custom to bring the patient into the operating room and place him upon the table. [The surgeon] would stand with his hands behind his back and would say to the patient, ?Will you have your leg off, or will you not have it off?? If the patient lost courage and said, ?No,? he had decided not to have the leg amputated, he was at once carried back to his bed in the ward. If, however, he said, ?Yes,? he was immediately taken firmly in hand by a number of strong assistants and the operation went on regardless of whatever he might say thereafter. If his courage failed him after this crucial moment, it was too late and no attention was paid to his cries of protest. It was found to be the only practicable method by which an operation could be performed under the gruesome conditions which prevailed before the advent of anesthesia.?

12. Surgery and Speed Surgeon was a ?clock-driven gladiator? Minimize shock and pain Speed at the price of tissue damage The fast surgeon minimied shock and many surgeons boasted that they could amputate a limb in less than 3 minutes. One British surgeon began every operation by proclaiming to onlookers, ?Now gentlemen, time me!? If it was a leg amputation, he would strrangle the femoral artery withone hand and lop the leg off with the other. The average time elapsed was 45 sseconds. The fast surgeon minimied shock and many surgeons boasted that they could amputate a limb in less than 3 minutes. One British surgeon began every operation by proclaiming to onlookers, ?Now gentlemen, time me!? If it was a leg amputation, he would strrangle the femoral artery withone hand and lop the leg off with the other. The average time elapsed was 45 sseconds.

13. 19th C Surgery Street clothes Bare hands Unclean and reused instruments Assistants were medical students and junior doctors Often performed at home This is a picture of The Gross Clinic, painted in 1875 by Thomas Eakins. Eakins was an influential painter in Philadelphia, who became famous for his portraits, paintings of rowers, and medical portraits. He took an anatomy course at Jefferson Medical College from Professor Samuel D. Gross, a distinguished surgeon, anatomist, and medical educator. Gross had written an influential System of Surgery in 1859. The painting is set in the surgical amphitheater. Gross is in command. He is surrounded by surgical assistants, the patient, and the patient?s mother. Tiers of medical students are in the background. Bandages and instruments are in the foreground. The patient has osteomyelitis and Dr. Gross is explaining how to remove a segment of diseased femur. He is receiving chloroform anesthesia. The only real color in the painting is the blood on the patient and the surgeon?s hands. Initial reception: too realistic for polite Victorian society ?It is a picture what even strong men find it difficult to look at long, if they can look at it at all; and as for people with nerves and stomachs, the scene is so real that they might as well go to a dissecting room and have done with it.? (New York Tribune reviewer)This is a picture of The Gross Clinic, painted in 1875 by Thomas Eakins. Eakins was an influential painter in Philadelphia, who became famous for his portraits, paintings of rowers, and medical portraits. He took an anatomy course at Jefferson Medical College from Professor Samuel D. Gross, a distinguished surgeon, anatomist, and medical educator. Gross had written an influential System of Surgery in 1859. The painting is set in the surgical amphitheater. Gross is in command. He is surrounded by surgical assistants, the patient, and the patient?s mother. Tiers of medical students are in the background. Bandages and instruments are in the foreground. The patient has osteomyelitis and Dr. Gross is explaining how to remove a segment of diseased femur. He is receiving chloroform anesthesia. The only real color in the painting is the blood on the patient and the surgeon?s hands. Initial reception: too realistic for polite Victorian society ?It is a picture what even strong men find it difficult to look at long, if they can look at it at all; and as for people with nerves and stomachs, the scene is so real that they might as well go to a dissecting room and have done with it.? (New York Tribune reviewer)

14. Anesthesia Horace Wells Dentist Reported use of Nitrous Oxide 1844

15. Anesthesia William E Clarke ether Crawford Long MD 1842 Georgia surgeon Ether Crawford Long had attended ?ether parties? while a student in Philadelphia Horace Wells became addicted to chloroformCrawford Long had attended ?ether parties? while a student in Philadelphia Horace Wells became addicted to chloroform

16. WT Morton and MGH WT Morton, dentist October 1846 1st public demonstration of ether Mass General Hospital Not 1st surgical use of ether Surgery was to remove a neck tumorSurgery was to remove a neck tumor

17. Demonstration of ether in the Ether Dome, October 16, 1846 Surgeon was John Collins Warren, who removed a vascular malformation from his 20 year old patient?s neck. Operation lasted 10 minutes. Warren afterwards claimed, ?Gentlemen, this is no humbug!?Surgeon was John Collins Warren, who removed a vascular malformation from his 20 year old patient?s neck. Operation lasted 10 minutes. Warren afterwards claimed, ?Gentlemen, this is no humbug!?

18. Chloroform 1847 James Young Simpson

19. Effect of anesthesia on surgery # operations increased Mortality increased Risk assoc?d w/ anesthetics Explosion Underanesthetized and overanesthetized Decreased patient fear Surgery lasted longer In 25 years before anesthesia MGH performed 333 operations (123 amputations); in the 23 years after anesthesia, 1924 operations (1098 amputations). After anesthesia, mortality increased at MGH to 23%. Anesthesia usually administered by medical students or nurses as late as 1895.In 25 years before anesthesia MGH performed 333 operations (123 amputations); in the 23 years after anesthesia, 1924 operations (1098 amputations). After anesthesia, mortality increased at MGH to 23%. Anesthesia usually administered by medical students or nurses as late as 1895.

20. Effect of anesthesia on surgery Not adopted immediately or universally Restricted in military Too expensive for charity patients Questioned on moral grounds Obstetrical anesthesia Socio-economic and racial disparities Only 1/3 amputations at Penn Hosp b/n 1853 and 1862 used anesthesia. WHY WOULD DOCTORS QUESTION THE MORAL USE OF ANESTHESIA IN OBSTETRICS? biblicalOnly 1/3 amputations at Penn Hosp b/n 1853 and 1862 used anesthesia. WHY WOULD DOCTORS QUESTION THE MORAL USE OF ANESTHESIA IN OBSTETRICS? biblical

21. Impact of the Civil War

22. Amputation, c. 1863 Civil war wounds notoriously destructive, due to changes in bullets and the technology of warfare. Amputation was often the only alternative.Civil war wounds notoriously destructive, due to changes in bullets and the technology of warfare. Amputation was often the only alternative.

23. Impact of Civil War Important training ground Exposure to injuries and infections Value of hospitals Dr. Mary Walker, an 1855 Syracuse Medical College graduate, served on the Union Army as an assistant surgeon until her capture.Dr. Mary Walker, an 1855 Syracuse Medical College graduate, served on the Union Army as an assistant surgeon until her capture.

24. Rise of Hospitals During 19th C most surgery performed in the home Mortality 3-5x higher in hospitals Hospitals for charity cases Social stigma

25. Rise of hospitals 1800: 2 hospitals Pennsylvania Hosp New York Hospital 1821: Mass General Hospital #3 1873: 178 hospitals 1909: 4359 hospitals WHAT FORCES DO YOU THINK CONTRIBUTED TO THE GROWTH IN THE NUMBER OF HOSPITALS?WHAT FORCES DO YOU THINK CONTRIBUTED TO THE GROWTH IN THE NUMBER OF HOSPITALS?

26. Forces contributing to rise of hospitals Professional Nurses/ anesthetists/ orderlies available Location for teaching/ learning Immigration Urbanization Lack of extended families Poverty/ expense of health care Technology and surgical equipment available

27. Bellevue Hospital, 1880s

28. Infection Post-surgical infection rises in 19thc Crowded hospitals Infection in hospitals Increase in traumatic injuries Hospitalism Gangrene, erysipelas, pyema Associated with large, old buildings Led to new hospital design w/ ventilation and more space

29. Bellevue, 1860 Dirty, crowded, filthy, often more than one patient per bedDirty, crowded, filthy, often more than one patient per bed

30. Pennsylvania Hospital, 1911 Emphasis on sunlight, high ceilings to facilitate cross ventilationEmphasis on sunlight, high ceilings to facilitate cross ventilation

31. Infection control Ignaz Semmelweis 1847 experiments w/ washing hands & instruments in chlorine solution to prevent childbed fever Publishes in 1860 Impact ignored Semmelweis initially noted that the maternity unit staffed by midwives had less post-partum infection than the unit staffed by doctors and medical students. He then introduced hand washing and soaking instrument in chlorine solution on his unit and the infection rate dropped. Semmelweis initially noted that the maternity unit staffed by midwives had less post-partum infection than the unit staffed by doctors and medical students. He then introduced hand washing and soaking instrument in chlorine solution on his unit and the infection rate dropped.

32. Louis Pasteur French chemist 1857 and 1860 Demonstrated that fermentation is caused by a living organism (not a chemical reaction) Refuted spontaneous generation Louis Pasteur

33. Antisepsis and Joseph Lister British Surgeon Influence: Pasteur Pus/ infection caused by microbes in air 1867 introduces Antisepsis Carbolic acid Rinse hands and instruments

34. Antiseptic Surgery Antiseptic Surgery, 1882

35. Antisepsis Coincides with heightened public interest in cleanliness and hygiene Erratically adopted, especially in America Solution caustic Many physicians opposed germ theory By 1880s, generally though not uniformly adopted Lister didn?t wash his hands; operated in street clothes

36. Robert Koch

37. Robert Koch 1843-1910, German 1876: discovers anthrax 1882: mycobacterium tuberculosis Demonstrates bacteria have specific etiological relationship to disease

38. Robert Koch, cont?d Made bacteriology clinically applicable refined culture and dye techniques Koch?s postulates Experimental process showing organism A causes disease B

39. Koch?s Postulates, 1882 Organism must be present in all cases of the diseased condition but not in healthy animals Organism must be isolated and grown in pure culture Culture must induce disease experimentally Organism can be reisolated from experimental infection

40. Impact of Germ Theory Idea of disease specificity Allowed possibility of equating disease with an organism Reclassification of disease Dynamic conception of disease

41. Impact of Germ Theory Belief that medicine could fight disease, improve public health provided scientific rationale for public health/hygiene efforts Shifted attention from internal organs to external invaders ironically reinforced prejudices about ?outsiders?

42. Impact cont?d Provided theoretical foundation for diagnosis and therapy Specific therapy for infectious diseases Search for vaccines, antitoxins, ?magic bullets?

43. Asepsis Introduced by Ernst von Bergmann in 1877 Recognition that hands, body, instruments were more likely source of infection than air Led to sterilization, cleaning patient, handwashing, eventually gloves and masks By 1890s most hospitals used autoclaves However, many surgeries still performed in homes

44. Hayes Agnew, 1886

45. The Agnew Clinic, 1889 (Thomas Eakins)

46. Hahnemann Hospital, 1899 Asepsis and antisepsis erratically adoptedAsepsis and antisepsis erratically adopted

47. 1901

48. Mobile, 1904

49. Women?s Medical College, 1903

50. Blossoming of Surgery By 1870s and 1880s surgeons can operate on head, chest, and abdomen 1886: 1st successful appendectomy 1886: MGH abdominal surgery ward Abdomen now available to surgeons 1880s and 90s: Physiological Surgery Conserved tissues, preserved anatomy, careful dissection Compare to slash and speed model

51. Increase in operations MGH 1841-1845: 37 operations/ year 1847-1851: 98 operations/ year 1898: 3700 operations Surgery in 1900 Safer Less painful More invasive Less infection risk

52. ?The Century of the Surgeon? 1870-1970 Explosion in surgical techniques New areas of the body accessible Attention to detail and tissue


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