A History of Surgery-1
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A HISTORY HISTORY OF SURGERY SURGERY THIRD EDITION
A HISTORY HISTORY OF SURGERY SURGERY THIRD EDITION THIRD
Harold Ellis Sala Abdalla
CRC Press aylor & Francis Group 6000 Broken Sound Parkway NW, Suite 300 Boca Raton, FL 33487-2742 © 2019 by aylor & Francis Group, LLC CRC Press is an imprint o aylor & Francis Group, an Inorma business No claim to original U.S. Government works Printed on acid-ree paper International Standard Book Number-13: 978-1-138-61740-7 (Hardback) Internationall Standard Internationa Standa rd Book Number-13: 978-1-138-61739-1 978-1-138-61739-1 (Paperback) Tis book contains inormation obtained rom authentic and highly regarded sources. Reasonable eorts have been made to publish reliable data and inormation, but the author and publisher cannot assume responsibility or the validity o all materials or the consequences o their use. Te authors and publishers have attempted to trace the copyright holders o all material reproduced in this publication and apologize to copyright holders i permission to publish in this orm has not been obtained. I any copyright material has not been acknowledged please write and let us know so we may rectiy in any uture reprint. Except as permitted under U.S. Copyright Law, no part o this book may be reprinted, reproduced, transmitted, or utilized in any orm by any electronic, mechanical, or other means, now known or hereater invented, including photocopying, microflming, and recording, or in any inormation storage or retrieval system, without written permission rom the publishers. For permission to photocopy or use material electronically rom this work, please access www.copyright.com (http://www. copyright.com/) or contact the Copyright Clearance Center, Inc. (CCC), 222 Rosewood Drive, Danvers, MA 01923, 978-750copyright.com/) 8400. CCC is a not-or-proft organization that provides licenses and registration or a variety o users. For organizations that have been granted a photocopy license by the CCC, a separate system o payment has been arranged. Trademark Notice: Product or corporate names may be trademarks or registered trademarks, tradema rks, and are used only or identifcation and explanation without intent to inringe. Library of Congress Cataloging-in-Publication Cataloging-in-Publication Data
Names: Ellis, Harold, 1926- author. | Abdalla, Sala, author. itle: A history o surgery / Harold Ellis, Sala Abdalla. Other titles: Cambridge history o surgery Description: Tird edition. | Boca Raton, Florida: CRC Press, [2019] | Preceded by Te Cambridge illustrated history o surgery / Harold Ellis. 2nd ed. 2009. | Includes bibliographical reerences and index. Identifers: LCCN 2018031277| ISBN 9781138617391 (paperback: alk. paper) | ISBN 9781138617407 (hardback: alk. paper) | ISBN 9780429461743 (ebook) Subjects: | MESH: General Surgery—history Surgery—history Classifcation: LCC RD19 | NLM WO 11.1 | DDC 617—dc23 LC record available at https://lccn.loc.gov/ https://lccn.loc.gov/2018031277 2018031277 Visit the Taylor & Francis Web site at http://www.taylorandfrancis.com and the CRC Press Web site at http://www.crcpress.com
Dedication
To Wendy, and our children and grandchildren—Harold Ellis To my late father, and to my mother and Sam— Sala Abdalla
Contents
Preface
xi
Acknowledgements
xiii
Authors
xv
1
2
3
4
5
6
Surgery in prehistoric times Circumcision
1 2
Trephination o the skull Cutting or the stone The early years o written history – Mesopotamia, Ancient Egypt, China and India Mesopotamia Ancient Egypt China India Surgery in Ancient Greece and Rome Ancient Greece Ancient Rome The Dark Ages and the Renaissance Southern Italy Byzantium
4 5 7 7 8 10 13 15 15 19 21 21 22
Arabian medicine The Renaissance The Renaissance o anatomy The age o the surgeon-anatomist surgeon-anatomist:: Part 1 – rom the mid-1 mid-16th 6th century to the end o the 17th century The 16th century The 17th centur y The age o the surgeon-anatomist surgeon-anatomist:: Part 2 – rom the beginning o o the 18th century to the mid-19th mid-1 9th century The 18th century France Italy Germany
23 24 32
47 47 48 50 51
Britain
55
35 35 41
vii
viii Contents
7
8
9
10 10
11
12 12
America The rst hal o the 19th century Dissection The advent o anaesthesia and antisepsis Anaesthesia The development o antiseptic surgery The development o aseptic surgery The birth o modern surgery – rom Lister to the 20th century Gallstone surgery Gastric surgery Surgery o the large intestine Cancer o the large bowel Cancer o the colon Cancer o the rectum The acute abdomen Appendicitis Perorated peptic ulcer Intussusception The ruptured spleen Ruptured ectopic pregnancy Obstruction Obstruc tion due to post-operative adhesions ‘ Visceroptosis’ Visceroptosis’ Urological surgery Prostatectomy Neurosurgery Caesarian section The surgery o warar warare e The invention o gunpowder The Napoleonic Wars The Crimean War The American Civil War The Franco-Prus Franco-Prussian sian War The Boer War
63 64 71 75 75 84 91 93 93 95 99 101 102 103 105 105 107 108 110 111 112 112 113 114 116 119 125 126 130 133 135 136 136
The Russo-Japanese The Russo-Japanes First World Ware War The Spanish Civil War The Secon Second d World War (1939–1 (1939–1945) 945) Orthopaedicc surgery Orthopaedi Fractures and dislocation dislocationss Elective Electi ve orthopaedic s Breast tumours The development o the radical operation The treatment o the advanced disease Cutting or the stone Perineal lithotomy Suprapubic lithotomy
136 137 13 7 146 147 14 7 151 15 1 151 15 1 158 165 174 17 4 179 17 9 181 18 1 181 18 1 188
Transurethral lithotrit y
191 19 1
Contents ix
13 13
14 14
15 15
16 16 Index
Thyroid and parathyroid Surgery Hypothyroidism Hyperthyroidism The parathyroid glands Thoracic and vascular surgery Lung surgery Tuberculosis Resection o the lung Cardiac surgery Extracardiac Ext racardiac surgery Constrictive Constric tive pericardit pericarditis is Persistent ductus arteriosu arteriosuss Coarctation Coarctati on o the aorta Fallot’s tetralogy Surgery on the beating heart Open-heartt surgery Open-hear Articial Arti cial heart valves The surgery o coronary arter arteryy disease Arterial surgery Aortic aneurysm surgery Endovascular surgery Organ transplantat transplantation ion Skin grating Kidney transplanta transplantation tion Articial Arti cial kidneys The immunological basis o transplant transplantation ation Transplantation o other organs Liver The heart Pancreas Intestine Multiple organ transplantati transplantation on
197 198 202 205 208 211 21 1 211 21 1 214 215 21 5 218 21 8 218 21 8 218 21 8 218 21 8 219 21 9 220 221 225 227 228 230 234 236 237 238 239 242 243 245 245 246 247 247 247
Envoi: Today and tomor tomorrow row
249 257
Preface
In the preparation o this new edition o A o A History of Surgery , I have been ortunate to recruit Miss Sala Abdalla as my co-author. I frst met her some years ago when she spent a year as one o my Anatomy Demonstrators at Guy’s, during which time she obtained her MRCS. Now in her advanced
surgical training she can ca n bring a resh resh approach approach to this edition and is well qualifed to contribute to the last chapter on the uture o surgery. Harold Ellis
xi
Acknowledgements
I m immensely grteul to the ollowing iniviuls or their ssistne with the photogrphs n illustrtions: Mr Json Constntinou MD FRCS, Consultnt Vsulr n Enovsulr surgeon, n the rest o the vsulr tem t the Royl Free Hospitl, Lonon; the surgil, nestheti n thetre tems t Queen Elizeth Hospitl, Lewishm & Greenwih NHS rust; Cmrige Meil Rootis Surgil, with
speil thnks to Luke Hres, tehnology tehnology iretor n o-ouner, n Ptrik Porge, he o mrketing; Heii Siegel, Diretor o Mrketing Communitions, Communitions, n the tem t AuV AuVein; Strtsys; Strtsy s; Pnkj Chnk, Ch nk, rnsplnt Registrr n Reserh Fellow, Guy’s n Evelin n Gret Ormon Street Hospitls n King’s College Lonon n Nik Byrne, Deprtment o Meil Physis St Toms’ Hospitl.
xiii
Authors
Professor Harold Ellis
CBE FRCS qulie in Meiine t Oxor in 1948. He ws ppointe Proessor o Surgery t Westminster Meil Shool, Lonon, in 1962, retiring in 1989. Sine then he hs tught ntomy. His prtiulr interests were ominl n rest surgery. He ws onsultnt surgeon to the rmy n ws ppointe CBE in 1987. BS MBBS MRCS is senior Speilist Registrr in Generl Surgery n memer o the Royl College o Surgeons o Engln. She grute rom Imperil College, Lonon, in 2008, with Bhelor’s egree in Physiologil Sienes n Bhelor o Meiine n Bhelor o Surgery. Sala Abdalla
Sl worke s ntomy emonstrtor t King’s College, Lonon, in 2010, uner the mentorship o Proessor Hrol Ellis. She is urrently ompleting her higher surgil trining in South Est Lonon. With speil interest in eution, she hs een ulty memer t the Guy’s & St Toms’ MRCS ntomy tehing ourse, ntomy tutor t Imperil College, Lonon n the Royl College o Surgeons o Engln, n hs irete linil tehing progrms. She is pssionte out glol surgery n helth provision n in 2017 emrke on her rst mission to West Ari on ‘Opertion Herni’. She is rst uthor on numer o peer-reviewe ppers n hs presente work in ntionl n interntionl orums. Tis is her rst textook ontriution.
xv
1 Surgery in prehistoric times Te wor ‘surgery’ erives rom the Greek wors cheiros, hn, n ergon, work. It pplies, thereore, to the mnul mnipultions rrie out y the surgil prtitioner in n eort to ssuge the injuries n iseses o his or her ellows. Tere seems no reson to out tht sine Homo sapiens ppere on this erth, proly some qurter o million yers go, there were people with prtiulr ptitue to rry out suh tretments. Aer ll, there is n innte instint or sel-preservtion mong ll mmmls, let lone mn, so tht og will lik its wouns, limp on three lims i injure injure, , hie in hole i ill n even seek out purging or vomit-mking grsses gr sses n n hers i sik. We re tlking out time mny thousns o yers eore written reors were kept, n, inee, the eviene o isese or injuries to so tissue o tht perio hs long sine rotte wy with the eris o time. Pleopthologists (those who stuy iseses o the istnt pst), however, hve unovere unnt eviene in exvtions o nient skeletons tht rtures, one iseses n rotten teeth torture our olest nestors. O ourse, nimls were lso sujet to ll sorts o iseses. Inee, ony tumour ws ovious in the til vertere o inosur tht live millions o yers go in Wyoming. Other exvtions lso revel tht injuries were inite y mn upon mn (Figures 1.1 n 1.2) 1.2) n, s we shll see, tht roken ones were splinte n skulls operte upon. We n mke resonle guess t wht primitive helers my hve one rom stuies rrie
stuies o ommunities s r prt s West n Centrl Ari, South Ameri n the South Pi, who never h ontt with ‘moern’ ‘ moern’ mn. It is surely resonle to surmise tht tretments oun in suh ommunities, oen mzingly similr in ierent prts o the worl, might well mth the re given y our prehistori nestors ne stors in mn’s unmentl instints o sel-preservtion. sel-preservtion. Te ssumption might e wrong, ut it woul require gret el o reserh eore istintion etween ‘moern’ primitive n prehistori meil n surgil tretments oul e me. It goes without sying tht these erly stuies re immensely vlule to us toy, sine ew i ny
out y nthropologists n who, ethnologists (those who stuy primitive tries) t roun the eginning o the 20th 20 th entury, rrie out etile
and probably the rst portrayal o wounding. (Reproduced rom Majno G: The Healing Hand . Harvard University Press, 1975.)
Figure 1.1 A warrior pierced with eight arrows. Drawn rom a rock painting in eastern Spain,
1
prehistoric times 2 Surgery in prehistoric
Figure 1.2 A fint arrow head embedded in the human sternum. From the Chubut Valley, Patagonia. Musée d’Homme, Paris.
primitive ommunities now remin untinte y Western ivilistion. Injuries inite y lls, rushings, svge nimls n y mn upon mn emn tretment. Among primitive tries in the orementione stuies, open wouns were invrily overe y some sort o ressing. Tis might tke the orm o
Figure 1.3 A warrior in Borneo, hit in the chest by an arrow, is treated by a healer. This photograph was taken some 50 years ago.
jws to hol the t he lertion lose, remrkly like l ike the metl skin lips employe in operting thetres toy.. Splints o rk or o so ly (whih ws then toy llowe to set) were use to immoilise rture
leves, prtssome o vrious plnts, owes (whihshes, (whih my well hve loo-lotting properties), nturl lsms or ow ung (Figure 1.3). Inee, even in reent times, ung ws use in West Arin villges vil lges s ressing or ies’ ut umilil umilil ors, whih ws responsile or mny ses o ‘neontl tetnus’ – lokjw in ies – rom the tetnus spores tht re lmost invrily present in ees. Among the Msi o Est Ari, wouns were stithe together y stiking i thorns long the two eges o eep ut n then pliting the thorns ginst eh other with plnt re. In Ini n South Ameri, termites or eetles were
lims,Anient n suh rk splints rom Egyptin uril hve sites (Figure (een Figureexvte 1.4). Aprt rom eling with wouns n rtures, erly surgeons rrie out three types o opertive proeures, nmely utting or the ler stone, irumision n trephintion o the skull. Te utting or the stone is suh sinting n importnt topi in the history o surgery, it merits hpter o its own (see Chpter 12).
employe to hel ite together ross the o the woun s the lips were y ege the surgeon. Te oies o the insets were then twiste o, leving the
most Anient wspriests prtise in Anient‘eletive’ Egypt yopertion ssistntsn to the on the priests n on memers o royl milies.
CIRCUMCISION Cirumision might well e lime to e the
Circumcision 3
Figure 1.4 Fractured orearm bones with bark splints, rom Egyptian excavation and dated about 2450 bc. Note the blood-stained lint dressing (arrowed), the oldest specimen o blood. (From Majno G: The Healing Hand . Harvard Universityy Press, 1975.) Universit 1975.)
Tere is remrkle eviene or this rve on the tom o high-rnking royl oil, whih ws isovere in the Skkr emetery in Memphis n is te etween 2400 n 3000 bc (Figure 1.5). It represents two oys or young men eing irumise. Te opertors re employing
rue stone instrument. While the ptient on the le o the relie is hving oth rms hel y n ssistnt, the other merely res his le rm on the he o his surgeon. Te insription hs the opertor sying ‘hol him so tht he my not int’ n ‘it ‘ it is or your enet’. Te Anient Jews my hve lerne the rt o irumision uring their onge in Egypt, n, inee, irumision is the only surgil proeure mentione in the Ol estment, the prtie o irumision mong Jews eing ttriute to Arhm. In the ook o Genesis (17; 1–2), proly written out 800 bc, we re: ‘Tis is the ovennt etween me n you n your see whih you must oey; ll mles mong you shll e irumise’. Agin, in the seon ook o Exous, Zipporh, the wie o Moses, ‘took shrp stone n ut o the oreskin oreski n o her son’. son’. Erly ethnologil stuies revele tht irumision ws prtise wiely mong primitive ommunities, inluing those o equtoril Ari, the Bntus, Austrlin Aorigines n in South Ameri n the South Pi, n it ws lso tritionl mong Jews, Muslims n Copts. We n only guess t its origins, perhps s ertility or initition rite or possily or lenliness or hygiene. Its tritionl sis is onrme y
Figure 1.5 Drawing o a tomb carving o a circumcision scene. Sakkara cemetery at Memphis, Egypt, c. 2400–3000 bc.
prehistoric times 4 Surgery in prehistoric
the t tht, in mny ommunities, even though metl instruments were ville, the opertion ws still perorme with int knie. k nie.
TREPHINATION OF THE SKULL Unoutely, the most extrorinry story in the history o erly surgery is tht, long eore mn oul re or write, s long go s 10000 bc, surgeons were perorming the opertion o trephintion or trepnning – oring or utting out rings or squres o ones rom the skull – n, just s remrkly, their ptients usully reovere rom the proeure. Although the wors ‘trepntion’ n ‘trephintion’ toy re interhngele in ommon prtie, trepntion omes rom the Greek wor trypanon , mening orer, while trephintion is o more reent Frenh origin n inites n instrument ening in shrp point, so it implies using utting instrument revolving roun entrl spike. repntion thus onnotes srping or utting, while trephintion esries rilling the skull, s in moern neurosurgil opertions. opertions. Dierent tehniques o trepntion in Anient times, n in reent primitive ommunities, involve srping wy the one, mking irulr irul r groove so tht entrl ore o the one woul loosen, oring n utting wy the one, or mking retngulr interseting inisions in the skull (Figures 1.6 n 1.7). Tis story egn in 1865 when generl prtitioner, Dr Prunires, who ws lso n mteur
Figure 1.7 Trepanned skull rom Ancient Peru. The operation has been perormed by means o a series o incisions placed at right angles to each other.
rheologist, isovere in prehistori stone tom in Centrl Frne skull tht ore lrge rtiil opening on its posterior spet. With it, he oun numer o irregulr piees o ones tht might hve een ut rom nother skull. He postulte tht the skull h een perorte so tht it might e use s rinki rinking ng up. Soon er this, numer o other hole skulls were oun in other prts o Frne n Proessor Pul Bro (1824–1880), istinguishe Frenh physiin, suggeste tht these openings were the result o n opertion o trepntion n tht the instrument employe ws int srper. Bro suggeste tht the survivors o the opertion were thought to e enowe with mystil powersespeilly n tht, when ie, portions o their skulls, those they tht inlue inlu e prt o the ege o n rtiil rt iil opening, were in gret emn s hrms. Following these isoveries, thousns o suh speimens hve een isovere in mny prts o the worl: the Unite Kingom (Figure 1.6), Denmrk, Spin, Portugl, Poln, the Dnue Bsin, North Ari, Plestine, the Cusus, ll own the western ostline o the Ameris n, espeilly, in Peru (Figure 1.7), where more thn 10,000 speimens hve een exvte. wo questions immeitely me to min: why
Figure 1.6 Trephined skull rom an Anglo-Saxon skeleton excavated in East Anglia.
ws nws how? In mny ses,theit opertion seems thtperorme, trephintion rrie out on ptients ollowing he injury. We n see n
Cutting or the stone 5
ovious rture line on mny speimens, oen oiniing with, or ner, the site o the trephine eet. We n e sure tht mny suh ptients reovere euse numerous speimens show ler eviene o heling o the rture n o the eges o the trephine eet. Te requent use o stone lus n sling stones mong Anient wrring Peruvins my ount or the lrge numer o speimens reovere rom tht ountry; in one olletion o 273 skulls rom Peru, 47 h een trephine rom one to ve ples. We n only guess t the requent use o trephintion in skulls with no ovious eviene o injury. In mny o these, inee, the opertion h oviously een perorme severl times t intervls. Intrtle hehes, epilepsy or n ttempt to oner mystil powers on the sujet re ll possile motives, n there seems little out tht the rgments o one remove were themselves oen regre s possessing mgil powers. O ourse, the opertion ws perorme without the enet o nesthesi, lthough uthorities hve surmise tht n extrt o the o plnt might hve een use y the Anient South Amerin prtitioners. Te instrument woul originlly hve een shrpene int or piee o osiin ( hr lk lvl lv l stone), stone), stene y or to wooen hnle. Tese were lter reple y opper or ronze le. ehniques vrie rom ple to ple: irulr ut through the skull one, series o irulr rill holes tht were then joine together, or tringulr tringu lr or qurngulr qurng ulr uts through the skull one. Bro, who we mentione
hve een ollete, whih show perortions similr to those oun in Stone Age speimens. Writing in 1901, the Reveren J. A. Crump note tht in New Britin the opertion ws only perorme in ses o rture, whih ws ommon injury in tril wrre. Te instrument employe ws piee o shell or osiin, n the woun ws resse with strips o nn stlk, whih is very sorent. Te mortlity rte ws out 20%, ut mny o the eths resulte rom the originl injury rther thn the opertion itsel. In other islns, the opertion ws perorme to ure epilepsy, hehe n insnity, while in New Ireln, n isln north o New Guine, lrge numer o ntives h unergone trephintion in youth s n i to longevity. In Te Lancet o 1888, there is n ount o the prtie o trephining in the Cusin provine o Dghestn, on the orers o the Cspin Se. Here, it ws rrie out or he injuries, n it is interesting tht it ws the ggressor who ws olige to py the surgeon or the opertion. In 1922, Hilton-Simpson pulishe ook out his our visits to the Aures Mountins in Algeri, where he ws le to stuy the work o lol surgil prtitioners. Here, knowlege ws psse rom ther to son, n the surgeons rrie out splinting o rtures, reution o islotions, irumisions n lithotomy or stones in the ler. rephintion ws ommonly perorme, lwys s tretment o some orm o he injury. Te opertion omprise the removl o irulr portion o slp with ylinril iron punh hete re hot n then utting n opening in the
erlier, showe thtminutes he oulusing proue suh eet in skull in 30–45 n Anient int instrument. Even more remrkly, in 1962, Dr Frniso Grn Gr n o Lim operte on 31-yer-ol 31-yer-ol ptient, prlyse er he injury, n evute loo lot rom eneth the skull using Anient Peruvin hisels to trephine the one. Te ptient reovere. Our knowlege o prehistori trephintion woul remin minly mtter o onjeture i it were not or the t tht the opertion ws still eing perorme y primitive res in some wiely seprte prts o the worl, the South Pi, the
skull y thews usetken o not smll rill nthe metl sw. Gret re to mge unerlying overings o the rin, the ur mter. Te question tht remins unnswere is how ws it tht this sophistite neurosurgil opertion me into eing so long go, in suh wiely seprte entres, in ommunities tht surely oul hve h no possile ontt or even knowlege o eh other? Tis is question tht will ontinue to e ete ut will proly never e nswere.
Cusus n Algeri, t the enNew o the 19th n in the erly 20th entury. From Guine n the surrouning islns o Melnesi, mny skulls
Tis, the thir n perhps eserves most interesting, these ‘primitive’ proeures, hpter o o its own (see Chpter 12) 12)..
CUTTING FOR THE STONE
2 The early years of written history – Mesopotamia, Ancient Egypt, China and India MESOPOTAMIA Civilistion s we reognise it toy, with ities, orgnise griulture, government n legl system, tes k some 6,000 yers to the Vlley o the Nile n the jent ln o Mesopotmi etween the igris n Euphrtes. Aove ll, mn lerne to write, n trnsltions trnsl tions (n (n extremely iult tsk) o rvings on stone, sttues n toms n writings on ke ly rom Mesopotmi n ppyri rom Anient Egypt give us muh lerer ie o wht meiine n surgery must hve een like in those times. Te igris ows or 1,200 miles rom the mountins o Armeni to the Persin Gul. Te Euphrtes, even longer, runs roughly prllel to its twin. twi n. Tese unpreitle rivers my overow overow their nks s the Armenin snow melts in Spring n oos vst res o ln – proly the sis o the story o the Floo in Genesis, story repete in muh Anient olk lore. At roun 4000 bc, there rose in this region the highly evelope ivilistion o Sumeri, with ity sttes o Kish, Lgsh, Nippur, Uruk, Umm n, est rememere o ll, Ur. In these ities, ms were uilt, surrouning els irrigte, txes levie n piturogrph sript invente, whih ws somewht similr to tht evelope in Egypt. Tis primitive writing evelope into sript tht oul e inise onto
ly tlets. On ly, it is esier to proue lines rther thn urves, n the wege shpe o the sript gve its nme to uneiorm writing, whih omprise some 600 signs. Gret kings rose, suh s Srgon o the ity o Akk (roun 2350 bc), who sujugte the whole o Sumeri n Hmmuri (roun 1900 bc), who estlishe his pitl t Bylon. In time, Bylon ws onquere roun 1100 bc y iglth-Pileser, king o the northern neighour Assyri, with its pitl t Nineveh. Te power o Bylon remine until, in 539 bc, it gve wy to the rise o the Persin Empire. Te meiine o Mesopotmi ws primrily meio-religious. meio-r eligious. Prtitione Prt itioners rs were priests n were rule y the strit str it lws inlue in the oe o King Hmmuri. Tis oe, rve r ve on lk stone out eight eet high, ws isovere t Shush in wht is now Irn in 1901 n n e seen toy t the Louvre Museum in Pris. At its top n e seen the Emperor Hmmuri reeiving the lws rom the sun go Shmsh (Figure (Figure 2.1). 2.1). His oe etils mily lw, the rights o slves, the penlties or the, the rewrs or suess n the severe punishment or ilure on the prt o the surgeon. We hve eviene rom these writings tht surgil surgi l onitions suh s wouns, rtures n sesses were trete. Tus, we re: 7
years o written history 8 The early years
I it were not or Hmmuri’s oe o lws, ll memory o surgery in Bylon, nerly 4,000 yers go, woul hve een lost. Surgery s r ws hrly worth mentioning; only when it eme o interest to the lw ws it engrve in stone.
ANCIENT EGYPT
I otor hels ree mn’s roken lim n hs
Te inuene o Sumerin ivilistion upon tht o Egypt is sujet o interesting n ontinuing ete, ut ertinly s long go s 4000 bc, there ws well-orgnise governmentl system in the Nile elt. With it me the evelopment o the pitoril writing o hieroglyphis n the isovery tht writing mteril oul e prepre rom the ppyrus ree, more onvenient meium thn ly riks. Aroun 2900 bc live the rst mous iniviul whose nme hs ome own to us in meiine, Imhotep, vizier to King Zoser. An ministrtor, politiin n uiler o the gret steppe steppe pyrmi o Skkrr, Skk rr, still to e seen toy, he must lso hve een istinguishe s physiin, lthough we know nothing o his meil ontriutions. He ws worshippe or mny enturies er his eth s the go o meiine (Figure 2.2). A numer o meil ppyri hve ome own to us whih re o gret interest. Te Eers ppyrus ws oun in tom t Tees in 1862 y Proessor George Eers n is now preserve in the University o Leipzig (Figure (Figure 2.3). 2.3). It onsists o 110 110 sheets n ontine 900 presriptions. As lenr hs een written wr itten on the k o the mn-
hele sprine tenon, the ptient to son py the otor ve shekels o silver. I it isisthe o nolemn, he will give him three shekels o silver. I the physiin hs hele mn’s eye o severe woun y employing ronze instrument n so hele the mn’s eye, he is to e pi ten shekels o silver. I otor hs trete mn or severe woun with ronze instrument n the mn ies, n i he hs opene the spot in the mn’s eye with the instrument o ronze ut estroys the mn’s eye, his hns re to e ut o.
usript, theury te o its n bc. e xe with resonle t writing out 1500 However, there is goo eviene to show tht muh o it hs een opie rom other works mny enturies eore. Te writings re sprinkle with innttions, whih suggest tht the remeies were given with the intention o riving out the emons o isese. Amulets were lso vise; these oen onsiste o imges o the gos n were to e hung roun the nek or tie to the t he oot. A whole vriety vrie ty o r rugs ugs re mentione, inlui inluing ng stor oil, whih ws use s purgtive. All sorts o niml sustnes were use, inluing the t
It ws oviously ngerous proession in those ys!
o vrious nimls ile. Meiine Anient Egypt woul ppern to hve een o ninempiril or mgil vriety.
Figure 2.1 The code o King Hammurabi. Louvre Museum, Paris.
Ancient Egypt 9
O even more interest to us in our stuy o the erly history o surgery ws the isovery y young Amerin Egyptologist nme Ewin Smith o nother ppyrus t the sme ple s the Eers ppyrus. It remine in Smith’s possession until his eth in 1906, when his ughter gve the ppyrus to the New York Historil Soiety. Te omplex tsk o trnsltion ws entruste to Proessor Jmes Breste. Te Smith ppyrus (Figure 2.4), like the Eers ppyrus, tes k to out 1550 bc, ut Breste emonstrte tht it ws unoutely opy o the muh more nient text, sine it use Egyptin wors tht were no longer urrent t tht time. It omprises 48 se reports tht ommene with the top o the he n proee systemtilly ownwrs – nose, e, ers, nek n hest – n then mysteriously stop t the spine. Hving esrie the physil signs o the ptient, the surgeon goes on to eie on the outlook o the se. I the prognosis is goo, or i there is hne o suess, tretment is then vise. I hopeless, then the ptient shoul e le to his inevitle te. Tis gure ttitue ws
Figure 2.2 Imhotep (c. 2900 bc), the rst named physician. Louvre Museum, Paris.
Figure 2.3 The Ebers papyrus.
Figure 2.4 The Edwin Smith papyrus.
years o written history history 10 The early years
wiespre in ntiquity: ntiquity : there ws rih rewr or reovery o your welthy ptient, while there ws grve risk o punishment in the se o ilure. Te esription o ptient with islote jw n n its tretment t retment is i s simil si milrr to tht t ht oun in moern textook: I you examine a man having a dislocation o his mandible, should you nd his mouth open, and his mouth cannot close again, you should put your two thumbs upon the ends o the two rami o the mandible inside his mouth and your ngers under his chin and you should cause them to all back so that they rest in their places.
Eqully ler re re the instrutions onerning rture o the upper rm: I you examine a man having a break in his upper arm and you nd his upper
sophistite tehniques o emlming were evelope. As result o our exmintion o these preserve oies, gret el hs een lerne o the iseses o Anient Egypt. Tese inlue ongenitl eormities suh s lu oot, entl ey, rthritis, one tumours n rtures. Some o these injuries, inee, show tretment y quite sophistite splinting (see Figure 1.4). Moels 1.4). Moels in toms n wll rvings emonstrte vriety o iseses, inluing poliomyelitis, spinl kyphosis n honroplsi (Figures 2.5–2.7). 2.5–2.7).
CHINA Te Chinese tre their t heir history k to six emperors. Shen Nung ws the inventor o griulture; Hungt i o ships, the ow n rrow, musi n writing; Fu Hsi oune the rts o hunting n shing; the emperors Yo n Shu estlishe the lenr n ministrtion; n the emperor Yu
arm hanging down separated rom its ellow, you should say concerning him – one having a break in his upper arm. An ailment which I will treat. You will place him prostrate upon his back with something olded between his two shoulder blades; you should spread his two shoulders in order to stretch apart his upper arm until the break alls into place. You You shall make or him two t wo splints o linen and you apply one o them to the inside o the arm and the other to the underside o the t he arm. You shall bind it with ymrw (an unidentied mineral substance) and treat it with honey every day until he recovers.
From these writings, it ppers tht the only surgil onitions trete, just s our eviene rom Bylon suggests, were wouns, rtures, islotions n sesses. Te exeption is tht irumision ws perorme, presumly y priests, s prt o religious eremony mong the noility (see Figure 1.5). From the erliest ys o Egyptin ivilistion, elie in reinrntion ment tht memers o the
Figure 2.5 An Ancient Egyptian stone relie
royl nthis noility h one theiry oies serve.mily Initilly, ws merely ryingprethe orpse in sn, ut over the enturies, inresingly
showing a patient with obvious poliomyelitis. Note the shortened right leg with muscle wasting and talipes deormity, together with the crutch.
China 11
Figure 2.7 Stone relie o an achondroplastic. Cairo Museum. Figure 2.6 Model o a patient with a kyphosis, probably tuberculosis. Cairo Museum.
ontrolle the oos oo s o the Yellow Yellow River. Aoring
eminine, ol n moist. Helth epene on hrmony etween these opposing ores. Disese represente ishrmony. retment h its gol in the restortion o hrmony y stimulting Ying or
to Chinese trition, theseextent rulersthese livekings etween 2852 n 2205 bc. o wht hel legenry inventions will proly never e estlishe, ut ertinly, y the seon millennium bc, thousns o ones exvte were insrie with hrters in sript not unmentlly ierent rom the Chinese piture writing o lter perios. Over these thousns o yers, Chin remine more or less in isoltion, n it is not surprising tht system o meiine evelope there ws quite ierent rom its Western ounterprt. It ws se on the oist philosophy o lie; kin o worl spirit, the o, permete ll growth n ey n ws
Yng so tht woul e regine restore. Lielne ore, ompose o Ying n n helth Yng, ows through hnnels in the oy tht re relte to points on the skin. By ssessing the ptient’s symptoms n y reul plption o the pulses, the meil prtitioner oul etermine whih prt ws isese, whih hnnel ete n whih ore ws responsile. From erliest times, the phenomenon o the pulse in the ierent prts o the oy sinte Chinese physiins, n the pulse eme the most importnt sign y whih internl proesses o the oy oul e etermine. Even the pulse o pregnnt womn oul e use to ig-
n interply etween two ores, Ynghot n Yng ws hr, mle, retive n rk, nYing. ry, in ontrst to Ying whih ws light, so, reeptive,
nose o the expete hil: ‘When pulse o thethe lesex hn is rpi, without ing, thethe womn will give irth to mle hil’. Te segment o the
years o written history 12 The early years
pulse t the right wrist gve inormtion onerning the stte o the lungs n tht o the le sie on the onition o the hert. A seon segment o the right wrist inite in ite whether the spleen n stomh were ete, while nother on the le wrist etermine the stte o the liver n ile or whether the onition ws eing use y n exess o Ying or Yng. Plption o the pulses, n omprison with the physiin’s own, ws n elorte ritul tht might tke severl hours. Te moern otor is tught to reognise the rte o the pulse, its ore n vrious irregulrities tht my our; how muh more sophistite the Chinese physiins oul hve een is mtter or speultion, lthough the prolonge ontt etween the otor n ptient must surely hve een soure o omort om ort to the ltter. lt ter. By stimulting pproprite prts o the skin, Ying n Yng oul e restore to hrmony n the ptient to helt helth. h. Tis stimultion stimult ion oul e rrie out either y urning the powere leves o the mugwort, proeure lle moxiustion, or y using neeles (upunture). Tis orm o tretment hs een ontinue or thousns o yers n hs enjoye reent vogue in the lterntive meiine o the West (Figure 2.8).
In ition, Chinese meiine me iine employe the use o herl remeies, n this ws wiely evelope. In the 16th entury, 52-volume ompenium title Classication o Roots and Herbs ws pulishe y government oil, Li Shih-Chou; this tlogue no less thn 1,892 meitions, mny o whih extene k into Anient history. Exmintion o the ptient, prt rom the pulse, plye little prt in ignosis. Inee, high-lss lies woul not e exmine t ll y the prtitioner. A smll wx or ivory moel ws employe, on whih the ptient oul point poi nt out the site o her pin n isomort to her physiin. Dissetion ws rowne upon, sine nestor worship ore the mutiltion o the oy o e person, so tht knowlege o ntomy ws primitive n restrite to ientl glnes t e or woune persons or uthere nimls. Surgery, prt presumly rom the tretment t retment o wouns n other injuries, ws lmost non-existent in ontrst to the ourishing rt in neighouring Ini. Inee, there ppers to hve een only one Anient Chinese surgeon o note, Hu uo (ad 190–265), who is piture operting on the upper rm o the wr lor generl Kun Yun (Figure 2.9) 2 .9) or wht ws proly
Figure 2.8 Chinese acupuncture diagrams, ad
Figure 2.9 Hua Tuo drains an abscess on the
630 and 1920. (From William Osler: Evolution of Modern Medicine. Medicine. New Haven, Yale University Press, 1921.)
arm o General Kuan Yun, who shows his indierence to pain by playing a board game gam e with his aide-de-camp.
India 13
n inete woun o the rm. He oere trephintion o the skull to Prine So, who ws suering rom severe hehes. Unortuntely, the prine suspete tht the surgeon wishe to murer him n orere his exeution. Hu uo inee might well hve een oreigner who entere Chin rom Ini who ws thereore quinte with the Inin rt o surgery. Te single opertion tht ws rrie out in Anient Chin ws not tretment o isese. Mny ourt employees n oils were eunuhs. Te opertion o strtion woul hve een ngerous, sine proly ll the externl genitli were remove – n opertion tht persiste into the 20th entury. Aoring to trition, when the surgeon Hu uo uo ws imprisone i mprisone y orer o the emperor, he entruste his mnusripts to his jiler, who urne them ll exept his improve improve strtion metho.
INDIA As with other Anient ivilistions, there is muh ontroversy onerning the erly ting o Inin ulture in generl n n the evelopment evelopment o surgery in prtiulr. In out 1500 bc, the Aryns inve the Inin suontinent suontinent rom Centrl Asi n rought with them the Snskrit lnguge. Te erliest writings on Inin meiine re to e oun in the Ves, the ooks o knowlege, whih were elieve to e o ivine origin. Here we n re o sges who woul rry gs o heling hers n who woul re or the injure, remove rrows n spers rom the woune, n n who woul employ plnt plnt nme
goo mily, possess the esire to lern, hve strength, energy o tion, ontentment, hrter, sel-ontrol, goo retentive memory, intellet, ourge, purity o min n oy, hve ler omprehension, ommn ler insight into the things stuie n shoul hve thin lips, thin teeth n thin tongue n e possesse o stright nose, lrge, honest, intelligent eyes, with enign ontour o mouth n ontente rme o min, e plesnt in speeh n elings n pinstking in their eorts. Even toy, it woul e iult to n n meil stuents who re suh prgons o virtue ! oy, muh emphsis is ple on surgil trining using moels to improve tehnique. Te writings o Susrut inlue vie on how surgeons shoul shoul prtise the rt r t o suturing on niml skins or strips o otton, improve their nging on lie-size olls, prtise surgil inisions on wtermelons or uumers, uterise piee o met eore trying this metho on their ptients n prtise the ligture o loo vessels n o looletting on lotus stems n the veins o e nimls. A isiple ws expete to stuy or perio o t lest les t 6 yers. It is quite evient tht Hinu surgery t this time t ime h rehe high stte o exellene. For exmple, there is etile esription o the opertion or removl o trt, in whih the opque lens o the eye is moilise n then pushe ownwrs into the lower prt o the gloe to llow restortion o vision:
er the go woul relieven pin. In ition, theySom, woulwhih uterise wouns snke ites n might even hve evelope theter to relieve retention o urine n whih woul ‘open the ow o urine gin like m eore lke’. Te erliest Inin surgil uthor ws Susrut. It will proly never e sertine whether he ws n tul historil personge or nme to whih ollete works o surgil literture re ttriute. Te time o his existene is lso vgue, ut it ws some time er Christ. His works were trnslte into Ari roun ad 800 n re oen quote quot e in the writings wr itings o Rhzes.
In the morning in a bright place, the temperature being moderate, let the surgeon sit on a bench as high as his knee opposite the patient. The latter, having washed and eaten and been be en tied, sits on the ground. Ater he has warmed the patient’s eye with the breath o his mouth, rubbed it with his thumb and detected the uncleanness which has ormed in the pupil, he orders the patient to look down at his nose. Then, while the patient’s head is held rmly, he takes the lancet between his orenger and middle nger and thumb and
the ollowing requirements orSusrut stuentsstresse who wishe to stuy meiine n surgery. Tey shoul e o tener yers, orn o
introduces into hal the aeye towards the pupil, on theit side, nger’s breadth rom the black o the eye (the pupil) and
years o written history 14 The early years
a quarter o a nger’s breadth rom the outer corner o the eye. He moves it back and orth and upwards. Let him operate on the let eye with the right hand or on the right side with the let. I he has probed correctly, there is a sound and a drop o water comes out painlessly. Speaking words o courage to the patient, let him moisten the eye with women’s milk, then scratch the pupil with the tip o a lancet without hurting. I the patient can see objects, the doctor should draw the lancet out slowly, lay cotton soaked in at over the wound and let the patient lie still with bandaged eyes (Figure 2. 2.10). 10).
Susrut lso esries wht must hve een the erliest plsti surgil proeure, the restortion o n mputte nose y mens o skin gr turne own upon the orehe. Removl o the nose ws punishment or ultery in those ys, so there ws no shortge o ptients or this proeure. Interestingly, it eviently remine in prtie in Ini mong itinernt surgeons or hunres o yers. A newspper ount o this in 1814 prompte Joseph Crpue o Lonon to
Figure 2.11 Joseph Carpue’s illustration o reconstruction o the nose in 1814 using the Indian technique. (‘An account o two successul operations or restoring a lost nose rom the integuments o the orehead’, London, 1816.)
perorm very similr opertion, using the orehe skin p, with suess in two rmy oers (Figure 2.11). Te rst ptient h lost his nose rom syphilis. A orehe p ws shione n stithe roun the eet. Te viilit y o the p gven some nxiety, ut it viility ortuntely reovere theinitil osmeti result ws goo. Te seon ptient, nother oer, ws hero o the ttle o Aluer, in the Peninsulr Wr in 1810. In sving the regimentl olours, olo urs, the poor ellow lost n rm rm n sustine ve other wouns, one tking o prt o the heek n the nose. Agin, the opertion ws suess. Crpue ws orn in 1764 in Hmmersmith. He ws tholi, who rst onsiere entering the Churh, ut inste stuie t St George’s Hospitl uner Sir Everr Home, eoming memer o the Compny o Surgeons in i n 1798. Te Figure 2.10 Couching or cataract. This early 19th century drawing shows the procedure as described by Susruta.
ollowing ppointe to Chelse. the surgil st t theyer, Dukeheows York’s Hospitl, He ie in 1846.
3 Surgery in Ancient Greece and Rome ANCIENT GREECE It n e truly si tht ‘moern’ rtionl meiine, ivore rom the supernturl ores o possession y the evil or y evil spirits, ws oune in Anient Greee. An importnt onept tht inuene not only meil ut lso ly onepts o isese ws the humorl theory o Empeoles (?500–430 bc), evelope y lter Greek philosophers, in prtiulr Aristotle (384–322 bc). Tis theory stte tht everything erives rom our elements – wter, ir, erth n re – with their ssoite qulities, respetively, o wetness, olness, ryness n het. With this theory, lter writers omine the somewht similr otrine o Hipportes, whih hel tht the oy ws ompose o the our humors or uis, lk ile, yellow ile, loo n phlegm, with their ssoite temperments – melnholi, holeri, snguine n phlegmti. A lne o these humors etermine the helth o the iniviul n the sujet’s temperment lso resulte rom his previling humor, thus the snguine, phlegmti, holeri or melnholi temperment. o this y, we still tlk o n ‘eril spirit’ or o ‘ery nture’ n, inee, this otrine o the our elements persiste into the 17th entury. Muh o our moern meil tritions n mny o toy’s meil terms erive rom Anient Greee. Te Greek ulture sore knowlege rom Mesopotmi vi Asi Minor n lso rom Egypt. By the 6thonentury bc,omeil were ourishing the isln Cos nshools on the jent peninsul o Cnios, whih is now in moern
urkey. Te most mous meil me il teher o Cos C os ws the mn who is ommonly regre s the ‘Fther o Meiine’, Hipportes (470–400 bc). He ws orn to Cos, the son o physiin (Figure 3.1). Suh person unoutely existe n he is mentione y
Figure 3.1 Hippocrates: a conventional bust, since
no one knows what he really looked like! (From William Osler: Evolution of Modern Medicine. Medicine. New Haven, CT, Yale University Universit y Press, 192 1921. 1.)) 15
16 Surgery in Ancient Greece and Rome
his younger ontemporry, Plto. However, the olletion o Hipporti writings, omprising some 70 works, proly represents the tehings o numer o uthors ssoite with Hipportes uring n er his lietime n oen expresses ontriontritory views. Teir titles inlue Frtures, Aphorisms, Epiemis, Prognostis, Ulers, Surgery, Fistule, n Hemorrhois. Te Hipporti writings re hrterise y eing tul; they t hey ontin esriptions esriptions o reul oservtions o tul ptients, they resist elorte theories o isese n emphsise the power o nture to hel, enourge y suitle iet, rest n exerise. In severe ses, urther i my e given y looletting, purging or sweting, n osionlly sion lly ril surgil interven intervention tion is require. Moern otors n it sinting exerise to interpret some o the linil esriptions in these writings. For exmple, se nine o Te Epidemics sttes: The woman who lodged at the house o Tisamenas had a troublesome attack o Iliac passion (acute abdominal pain and distension), much vomiting; could not keep her drink; pain about the hypochondria, and pains also in the lower part o the belly; not thirsty; became hot; extremities cold throughout with nausea and insomnolency; urine scanty and thin; dejections undigested, thin, scanty. Nothing could do her any good. She died.
meperitonitis. like n ttk o ppeniitis Tis with souns ruptureton Perhps the est known o his linil esriptions is tht o the ptient ying o inetion, whih we still term the Hipporti Fies: Nose sharp, eyes hollow, temples sunk, ears cold and contracted and their lobes turned out, the skin about the ace dry, tense and parched, the colour o the ace as a whole being yellow or black, livid or lead coloured.
From the surgil point o view, Hipporti writings us esriptions o how to rry out tretmentgive o wouns, rtures n islotions; there re lso esriptions o eletive opertions
or numer o surgil onitions. Creul vie is given to the surgeon on how to onut himsel. He is tol tht The nails should be neither longer nor shorter than the points o the ngers and the surgeon should practise with the extremities o the ngers, the index nger being usually turned to the thumb; when using the entire hand it should be prone; when both hands, they should be opposed to one another. Greatly promote a dexterous use o the ngers when the space between them is large and when the thumb is opposed to the index. One should practice all sorts o work with either hand and with both together, endeavouring to do them well, elegantly, quickly, without trouble, neatly and promptly.
Detile vie is given out how to pply nge: It should be done quickly, without pain, with ease and with elegance; quickly by despatching the work; without pain by being readily done; with ease, by being prepared or everything; with elegance, so that it may be agreeable to the sight.
In Artiultions, we n esription o the metho o reuing islotion o the shouler tht is still use toy n whih, inee, is terme the Hipporti metho (Figure (Figure 3.2): The patient must lie on the ground on his back while the person who is to eect the reduction is sitted on the ground upon the side o the dislocation; then the operator seizing with his hand the aected arm, is to pull it while with his heel in the armpit he pushes in the contrary direction. A round ball o a suitable size must be placed in the hollow o the armpit, or without something o the kind the heel cannot reach to the head o the humerus.
In Wouns o the He,o there is Te etile esription o trephintion the skull. surgeon is vise:
Ancient Greece 17
Figure 3.2 The Hippocratic method o reduction o a dislocated shoulder. (From an edition o Galen’s works published in Basel in 1562.)
While trephining, oten remove the instrument instrume nt and dip it in cold water, i you do not do this, the trephine becomes heated by the circular motion and heating and drying the bone bon e may burn it and cause an unduly large piece o the bone around the sawing to come away.
Te trephine ws hel either etween the plms o the hns n rotte y the tion o ruing them together, or ws rotte y rosspiee n thong. In the ook On Haemorrhoids, there is rther horriying esription o the surgil tretment o piles, n one n only stn mze t the ourge o the ptient sumitting himsel to this tretment: Having laid him on his back, and placing pla cing a pillow beneath the breach, orce out the anus as much as possible with the ngers and make the irons red hot and burn the pile until it be dried up and so that no part may be let behind.
Another metho o uring hemorrhois is s ollows: You must prepare You prepa re a cautery and an iron that exactly ts t s to be adapted to it, then
the tube being introduced into the anus, the iron, red hot is to be passed down it, and requently drawn out so that the part may bear the more heat and no sore may result rom the heating, and the dried veins may heal up.
However, shoul the ptient eie ginst opertive tretment, vrious lol pplitions re esrie ontining lum, honey, the shell o the uttlesh n vrious v rious other ingreients. Mlri ws very ommon n oen tl in Anient Greee. A prtiulrly serious vrint is ‘lkwter ever’; here, the re ells re roken own y the mlri prsite in lrge numers n the relese hemogloin pigment is exrete in the urine. Te ollowing se report seems to e lssil exmple o this onition: Philliscus lived by the wall. He took to his bed with acute ever on the rst day and sweating; night uncomortable. Third day, until midday, he appeared to have lost the ever ever,, but towards evening acute ever, ever, sweating, thirst, dry dr y tongue, black urine. Fith Sleepless; completely out o his mind. day, distressing night, irrational talk, black urine, cold sweat.
18 Surgery in Ancient Greece and Rome
About midday on the sixth day he died. The breathing throughout as though he were recollecting to do it, was rare and large.
Te irregulr rething o ying ptient, esrie in the lst sentene, is terme Cheyne– Stokes respirtion in ommemortion o two Irish physiins in the 19th entury who rought it to the ttention o the meil proession. Here it is, esrie quite lerly in the Hipporti writings. Not only i Hipportes n his ollowers ly own rtionl pproh to meiine ut they lso l so emphsise the importne o the otor–ptient reltionship. Nothing etter reets the spirit o the Hipporti physiins thn the oth tht ws oviously esigne or young mn to swer on entering his pprentieship to his physiin mster. Tis lys own the regr he must owe to his tehers, n emphsises the overll importne o the ptient n the sreness o the ptient’s onene:
or the enet o the sik, rerining rom ll wrongoing or orruption, n espeilly or ny t o seution o mle or emle, o on or ree. In my ttenne on the sik, or even prt thererom, whtsoever things I see or her onerning the lie o men, whih ought not to e noise ro, I will keep silene thereon, ounting suh things to e s sre serets. Pure n holy will I keep my lie n my Art. While I ontinue to keep this oth unviolte, my it e grnte to me to enjoy lie n the prtie o the Art, respete y ll men in ll ll times. But shoul I trespss n violte this oth, ot h, my the reverse e my lot.
I swer y Apollo the heler, invoking ll the gos n goesses to e my witnesses, tht I will ulll this oth n this ul t his written ovennt ovennt to the est o my ility n jugement. I will look upon him who shoul hve tught me this Art even s one o my own prents. I will shre my sustne with him n I will supply his neessities, neessities, i he e in nee. I will wi ll regr his ospring even s my own rethren, I will teh them this Art, i they woul lern it, without
O relevne to toy’s etes on meil ethis, note the Hipporti prosriptions ginst euthnsi n ortion. Aristotle (384–322 bc) ollowe losely er Hipportes n, lthough not himsel physiin, h prooun eet on meil thought n prtie or sueeing enturies. Inee, he n e regre s one o the gretest sienti geniuses the worl hs ever seen. Aristotle ws the son o physiin n pupil o Plto; lter, he eme tutor to the young Alexner the Gret. Although Aristotle never issete humn eing, he rrie out ntomil ntomil stuies o wie rnge o nimls, n imls, li the ountion o emryology y stuying the eveloping hik n gve n urte ount o the lie o ees. He li the sis o the otrine o evolution, esriing ler o nture sening through lower plnts, higher plnts, insets, sh,
ee ory ovleture ovennt. ennt. n I willyimprt t his Art this presene, every moe o y tehing not only to my own son ut to the sons o him who hs tught me, n to isiples oun y ovennt o oth, oring to the lw o meiine. Te regimen I opt shll e or the enet o the ptients oring to my ility n jugement, n not or their hurt or or ny wrong. I will give g ive no ely rug to ny, ny, though it e ske o me, nor will I ounil suh, n espeilly I will wil l not i womn to proure ortion. I will not ut persons
mmmls to mn. Soon er the eth o Hipportes n Aristotle, the gret ys o Athens rew to n en. Te Meonin, Alexner the Gret, the pupil o Aristotle, onquere Greee, Asi Minor n Egypt, mrhe m rhe through Persi n rehe rehe Ini. In his progress, he oune string o t lest 17 Alexnris, ut it ws Alexnri o Egypt tht ws y r the most importnt. Aer the eth o Alexner, one o his generls, Ptolemy, elre himsel Phroh, took up resiene in Alexnri n there oune gret meil shool n lirry t out 300 bc; into these institutions
louring thewho stone, will leve o thisthis to e oneuner y men re ut prtitioners work. Whtsoever house I enter, there will I go
were importethe sientists, minly Greee. Unortuntely vst lirry, sirom to hve ontine some 700,000 mnusripts, ws urne y
Ancient Rome 19
mo o ntis intent on estroying the pst, phenomenon not unknown in lter perios o history ! We hve to rely, thereore, on the writings o Glen n other uthors to lern something o the Alexnrin shool o meiine. O prtiulr me were two surgeons, Herophilos n Ersistrtos, oth o whom ourishe roun 300 bc. Teir most importnt ontriution ws systemti issetion o humn oies; inee, Celsus sttes tht they tully perorme vivisetions on onemne riminls. Herophilos (ourishe . 300 bc) nme the uoenum n prostte n estlishe the rin s the entre o onsiousness; his nme survives in one o the venous sinuses o the rin rin.. Ersis Ersistrtos trtos (330– 250 bc) is regre y some s the ouner o physiology; he istinguishe the ererum rom the ereellum, note the ierene i erene etween sensory n motor nerves n gve goo esription o the hert vlves. With the sorption o Egypt into the Romn Empire in 50 bc n with the eth o Cleoptr in 30 bc, mrking the en o the Ptolemi ynsty, Alexnri ese to hve gret meil inuene n Rome eme o entrl importne.
Aoring to trition, Rome ws oune in 753 bc y Romulus n Remus. Be tht s it my, trie lle the Ltins live on the site o Rome t roun this time, n y 509 bc, the Romns h riven out the Etrusns Etrus ns n estlishe Rome s
were highly vlue uring the Renissne. Te lst two ooks el with surgery. Celsus esries the surgery o injuries, rtures n n islotions, iseses o the nose, er n eye, o herni, ler stone n vriose veins. He gives n ount o the surgery or trt; this is perorme with neele tht is ‘inserte through the two ots o the eye until it meets resistne, n then the trt is presse own so tht it my settle in the lower prt’. He esries how isese tonsils n e remove: ‘tonsils tht re inurte er n inmmtion, sine they re enlose in the thin tuni, shoul e isengge ll roun y the nger n pulle out’. Among the mny Greek immigrnt surgeons must e mentione Sornus o Ephesus (ad 90–138), 9 0–138), who stuie in Alexnri n ourishe uner the Romn emperor Hrin. As well s writing on rtures n skull injuries, Sornus n e regre s one o the ouners o ostetris. He introue the irth stool, whih h supports or the k n rms n resent-shpe perture. He lso esrie the neessity o emptying the ler eore elivery o the y. Unoutely, the most mous o the physiins o this perio, n inee perhps o ll time, ws Glen (?ad 131–201) (Figure (Figure 3.3). 3.3). He ws orn t Pergmon, in wht is now urkey, evote himsel to the stuy o meiine t n erly ge, n t 21, ws stuent o ntomy t Smyrn. He stuie extensively in Asi Minor n Alexnri; here, he h the opportunity o exmining humn skeleton. In ad 158, he
repuli. By 201 bc,on Rome eete Hnnil, nnexe Crthge the h ost o North Ari n ominte the Meite Meiterrnen. rrnen. Romn surgery ws strongly inuene y Greee. Upper lss Romns onsiere meiine, in generl, n surgery, in prtiulr, s eing eneth the notie o ulture iniviul, n most prtitioners were importe rom Greee. However, it ws Romn nolemn, Celsus (25 bc–ad 50), who wrote gret enylopei eling with philosophy, lw, meiine n proly other sujets roun ad 30. Te only prts o this to hve survive re the eight ooks title De Re
returne Pergmon to the glitors, nto in the nexts 5surgeon yers, evelope n extensive prtie in trumti surgery. He then move to Rome, where he eme physiin to the emperor Mrus Aurelius. He issete n experimente extensively on nimls, sine humn issetion ws not permitte, n wrote vstt num vs numers ers o ook ookss on n ntomy, tomy, physiol physiolog ogy, y, pthology, therpeutis n, inee, on every rnh o meiine known t the time. He proue no spei surgil textook, ut his writings on surgery re sttere throughout his ooks. He esries opertions or vriose
Medicina Celsus some enturies,. ut he ws ws lmost the rstorgotten lssilor meil
vein veins, s, repi re pir r osuture le l e o l ip,the lip, remov removl l o o poly rom rom the nose n intestine erpspenetrting injuries o the t he omen.
ANCIENT ROME
writer to pper in i n print (ad 1478), 1478), n his writings w ritings
20 Surgery in Ancient Greece and Rome
Figure 3.4 Detail o Trajan’ Trajan’ss column in Rome. Surgeons attending to wounded Roman legionnaires. Author’s photograph.
Figure 3.3 Galen; a hypothetical portrait.
Tere ws muh tht ws goo in Glen’s iti writings; or exmple, he gve exellent esriptions o the skeleton n the musulr system, worke out the physiology o the spinl or y injuring it t vrious levels n gve esription o the rnil nerves. However, he h no rel knowlege o the irultion o the loo. He thought tht loo psse rom the hert to the tissues, oth in the rteries n the veins. New loo ws mnuture in the liver n ws urnt up in the tissues like uel onsume y re. He tught tht there were invisile pores etween the right n le sies o the hert hmers, whih llowe loo to ross this rrier.
Te whole orpus o Glen’s knowlege ws regre s sre y lter genertions. Glen’s tehings remine lmost unhllenge or the next 1,500 yers, until the 16th entury, when men lerne one more to oserve nture. Te issetions o Anre Anress Veslius (1 (151 514–1564) 4–1564) (see pge (see pge 33 33 o De Humani Corporis Fabrica, 1543) swept wy mny o Glen’s lse ntomil onepts, n Willim Hrvey (1578–1657) (see pge 44 44 o De Motu Cordis, 1628), using experimentl oservtions, prove the true nture o the irultion o the loo. Beore leving Anient Rome, mention must e me o the highly eient n well-plnne hospitls tht were estlishe throughout the Empire to el with woune n sik soliers. An inspetion inspet ion o rjn’s rjn’s olumn in Rome (Figure 3.4) revels relies o surgeons hr t work ining up the wouns o injure legionnires.
4 The Dark Ages and the Renaissance Alri the Goth n his hores entere Rome in ad 410, n this te mrks the ll o the Romn Empire in the West. Following this, little progress ws me in the rt n siene o meiine, in generl, n surgery, surgery, in prtiulr, pr tiulr, until the eginning o the Renissne er some 1,000 yers o the Drk, or the Mile, Ages. Muh tht h een lerne y the Greeks n Romns ws orgotten. Te prtie o tying loo vessels vessel s to ontrol leeing, or exmple, ws none n ws reple y the rrous prtie o using oiling oil or the re-hot utery. Meil shools i not exist, issetion ws orien y Churh eit n the prtie o surgery ws usully le in the hns o itinernt quks. Aer ll, knowlege other thn tht whih me mn ‘wise unto slvtion’ ws useless; ll tht ws neessry or this ws either ontine in the Bile or tught y the Churh. Siene ws simply isregre. Disese ws the result o ivine isplesure. When sinning eme enough, it woul e punishe y hellre n eternl mntion. A plgue woul e visite on sinul ommunity. Conversely, reovery rom illness oul e rought out y the ith o the sik sujet or through the meium o pryer to Go the meriul. Tis ws the perio o the heling sints, suh s the twin rothers St Cosms n St Dmin, who eme the ptron sints o meiine n who will e enountere gin in the hpter on trnsplnttion (Chpter (Chpter 15) 15).. Illness might e use y sin, ut it lso gve opportunity or reemption mong the sik n n opportunity o servie y the lergy, so tht
estlishments, oune in the Mile Ages, still exist, or exmple, the Hôtel Dieu in Lyon, whih tes k to the 6th entury, n the rst in Lonon, St Brtholomew’s, whih ws oune in 1123 y Rhere, non o St Pul’s Ctherl, in the reign o Henry I. Te strem o sienti meiine, whih rie up in most o the known k nown ivilise worl, survive in three lotions: Southern Itly, the Byzntine Empire n mong the Ars.
thehostels Drk Ages thewnerers estlishment y monks o or thesw poor n inrmries or the ill n ying (Figure 4.1). Some o these
Singer C, Ashworth Underwood E: A Short History of Medicine, Medicine, 2nd edn. Oxord, Oxord Universityy Press, 1962.) Universit
SOUTHERN ITALY Greek ws the lnguge o Southern Itly – meeting groun o Ltins, Greeks n Srens.
Figure 4.1 A hospital ward in the 1500s; the Hôtel Dieu, Paris. Note two patients to a bed, being ministered to by nuns and a priest, and bodies being sewn into their shrouds. (From
21
22 The Dark Ages and the Renaissance
During the Drk Ages, the lmp o ol lerning ws kept light in the university in the town o Slernum (Slerno) 30 miles southest o Nples, whih ws estlishe out the 9th entury ad. At the meil shool, issetion o nimls, espeilly the pig, n osionlly o humn, ws rrie out. Meil n surgil linis existe with oth mle n emle proessors, n there were potheries n sisters o hrity (Figure 4.2). Te meil shool t Slerno rehe its height o me in the 11th n 12th enturies n perpetute the uthority o Hipportes n Glen. Its most prominent teher ws Constntinus Arinus (1010–1087), ntive o Crthge in North Ari (s shown y his nme) n Christin monk. He ws milir with w ith the writings o oth the Greeks n Ars, n his h is trnsltions o the works o the Ar physiins Rhzes n Avienn were responsile or their eing introue into the West. One work mong ll others spre the me o the Shool o Slerno. Tis ws the Regimen Snittis, Sn ittis, poem on populr meiine, iet n househol remeies. It ws originlly written s work o meil vie or Roert, Duke o Normny, the elest son o Willim the Conqueror. It spre throughout the ivilise worl in numerous mnusript opies n remine populr or enturies. Inee, the rst English trnsltion ws pulish pulishe e in 1607 y Sir John Hrington, n Elizethn ourtier, n it is well worth reing toy:
Another piee o meil wisom might not e so soilly eptle toy: Gret hrmes hve grown, n mlies exeeing By keeping in little lst o win. So rmpes n ropies n olikies hve their reeing – For wnt o vent ehin. Drink not muh wine, sup light n soon rise, when met is gone, long sitting reeeth smrt: n ernoon still wking wk ing keep your eyes. When move you n yoursel to nture’s nees, orere them not, or tht muh nger rees, use three physiins physiins still; rst Dr Quiet, next Dr Merry mn n Dr Diet. By the 15th entury, the Shool o Slerno ws elining in reltion to other universities in Itly n ws nlly suppresse in 1811 y Npoleon Bonprte.
BYZANTIUM Between the 3r entury n the ll o Constntinople to the urks in 1453, series o Byzntine physiins kept live the Greo-Romn tritions o meiine. Tese inlue Orisius, Aetius o Ami n Pul o Aegin. Orisius (325–403) o Pergmum, the irthple o Glen, wrote the Encyclopaedia o Medicine whih inlue esriptions o srew trtion n elorte pulleys or the reution o rtures. Aetius o Ami (502–575), physiin to Justinin I, lso proue extensive ompiltions, with emphsis on the Greek meil uthors. However, he is lso reite with the rst esription o ligtion o the rhil rtery or neurysm: An aneurysm located at the end o the
Figure 4.2 Extraction o an arrow rom the arm. (From a 14th century manuscript o Roger o Salerno.)
elbow is thus treated. First careully trace the artery leading to we it rom the armpit to the elbow along the inside
Arabian medicine 23
o the arm. Then we make an incision on the inside o the arm, three or our nger breadths below the armpit, where the artery is easily elt. We expose the blood vessel, and when it can be lited ree with the hook, we tie it with two ligatures and divide it between them. We ll the wound with incense and a lint dressing and then apply a bandage. Next we open the aneurysm itsel and no longer ear bleeding. bleedi ng. We remove the blood clot present and seek the artery which brought the blood. Once ound, it is lited ree with the hook and tied as beore. By again lling the wound with incense we stimulate good suppuration.
Aetius gve esriptions o other surgil opertions, inluing tonsilletomy n exision o hemorrhois, ut whether he tully rrie out the proeures remins somewht outul. Pul o Aegin (625–690) stuie n prtise in Alexnri. He too proue mssive ompenium o Greek n Romn meiine in Greek in seven volumes. His writings were trnslte into Ari n then k into Ltin in the Renissne. Reniss ne. His sixth volume is entirely evote to surgery. He vises removl o the testis in herni repir, esries removl o the rest or ner n trephintion o the skull, n gives this ount o trheostomy:
is divided but the membrane connecting the cartilages… we judge that the windpipe has been opened rom the air rushing through it with a hissing noise and with the voice being lost. Ater the urgency o the suocation has passed over, we pare the lips o the incision so as to make them raw suraces and then have recourse to sutures, but sew the skin only without the cartilage.
Tis esription woul well serve moern textook. Pul’s ounts o leeing, upping n the extensive use o the uterising iron or ll sorts o onitions were going to ominte surgil tretment when the ll o Constntinople isperse mny Greek sholrs n meil mnusripts to Western Europe.
ARABIAN MEDICIN MEDICINE E
In infammation about the mouth and palate and in cases o indurated ton-
Te thir n y r the most importnt preservers o Greek ulture were the Arins. From the eginning o the 7th entury to the eginning o the 8th, in perio o less thn 100 yers, n empire spre rom the t he Arin Ar in Peninsul long North Ari, ross the Strits o Girltr to Spin, n through the Mile Est, Egypt n Plestine to the Cspin Se. Shortly er the onquest o Egypt, Greek works were trnslte into Ari n these, o ourse, inlue the writings o Hipportes, Aristotle n
sils which as obstruct the mouth o the windpipe, the trachea is unaected it would be proper to have recourse to pharyngotomy in order to avoid the risk o suocation. When we engage in the operation we slit open a part o the trachea below the top o the windpipe, about the third or ourth ring, or this is a convenient situation, being ree o fesh and because the vessels are at a distance rom the part which is divided. Thereore, bending the patient’s head backwards so as to bring the windpipe
Glen. were Te writings o the physiins Ini Persi lso trnslte n, y theoen o n the 9th entury, this inux o ulture proue notle sientists n physiins, o whih the most mous were Rhzes, Avienn n Alusis. Rhzes (854–925), ntive o Ry, ner moern ehrn, eme the Cliph’s personl physiin in Bgh. He wrote extensively, gve reul ount o smllpox, whih he ierentite rom mesles, n proue the lrgest n heviest meil ook printe eore 1500! Te Persin Avienn (980–1037) ws hil proigy. By the ge o 10, he oul reite the Korn y hert. He
better view, we a transverse incisioninto between twomake o the rings so that it may not be the cartilage which
trine meiine, in Bgh n pulisheinTe oition o Greek n Canon, prtise Ari meiine. rnsltions o this work were
24 The Dark Ages and the Renaissance
ppering until the 17th entury, the lst eition eing printe in 1663. Shools o meiine were oune in Spin in Coro, Seville n oleo, s well s in the importnt ulturl entres in Ciro, Bgh n Dmsus in the Est. Te most mous proessor in Coro ws Alusis (926–1013) (Figure 4.3), who wrote the only textook in Ari tht trete surgery s seprte sujet. Tis ws the lst o his 13 volumes, terme Te Collection. In his introution, Alusis ompline tht surgery h lmost ompletely isppere s speilty in Spin. Proient surgeons oul no longer e oun s result o the sene o ntomil knowlege; issetion inee ws prohiite. It gives severl exmples o surgil inompetene: I have seen an ignorant physician incise o a scroulous tumour o the neck in a woman, open the cervical arteries and provoke such haemorrhage that the patient died in his hands. I have seen another doctor undertake the extraction o a stone in a very old man. The stone was huge; in perorming the extraction he removed a portion o the bladder wall. The patient died in three days.
Alusis’ textook inlue mny illustrtions o surgil instruments, inst ruments, mong whih n e oun guillotine or removl o the tonsils, tror or rining o siti ui ui rom the ominl vity n onele knie or ringe o n sess. Surgery is to e voie wherever possile, n the
Figure 4.3 Albucasis applying the cautery to the back o a patient.
utery ws preerre to the knie. Bleeing, upping n the use o leehes re importnt mens o tretment. An interesting ning in his hpters on the tretment o rtures is goo esription o rture o the penis. He reommens splinting it y mens o the skin o goose nek, whih is pushe over the memer. In the 12th entury, trnsltion institute ws oune in oleo n vst numers o works on philosophy, mthemtis, stronomy n meiine, representing muh Greek, Romn, Persin Pers in n Inin ulture, s well s s Ari, were trnslte into Ltin n so eme ville in Western Europe.
THE RENAISSANCE Te Renissne (‘reirth’) in the rts, siene, meiine n, o prtiulr interest in this ook, surgery in Europe er the long enturies o the Drk Ages ws not suen phenomenon; inee, it spre over long perio rom its rst glimmerings in the 12th entury to its ull ourishing in the 15th to the en o the 16th entury. Moreover, this wkening ourre t very ierent times in ierent prts o Europe, s it steily spre rom the South. Its uses were multiple: the evelopment o new universities; the introution o printing, whih is ttriute to Johnnes Gutenerg (1400–1468) o Minz, whih llowe more rpi issemintion o knowlege; the onquest o Constntinople y the urks in 1453, whih sw n inux o Byzntine sholrs into the West, espeilly the evelopment, the reisover reisovery, y, o oItly; the onept o lerning or y rther i ret iret oservtion thn y rigi herene to nient uthority; n, nlly, the ppl n on humn issetion isse tion eme less n less strit n ws eventully lie in the erly 16th entury, entury, thus llowing n enormous expnsion in ntomil, physiologil n n pthologil knowlege. knowlege. Certinly, the new universities, whih were estlishe in the 12th n susequent enturies, plye n importnt prt in the wkening o meiine, even though meil tehing t rst ws entirely theoretil, se on the nient Greek n Romn writings, nesie with noorelement o instrution t the ptient’s in the utopsy room.
The Renaissance 25
An importnt lnmrk in meil tehing took ple in Bologn, in Northern Itly, where, uner the inuene o the Shool o Slerno, meil ulty ws estlishe in the 12th entury y Hugh o Lu (1160–1257). Here, puli issetion o the humn oy ws rst perorme in the 14th entury. However, these post-mortem exmintions were or orensi rther thn sienti purposes, in n ttempt to estlish the use o eth o the vitim. Te ntomil issetions were simply use s tehing i to veriy the writings o Avienn, themselves, o ourse, se on those o Glen. Te lssil illustrtions o issetions t tht time (Figure 4.4) show the issetion itsel eing rrie out y lowly servnt, while the proessor, sete lo n loo on his
proessoril hir, res rom lrge tome n ertinly keeps well ler o the looy n smelly proeeings elow. Little is known iretly o Hugh o Lu, ouner o the Bologn shool, ut his ontriutions hve ome own to us in the writings o his most istinguishe isiple, the Dominin rir Teoori (1205–1296) (Figure 4.5). Te ltter ws one o smll group o leris who were trine in surgery s well s meiine. In 1257, he pulishe his Chirurgi, whih ispute the urrently hel view, se on the tehings o Glen n the susequent Ari uthors, tht suppurtion n the ormtion o pus were the neessry junts o woun heling. I this ile to our, it ws promote y the surgeon’s use o pks n ressings o vrious rther oul n gresy ointments.
Figure 4.4 A dissection rom the Anathomia o
Mundinus, 1316. 1316. The proessor sits in i n his proessorial chair while an assistant dissects under his instruction. Compare this with Figure 4.13.
Figure 4.5 Theodoric’s Chirurgia o 1257; 1257; examinations o the breast and rectum.
26 The Dark Ages and the Renaissance
Inee, this theory tht pus ws ‘lule’ n shoul e enourge, hel swy until the tehings o Lister, n ws only enie y numer o inepenent surgil thinkers, o whom Teoori must ount s the rst. He wrote As all modern surgeons proess, pus should be generated in wounds. No error can be greater than this. Such a practice is indeed to hinder nature, to prolong the disease and to prevent the consolidation o the wound.
His vie on woun mngement hs moern ring to it: In whatever part o the body a cut may have occurred, let everything be done in order. Indeed, above all else a wound must be made clean. Secondly, having brought the lips o the wound together, they should be replaced accurately in the position which they had in their natural state; i necessary they should be held there by stitches taken in accordance with the size o the wound. Let the size and depth o the wound determine the closeness and depth o the stitches… ater the suturing has been properly done and the dressings have been careully arranged, let the wound be bound up skilully as the position and condition o the part require, that is to say so that neither the stitches
An importnt ontemporry o Teoori ws Willim o Slet (1210–1277), who tught surgery t Bologn n lter t Veron. At the en o his reer, in 1275, he pulishe his mjor work Cyrurgi, whih ws the rst systemti tretise on surgery to emerge er the Mile M ile Ages. One o its ve volumes ws evote to surgil ntomy. Willim vote the use o the knie rther thn the utery n initite the prtie o quoting ptients he h trete personlly rther thn quoting rom the lssil uthors. His ook ws ull o goo vie to the young surgeon: The wise physician does not commit any wickedness, he does not sow or excite discord among the relatives o the patient, he does not give any advice that is not asked or, he does not employ people who have a bad reputation or a vice which is displeasing to respectable persons. He should shou ld not have any quarrel with the inhabitant o the house, or all this spoils the operation and degrades the physician.
With regr to ees, he vises s ollows: Know just this; a remuneration worthy o your labours, that is to say, a very good ee, makes or the authority o the physician and increases the condence which the patient has in him, even i the physician be o great ignorance (!).
Te thir o the gret surgil tehers o
nor dressings canhave be oten disturbed at all.the And, just as we said beore, do not undo the dressing until the third or ourth or th day i no pain occurs. Aterwards let the dressings be changed every third day unless too much putridity should occur in the wound, in which case it should be changed every day. And always, whenever the dressing is changed, by pressing gently upon the wound with a little wine-soaked tow you may express any retained bloody matter. Aterwards let it be bound up
Bologn ws perhps thesignine. most importnt o them ll s regrs historil Monino e Luzzi (1275–1326), usully known y his Ltin nme o Muninus, must e given the reit o reviving the stuy o the ntomy o the humn oy y systemti issetion, whih h remine ormnt or some 1,500 yers sine the ys o the gret Alexnrin ntomists, Ersistrtus n Herophilus (see Chpter 3). Muninus 3). Muninus ws orn in Bologn n spent his lie there. He reeive his meil egree in 1290 n eme proessor o oth ntomy n surgery t the university, joint hir whih eme e me tritionl tr itionl n persiste p ersiste
according to the let it be kept thusaoresaid until themethod patient and has completely recovered.
or the next two enturies t thisMuninus n other tht Itlin universities. It sys muh out he esene rom the height o his proessoril hir
The Renaissance 27
n perorme issetions personlly. We n presume tht his sujets or issetion were minly exeute riminls, or he writes ‘Hving the oy o one tht h ie rom epittion or hnging on his k…’ n then proees with his ntomil esription. Te tretise on ntomy, Anathomia, y Muninus ws pulishe in 1316 (see Figure 4.4) 4.4) n ws the rst moern textook on the sujet. Mny mnusript opies were irulte, n it ppere in print in 1478. It It remine s stnr stn r text or some 200 yers until reple y the gret Fabrica o Vesalius tht we shll esrie lter. However, lthough Muninus revolutionise the stuy o ntomy y perorming humn issetions personlly n pulily, he himsel ws r rom hving revolutionry revolutionr y outlook on the sujet n remine rmly onvine tht the writings o Glen were inllile. For exmple, the esription o the liver in Glen’s writings, whih ws se on issetion o lower nimls, presente it s hving ve loes. Muninus, in spite o the t tht he oul oserve tht this ws w s not true in mn, sttes ‘the intrinsi n integrl prts re ve loes. Yet in mn these loes re not lwys istint’. A rige etween Itlin surgery n the Renissne o surgery in Frne ws rete y Guio Lnrnhi, known k nown s Lnrn L nrn (1250–1306) (1250–1306) (Figure 4.6), who my e regre s one o the ouners o the Frenh Shool o Surgery. rine in Miln, he le Itly s result o the unrest in the eus etween the Guelphs (supporters o the
28 The Dark Ages and the Renaissance
Here he esries his suessul tretment o ptient with, s ny surgeon toy woul reognise, Luwig’s ngin: I will set in this place a cure that beell a lady in the city o Milan o a lady that was ty winters old and had a quinsy o phlegm that occupied all her neck in ront within and without, except that most o the swelling was outward, and the woman could not speak or swallow. And this woman was under the cure o a young man that was my scholar, and he could not well are therewith and so he was in despair o her lie. I was sent ater and ound her in a wicked state, or she ate no meat or many days beore, and she dared not sleep, lest she should be choked. Then I elt her pulse and it was remarkably eeble, and I elt the base o the abscess and I knew well that she would choke beore the abscess broke externally or internally, or the matter was so great. And then I took a razor and looked where the matter was most collected to accomplish drainage and it was most able under the chin, and I elt the base with my hand and palpated it about that I might beware o nerves and arteries, and there I made a wound and drew out the matter that was corrupt, and all and it was oul stinking matter and all might I not avoid anon. And so the patient had bettered breathing, and her pulse was comorted that the lungs might take in air and herewith the heart was comorted, and then I gave her broth, and that escaped through the most part through throu gh the wound, so I studied how I might best bes t do, and I had made a pipe o silver and put it in her mouth and passed it beyond the wound, that it might ull the place o the throat… and the woman began to be stronger and when the wound was made clean I dried it up and sewed it, and it is in this manner the patient was made well.
Another importnt link etween Itlin n Frenh surgery took ple t the en o the 13th
entury, when Frenhmn, Henri e Moneville (1260–1320), me to Bologn n stuie uner Teoori. In 1301, he move to the meil shool t Montpellier in Southern Frne. Here, s in Pris, guil o rer surgeons h een estlishe in 1252 – inee, rther erlier thn in the pitl ity. Like his teher, e Moneville elieve tht primry heling o wouns ws possile n esirle. His textook, Chirurgie , ws the rst to e written y Frenhmn. It eme populr n mny mnusript eitions hve een preserve. It ws soon trnslte into Frenh rom the originl Ltin n lso ppere in Duth trnsltion. O the mjor opertions, e Moneville only esries mputtion, whih he perorme in ses o gngrene. However, he reognise tht one gngrene h progresse ove the knee the ptient ws oome. Unortuntely, e Moneville ie, proly o tuerulosis, eore his gret textook oul e nishe. An importnt import nt ontriutor to the evelopment o Frenh surgery ws Guy e Chuli (1298–1368), leri who stuie t oulouse, Montpellier n Pris (Figure 4.7). Like Henri e Moneville, he spent some time in Bologn. He eme the personl otor o three suessive Popes in exile in Avignon. In his 60s, he wrote his seven-volume
Figure 4.7 Guy de Chauliac. (From Zimmerman L, Veith I: Great Ideas in the History of Surgery . Baltimore, Williams W illiams and Wilkins, Wil kins, 19 1967 67.) .)
The Renaissance 29
Chirurgia Magna, one o the highlights in surgil
history. It ppere in mny mnusript eitions n, er the invention o printing, in severl lnguges n some 56 printe eitions, one s lte s 1683. As well s quoting extensively rom the gret uthorities o the pst, it is lso se on lietime o prtil experiene (Figure 4.8). De Chuli esrie vriety o opertions or herni, trt extrtion n mputtion, proeure he ws relutnt to perorm. Te rst English surgeon o istintion, John o Arerne (1306–1390), ourishe t out this perio (Figure 4.9). We o not know where he trine, ut he otine onsierle surgil experiene uring the Hunre Yers’ Wr s surgeon rst to the Duke o Lnster n lter to John o Gunt. His wr servie inlue the Bttle o Créy in 1346, n he woul hve seen some o the erliest exmples o gunshot wouns. Leving the rmy in 1349, John settle in Newrk n move to Lonon 20 yers lter. He serve s Serjent surgeon to Ewr III.
Figure 4.9 John o Arderne operating on a stula in ano. (From John o Arderne: Tr Treatises eatises of Fistula in Ano, Ano, Haemorrhoids and Clysters . edited by D’Arcy Power, London, Keegan Paul, 1910.)
Arerne prtiulrly intereste in John retl o iseses nws inee is regre s the ther o protology. He wrote the rst ook eling with this topi, reatises o Fistula in Ano, Haemorrhoids and Clysters. Fistul in no ws prtiulrly ommon in those times ti mes n regre usully s inurle. John relise tht this onition ws oen the result o perinl sess, n oth these onitions were ommon mong the noility who spent mny hours in the sle in their suits o hevy rmour, renhe in swet, lternting in perios o ol n mp. Not surprisingly, thereore, mny o John’s ptients me Figure 4.8 Extraction o a sword blade rom the thigh. (From Guy de Chauliac’s Chirurgia Magna.) Magna.)
rom the upper o rnks o soiety. Hethe relise erly tretment sesses roun nus tht ws importnt n wrote:
Renaissance 30 The Dark Ages and the Renaissance
And I have proved it or certain experience that an abscess breeding near the anus should not be let le t to burst by itsel, but the leech should visually or to eel with his nger the place o the abscess, and whereso is ound any sotness, there, the patient not knowing, be it boldly opened with a very sharp lancet so that the pus and the corrupt blood may go out. Or else, orsooth, the gut or the bowel that is called rectum that leads to the anus will burst within the anus... i it bursts both within and without, then it can never be cured except by a surgeon ull expert in his crat. For then may it rom the rst day be called a stula. (Figure 4.10) 4.10)
For the estlishe stul, John o Arerne’s opertion ws similr to the tehnique employe
toy; ligture ws three through the trk into the nus n then tie tightly to prevent leeing. He then inise the tissue in the grsp o the ligture to ly open the entire trk. I multiple sinuses were present, eh o them h to e opene. He stresse the importne o erre, whih insiste upon lenliness n the voine o irritting ointments n slves use y other prtitioners. Bol s surgeon, John ws lso not hesitnt in hrging lrge ees: Thereore or the cure o Fistula in Ano, when it is curable, ask he competently o a worthy man and a great a hundred mark or orty pounds with robes and ees o a hundred shillings term o lie by year. O lesser men orty pound or orty mark ask he without ees and take he naught less than a hundred shillings. For never in my lie took I less than a hundred shilling or cure o that sickness. During the long lossoming o the Renissne, gret vnes were lso eing me, o ourse, in mny rnhes o siene n isovery. Te se voygers o Spin, Portugl, Engln n the Low ountries were enlrging the known worl; Christopher Columus rehe the Ameris in 1492. Nihols Copernius (1 (1473–1543 473–1543)) pulishe On the Revolutions o the Celestial Spheres n ple the Sun, not the Erth, t the entre o the Universe. Glileo Glilei (1564–1642) invente the telesope, n the ompoun mirosope n n
Figure 4.10 Illustrations o stula in ano and the surgical instruments used in its surgery. Note the multiple external openings o these complex cases o anal stulae. (From John o Arderne: Treatises Tr eatises of Fistula in Ano, Haemorrhoids and
ws one o(Sntorius) the thers o(1561–1636), moern physis. Sntorio Sntorio proessor o meiine t Pu, mesure the pulse o ptients using the penulum n stuie the oy temperture y mens o thermometer evise y Glileo – he my e regre s the ther o moern physiologil mesurements. Willim Hrvey (1578–1657), who stuie t Cmrige n Pu n ws physiin to Chrles I, pulishe De Motu Cordis (Te Motion o the Heart ) in 1628 n emonstrte, on the sis o etile et ile niml n humn oservtions, the mehnism o the irultion o the loo. Te nl element
Clysters . edited by D’Arcy Power, Power, London, Keegan Paul, 1910.)
in Hrvey’s rgument, theveins tulvi pssge o loo rom the rteries to the pillries, s
The Renaissance 31
he postulte, ws emonstrte y Mrello Mlpighi (1628–1694) o Bologn in his mirosopi stuy o the lung o the rog. Mlpighi estlishe the t he mirosopi ntomy s sujet;
he emonstrte the ne ntomy o the spleen, liver n skin, n li the sis o erly emryology y his stuy uner the mirosope o the evelopment o the hik emryo.
Figure 4.11 Leonardo da Vinci, drawings o the skull. The lower one demonstrates the maxillary antrum
(or the rst time).©(From at Windsor Royal Collection 2008, the HerQueen’s Majesty Collection Queen Elizabeth II.) Castle, reproduced with permission o The
32 The Dark Ages and the Renaissance
THE RENAISSANCE OF ANATOMY In the history o surgery, the importne o the Renissne ws tht it sw the irth o moern ntomy. For enturies, surgeons n ntomists ‘sw wht they elieve’ – the tehings o the nient Greeks n Romns, oen hne own to them in inurte trnsltions. Now they were to lern to ‘elieve ‘ elieve wht they sw’ n to trust their own oservtions. Mny o the gret rtists o the Renissne, inluing Dürer, Mihelngelo n Rphel, egn to stuy ntomy losely, relising tht knowlege o the musles n ones in prtiulr ws essentil or urte reproution o the humn orm in their pintings n sulptures. Some, t lest, tully engge in issetion or this purpose; this ws unoutely true o Leonro Vini (1452–1519), who rrie out etile stuies in some 100 issetions o the humn oy. He me metiulous rwings o the internl viser, v iser, the pregnnt uterus n the oetus, injete wx to stuy the ventriulr vities o the rin n introue ross-setionl stuies o the lims. He never pulishe his work lthough his super illustrtions (Figure (Figure 4.11) 4.11) hve ome own to us toy. Tere n e little out tht he shre his etile knowlege with others. Interestingly, he elinete the mxillry sinus, the vity in the mxill,, whih so regulrly gets inete s ommxill plition o the ommon ol, entury eore its ‘oil’ esription y Nthniel Highmore (1613– (1 613–1688), 1688), physiin t Sherorne (‘the ntrum ntrum o Highmore’). We hve lrey note the importnt ontriution o Muninus, proessor o surgery n ntomy t Bologn until his eth in 1326, who vote n perorme iret issetion o the humn oy. However, it ws the surgeonntomist Anres Veslius (1514–1564), more thn two enturies er Muninus, who most signintly ete the evolution o the siene o meiine t this perio n must e regre s the ther o moern ntomy (Figure 4.12). Veslius ws orn in Brussels, the son, grnson n gret-grnson o physiins n potheries, rstJous t Louvin n(1478–1555), then Pris. Heren his stuie teher ws Sylvius who, lthough he introue the injetion
Figure 4.12 Andreas Vesalius, rom De Humani Corporis Fabrica 1543.
tehnique or the stuy o loo vessels, ws onrme Glenist who tught rom the textook rther thn rom issetion, in the est meievl trition. Veslius move k to Louvin n then to Pu, where he reeive his otorte in meiine with highest ws immeitely ppointe s theistintion proessor on surgery t the ge o 23. In the ootsteps o Muninus, ut unlike his immeite preeessors, he perorme his own issetions. His msterly emonstrtions ttrte rows o stuents rom ll over Europe. In 1538, Veslius pulishe his abulae anatomicae Sex , six sheets o ntomil hrts, three epiting the rteril, venous n vl vsulr systems, whih were proly rwn y Veslius himsel, n three rwings o the skeleton, rwn y the Flemish rtist, John Stephen o Clr (?1499–?1546), who h trine uner itin. Tese were immeite suess, ut ntomil were soon ollowe, in n 1543, y the most mous tls n text o ll time, the De Humani Corpora
The Renaissance o anatomy 33
Figure 4.13 Vesalius dissect s in ront o his students at Padua. The rontispiece ronti spiece to De Humani Corporis Fabrica 1543. Fabrica 1543.
), in Fabrica (Te Structure o the Human Body ), seven volumes, o totl o more thn 700 pges, n with 250 illustrtions. Tis ws pulishe in Bsle when Verslius ws w s mere 28 yers o ge. Tere is still something o mystery, n some
elieve to e the erless mn with the oppy ht immeitely to the le n ove the he o Veslius in the rontispiee (Figure 4.13), ut this he is ‘rushe ‘rus he out’ rom the seon eition, pulishe in 1555, some 9 yers er Clr’s eth.
ete, s to the rtist (or rtists?) the Fabrica John Stephen o Clr is the mostolikely, ut his. nme is nowhere mentione in the text. He is
wooutme illustrtions urte nTe oviously iretly re romhighly the issete oy; they re works o rt tht n e, n inee
34 The Dark Ages and the Renaissance
hesittion in pointing out mistkes in lssil writings, even those o the sre Glen. For this, he ws ttke y numer o his tehers n ollegues, inluing Sylvius. Veslius relise tht mny o the mistkes in Glen rose rom issetions hving een me on nimls n n not on mn. For exmple, the humn liver oes not possess ve loes, nor is the kiney loulte s it is, or exmple, in the pig. Other lssil errors er rors were simply nonsense. nonsense. For exmple, men o not hve ri missing (‘Am’s ri’) ut hve 12 on eh sie just s in the emle! Glen h postulte tht pores existe etween the right n le hmers o the hert to enle loo to pss rom one to the other. Veslius pointe out in the Fabrica tht this ws not so: Not long ago I would not have dared to diverge a hair’s breadth rom Galen’s opinion. But the septum is as thick, dense and compact as the rest o the heart. I do not, thereore, see how even the smallest particle could be transerred rom the right to the let ventricle through it.
Figure 4.14 The muscles o the anterior aspect o
the body. A woodcut rom the Fabrica o 1543. Illustrations such as these are oten better than those ound in some modern texts!
requently re, use to illustrte toy’s textooks n letures (Figure 4.14). Although n instnt suess, the Fabrica (so well-known tht its shortene title is oen use) lso rouse envy n ttk. Veslius h no
Overll, Veslius orrete 200 o Glen’s ntomil mistkes. A yer er the pulition o his msterpiee, Veslius retire rom emi lie t the ge o only 29 n entere the servie o Chrles IV n then Philip II o Spin s prtising surgeon. In 1563, he set o on long pilgrimge to the Holy Ln, ut on his return ws shipwreke on the islet o Znte in the Peloponnese n ie o exposure n hunger. o ey ogm ws oen ngerous in those ys. Te Spnish ntomist Mihel Servetus (1511–1553) ws urne t the stke y orer o John Clvin or the heresy o writing tht the loo, hving een mixe with ir in the lungs, psses k into the hert. He ws true mrtyr or ntomil ntomil truth. t ruth.
5 The age of the surgeon-anatomist: surgeon-anatomist: Part 1 – from the mid-16th century to the end of the 17th century Following the renissne in ntomy n the pulition o Te Structure o the Human Body y Anres Veslius in 1543, there egn long
their tehings n their writings, lone or in omintion, justiy their inlusion in these pges.
perio o surgil evelopment – perio tht will tke us up to the isoveries o nesthesi n ntisepsis in the mi-19th entury. Tese 300 or so yers were hrterise y the evolution o the surgeon-ntomists; these were men well quinte with the ntomy o the humn oy, most o whom spent onsierle prt o their trining in the isseting room, n who woul push orwr the rontiers o surgery s r s possile with the primitive mens ville to them. Rememer their isvntges: no mens exept lohol or opium to ssuge the gonies o their mnipultions; no knowlege o teri n the uses o the woun inmmtion tht eeville their opertions; primitive ies o the oy’s physiology n o the unerlying pthology o most o the iseses they enountere – ner, tuerulosis, syphilis n so on. Yet, within these severe limittions, they evise methos o eling with rtures, ler stones, rteril injuries n iseses, hernis, trts n mny superil tumours. O ourse, the ptient woul only sumit to the surgery i the onition renere lie in peril, the eormity unerle or the pin intolerle. We n perhps est illustrte this perio y esriing some o the surgil gints o these enturies; men who, y their exmple, their ingenuity,
THE 16TH CENTURY One o the leing surgeons o the 16th entury is knowlege s the ther o wr surgery, n he will e enountere gin in Chpter 9. 9. Amroise Pré (1510–1590) (Figure (Figure 5.1) 5.1) ws rer-surgeon who trine t the Hôtel Dieu in Pris, stresse the importne o ntomy, n inee, kept with him or mny yers issete speimen. He writes I attest having a body given me ater execution by the Criminal Lieutenant. I dissected it 25 years or more ago. I dissected nearly all the muscles musc les o the right side so when I wanted to make some incision, seeing the parts aresh made me more sure in my work; the let side was let complete. compl ete. To To preserve it better, be tter, I punctured it in many places with a punch to let the liquor penetrate deeply into the muscles and upper parts. One can still see the entire lungs, heart, diaphragm, stomach, spleen and kidneys. Similarly one can see the hair o the beard, the head and other parts, the nails which I have noticed growing evidently ater cutting them several times. 35
surgeon-anatomist: Part 1 36 The age o the surgeon-anatomist:
hemorrhge rom loo vessels in trum n in lim mputtion. He esries the ollowing se: A sergeant o the Châtelet got a sword thrust in the throat in Pré-au-Clercs [the Pré-au-Clercs eld outside the walls o Paris which in Paré’s day was much used or private duels. Being convenient to his house, he treated many o the casualties!]. It cut the external jugular vein completely across. As soon as he was injured he put a handkerchie on the wound and came to my house to nd me. When he removed the handkerchie blood fowed very reely. I immediately tied the vein towards its root; thus it was stanched and he recovered, thanks to God. I you had ollowed your method o stanching the blood with cauteries, I wonder i he would have recovered. I Figure 5.1 Ambroise Paré. (From Keynes G, ed.: The Apologie and Tr Treatise eatise.. London, Falcon Press, Pres s, 195 1951.) 1.)
Here is n exmple rom Pré’s Pré ’s se reports report s tht emonstrtes the vlue o unmentl ntomil knowlege: At this point I want to advise the young surgeons that sometimes the testes are not yet descended into the scrotum. They are retained in the groin and make a painul tumour, and since it is considered an intestinal hernia it is treated with astringent plasters, trusses and bandages to restrain it. This increases the pain and prevents descent o the testis. Not long ago I was called to such a case and ater nding a single testis in the scrotum, the child not having been castrated, had the plaster and the truss he wore removed. I told the ather to let the child run and jump to help the testis descend to its natural natu ral place, which it did little by little without any complication.
One o Pré’s most importnt ontriutions ws to teh the use o the ligture in preventing
believe he would have died in the hands o the operator. o perator.
Pré pulishe his extensive writings, not in Ltin (whih he never lerne), ut in his ntive Frenh so tht the humlest surgeon pprentie oul lern rom him. Reing the ove pithy exmples o his style, one is not surprise t the populrity o his numerous ooks, whose pulitions were spre over his long lie, rom his rst Te Method o reating Wounds Made by Firearms in 1545, little work o 64 pges illustrte with 23 gures, to his Apologie and reatise reatise Containing the rips in Divers Places in 1585. ontemporry A Made less well-known Frenh-orn
o Pré, ut one who well eserves our reognition s shining str o Renissne surgery, ws Pierre Frno (1500–1561). He ws orn in Provene to humle prents n h little shooling, ut ws erly pprentie to rer-surgeon. As Protestnt, he ws ore to ee rom Frne n prtise his lling in Lusnne in Switzerln, lthough he eventully returne to Ornge in Frne n his mjor work, reatise on Hernias, ws pulishe in Lyon in 1561, just eore his eth. He eplore the t tht surgeons o his y rejete therisks use involve o open opertions. Tis ws euse o the in suh proeures, whih they woul oen leve in the hns o
16th 6th centur y 37 The 1
hrltns. Frno ws oviously ol surgeon who rrie out wie rnge o opertive proeures known t tht time. He esries in etil his metho o ril surgery or strngulte herni, evising n inision t the se o the srotum, whih he lime ws less ngerous thn the higher inision. He lso rrie out trt n plsti surgery on the e n esrie new metho or operting on le lip. In the surgery or ler stone he ws eqully inventive; in Chpter 12, 12, we shll enounter him gin s the rst surgeon to remove ler stone suessully suessul ly vi n ominl ominl pproh. In Itly, Gspre gliozzi (1545–1599) ws nother exmple o pioneer who i not er to ttempt, with ll its iulties t tht time, mjor surgery. He n e regre s the ther o plsti surgery, n we shll isuss him gin in Chpter 15. 15. He ws orn, trine n prtise in Bologn, where he ws ppointe s proessor o surgery. wo yers eore his eth, he pulishe On the Surgery o Mutilations by Graing, whih esries the opertive methos evolve y him over mny yers o tril n error n whih were illustrte with numerous ler rwings. He esrie reonstrution o the ers n lips, n his esription o replement o the nose, lost either s result o trum or o syphilis, y mens o n rm p prete the peile p o Hrol Gillies in the First Worl Wr y some 300 yers (see Chpter 9). Tis pinting is in the Hll o the Compny o Brer-surgeons, Lonon (reproue y kin
George II. Viry’s genius ly in ministrtion n orgnistion, so tht in 1540, he no out use his royl inuene to otin hrter rom Henry to inorporte the Compny o Brers n the Guil o Surgeons into the Compny o Brersurgeons. Tis event hs een immortlise in the pinting y Hns Holein, the rtoon o whih hngs in the Royl College o Surgeons o Engln n the pinting itsel in the hll o the Compny o Brers. Tis is proly the est known meil group portrit in the Unite Kingom (Figure (Figure 5.2). Viry eme the rst Mster o the Brersurgeons Compny, whih eree tht surgeons shoul no longer t s rers n tht rers shoul restrit their surgery to entl extrtions. ex trtions. Te ompny ws entitle to ne unliense prtitioners in Lonon n lso to hve the oies o our exeute prisoners eh yer or the purpose o issetion (Figure (Figure 5.3). Apprenties 5.3). Apprenties were to serve or 7 yers n then to tten the Brer-surgeons Hll or exmintion. Even er qulition, memers o the ompny were olige, uner penlty o ne, to tten the ntomil issetions n the letures given in their Hll. Tey were llowe to tret ‘ll outwr hurts n tokens o isese’ ises e’ ut were not permitte to minister m inister meiine or internl omplints. Te ompny existe until 1745 when the union ws issolve, n then the surgeons n rers reverte to their ormer inepenent sttes. Te Worshipul Compny o Brers still exists s one o the nient Livery Compnies o the City o Lonon. Te Compny o Surgeons ws the orerunner o the Royl College
permission theinworshipul Te rtoon is to eoseen the Royl ompny). College o Surgeons o Engln. In Engln, trivil event ws to hve importnt onsequenes in the evolution o surgery in this ountry. In 1525, King Henry VIII visite Mistone in Kent. Tere he met lol surgeon, Toms Viry (?1495–1561), who trete his hroni vriose uler o the leg with some suess. Viry ws promptly ppointe s Surgeon to the King, n in 1530, eme Mster o the Compny o Brers s well s the Serjent Surgeon. Tis ppointment rrie with it the requirement to
o Surgeons o Engln. Viry himsel ws no pioneer surgeon. He ppere to ignore the isoveries o Veslius even though pirte version o the Fabrica h een pulishe in English y Toms Geminus in 1545. Tree yers lter, Viry’s A reasure or the Englishman Containing the Anatomie o Man’s Man ’s Body ws pulishe. Tis ppers to e n
ompny the sovereign ttle(1703–1773) – uty lst lle upon when Johninto Rny ws present t the ttle o Dettingen with King
its inuene retrogre one; its populrity seems to hvews reste on the useul reipes or meiments tht it inlue.
rigement o 14th entury mnusript n is nothing more thn meievl reli trnslte into English. However, it prove to e populr work n rehe its 11th eition in 1651. As textook on the sujet it ontriute nothing t ll, inee
38 The age o the surgeon-anatomist: Part 1
Figure 5.2 Henry VIII presents the charter to the Company o Barber-surgeons, 1540. Thomas Vicary stands immediately to the right o the King.
Figure 5.3 John Bannister giving the visceral lecture at the Barber-surgeons Hall, 1581. (From a print at Barber’s Hall. The original is in the Glasgow University Library.)
The 16th centuryy 39 16th centur
Viry ws ppointe to the st o St Brtholomew’s Hospitl in 1548. Te use o his eth n his ple o uril re unknown, n there oes not pper to e monument erete in his memory. Te estlishment o the Compny o Brersurgeons ws typil o move throughout Western Europe t out this time to orgnise surgeons into proessionl oies n to istinguish them rom the quks, rers, itinernt toothrwers n hrltns tht provie muh o the surgil re o ormer times. In Sotln, eree y Jmes IV estlishe the Inorportion o Brer-surgeons in Einurgh in 1505, n in 1599, the Fulty o Physiins n Surgeons reeive its hrter in Glsgow. King Philip II o Spin, in his pity s Count o Holln, in 1556 grnte the Brer-s Brer-surgeons urgeons Guil in Amsterm, only reently ethe rom its ssoition with the log n pttern mkers, the sttus o n n inepenent orgnistion with the nnul privilege o isseting humn ver. ver. For this purpose, the juiiryy h to ple t the ispos juiir isposll o the ompny the mortl remins o riminl who h een exeute. In Pris, the rer-surgeons h orme guil in the mi-14th entury. Sine they rrie out menil uties suh s rering n venesetion, they were rther espise y the emi surgeons o the College o St Côme. Sine the rer-surgeons were more essile, greter in numer n, perhps, heper thn their emi ollegues, they were ertinly ertin ly more populr, n
Figure 5.4 Thomas Gale. (Royal College o Surgeons o England.)
Gle writes this vivi ount o the mltretment o the sik poor y quks: In the year 1562 I did see in the two
unoutely ute to this. the me o Amroise Pré ontriTree British surgeons o the 16th entury re worthy o note. Toms Gle (1507–1587) (Figure 5.4) serve s n rmy surgeon uner Henry VIII n ws Serjent Surgeon to Elizeth I. He sueee Viry s Mster o the Compny o Brersurgeons. Gle wrote extensively – in English rther thn Ltin – n vigorously ttke quks n hrltns who pose s surgeons. In 1563, he pulishe his Excellent reatise o Wounds made with Gunshot in whih, like
hospitals in London called St Thomas’ Hospital and St Bartholomew’s Hospital to the number o 300 and odd poor people that were diseased o sore legs, sore arms, eet and hands, with other parts o the body, so sore inected that 120 o them could never be recovered without loss los s o a leg or o an arm, a oot or a hand, ngers or toes, or else their limbs crooked so that they were either maimed or else undone orever. All these were brought to this mischie by witches, by women, by countereit ras-
Pré, tht n gunshot wouns were poisonehe y enie gunpower neee to e trete y oiling oil.
cals that o take upon them them o to their use the art, not only robbing mo ney money but o their limbs and perpetual health.
Part 1 40 The age o the surgeon-anatomist: Part
And I, with certain other, diligently examining these poor people, how they came by their grievous hurts and who were their chirurgeons that looked unto them and they conessed that they were either witches, which did promise by charms to make them whole, or else some women which would make them whole with herbs and such like things, or else some vagabond rascal which runneth rom one country to another promising unto them health only to deceive them o their money.
Willim Clowes (1540–1604) (Figure 5.5) h n extensive experiene o wr surgery, oth on ln n t se, n on the sis o this wie experiene, evise surgil hest or the use o militry surgeons with reully ompile list o the rugs n supplies it rrie. Lter he serve on the surgil st o St Brtholomew’s Hospitl,
Figure 5.5 William Clowes. (Royal College o Surgeons o England.)
Lonon. He pulishe ook on syphilis, isese whih me uner the re o the surgeon, title A Brie and Necessary reatise, ouching the Cure o the Disease Now Usually Called Lues Venera s well s A Proved Practice or All Young Young Chirurgions, Concerning Burnings with Gunpowder and Wounds Wounds Made with Gunshot etc. He inite in his writ-
ings n ernest wish to pss on the enets o his oservtions to younger surgeons n gin wrote in English rther thn Ltin. He too i not elieve tht gunshot wouns were poisone y gunpower, lthough he eme onvine tht t ht it ws possile or ullet to e intentionlly smere with poison eore ring. Peter Lowe (1550–1612) (Figure 5.6) ws one o the rst n, n, ertinly, erti nly, one one o the most impori mportnt o the erly surgeons in Sotln. He le Sotln t out the time t ime o the Reormtio Reormtion n in
Figure 5.6 Peter Lowe. (Royal College o Surgeons o England.)
17th 7th centur y 41 The 1
tht ountry n proly stuie meiine in Orlens in Frne. Aer 30 yers o prtie on the ontinent o Europe, inluing 6 yers o wr surgery with the Frenh rmy, he settle rst in Lonon in 1596, where he pulishe ook on the ‘Spnish sikness’ (yet nother euphemism or syphilis) eore returning to Glsgow in 1598 s slrie surgeon to the City. He must hve een mn o onsierle uthority n persusion, euse his eorts resulte in the ountion o the Fulty o Physiins n Surgeons o Glsgow with the powers to exmine n liense ll prtition prtitioners ers o meiine n surgery surger y in Glsgow n the surrouning ountrysie, whih t tht time emre the entire western portion o Sotln. In 1597, Lowe pulishe his Chirurgerie, whih is the erliest systemti work on the whole o surgery to e pulishe in Britin n is in prt in the orm o ilogue etween the teher, Peter Lowe, n his son John. Muh ontins reerenes to his own oservtions n experienes, s is shown in the ollowing extrts on neurysm, whih I hve trnsliterte into moern English: Aneurisma is a tumour sot to touch, the which is engendered o blood and spirit under the skin and muscle which happens in diverse parts o the body, chiefy in the sides o the cragg (the neck). The cause is either dilatation, incision or rupture o the artery, which oten chances to women in the time o their birth, to trumpeters, criers, watermen and others who use violent labour and great crying or other violence by the which some o the artery does dilate. The signs are tumour, in pressing on with the nger, great pulsation. The tumour is o the same colour as the rest o the skin, sot to touch, yielding to the nger, by reason o the blood bloo d and spirit retire unto the arteries and parts adjacent, having removed the nger it presently returns with a noise or bruit by reason o the blood and spirit that return… those which are supercial in the exterior parts, as the head, legs and arms may be knit and are curable; cura ble; those
which are proound and interior, in the breast as oten happens to those who sweat excessively o the venereal sickness and otherwise; also those in the neck under the arms and the roots o the thighs and when there is great dilatation o the arteries are not curable, but death ensues within a ew days, or at the least are very perilous and i the tumour be opened, the patient dies presently. This happens oten times by the unskilulness o ignorant barbers and other abusers who meddle with this art… as I have oten seen. Such ignorance do esteem all tumours that are sot should be opened as common apostumes (abscesses). I remember in Paris in 1590 there happened such a disease to a valiant captain on the right side o his cragg, which, I as Surgeon Major to the regiment was sent or, and ound it to be an aneurisme [sic so not to be touched… we did ordain [sic] remedies to let the increase o it, which receipt being sent to the Apothecary, who beore had seen the said captain, did think it no meat medicine or an apostume, as he termed it. So presently he sent or an ignorant barber like unto himsel, who did swear unto the captain that they had salves and charms or all sores, so without urther trial did open it, with a lancet to void the matter (as they thought) done,such the spirit and blood which came being orth with violence that the captain died a ew hours ater.
THE 17TH CENTURY Te 17th entury ws not mrke y ny gret vnes in surgery, surger y, whih, one gin, ws minly onerne with eling with the injuries o pee n wr n with superil n reily essile lesions. Te outstning militry surgeon o the entury ws n n Englishmn, Engl ishmn, Rihr Wisemn (?1621– (?1621–167 1676), 6), o whom more will e her in Chpter 9.
42 The age o the surgeon-anatomist: Part 1
Jmes Yonge (1646–1721), himsel the son o nvl surgeon in Plymouth, serve his pprentieship s nvl surgeon n spent muh o his time t se. Cpture y the Duth, he ws prisoner in Amsterm or yer. Yonge introue the p opertion or lim mputtion, whih llowe muh more rpi heling thn the lssil guillotine proeure. Initilly, single p ws use, ut the opertion unerwent mny moitions n usully oule p reple the single p. John Wooll (1569–1643) h extensive experiene s surgeon oth t se n on shore in the servie o the Est Ini Compny, n or some yers, te s surgeon to olony o English merhnts in Poln. He wrote numer o ooks, inluing Te Surgeon’s Mate in 1617, whih ws one o the erliest ooks on meiine t se. Te Est Ini Compny eree tht every ship’s surgeon in its employ ws to own opy. Wooll invente new kin o trephine or use in rnil surgery, ut greter lim to me ws his remrkle voy o lemon juie s ure or survy, some three enturies eore the isovery o vitmin C. He wrote I nd we have many good things that heal the scurvy well on land but the sea chirurgeon shall do little good at sea with them, neither will they endure. The use o the juice o lemons is a precious medicine and well tried, being sound and good, let it have the chie place or it will deserve it… it is to be taken each morning two or three spoonuls.
It ws not until the pulition o A reatise o in 1753 y the nvl surgeon su rgeon Jmes Lin the Scurvy in (1716–1794) tht ontrolle tril showe tht survy oul e prevente y the equte use o resh ruit, the t he use o whih eme wiesp w iespre re in the English Nvy. On returning to Engln, Wooll ws ppointe Surgeon t St Brtholomew’s Hospitl n serve on its st st or over 20 yers. He lso serve s Mster o the Compny o Brer-surgeons. B rer-surgeons. Willim Cowper (1666–1709) (Figure 5.7) wrote mgnient n eutiully illustrte ook o ntomy, muh rom o whih ws ‘lie’ without knowlegement the mgniently illustrte ntomil ntomil tls tl s y Govert Biloo Bi loo (1649–171 (1649–1713) 3)
Figure 5.7 William Cowper. (Royal College o Surgeons o England.)
o Te Hgue n lter o Leyen. Cowper gve the rst privte lessons in ntomy in this ountry. He esrie the smll glns t the se o the ler whih re still known s Cowper’s glns. Perhps his gretest ontriution ws to inspire Willim Cheselen – mn we shll shl l meet s one o the importnt surgeons o the 18th entury – with his love o ntomy n surgery. Willim Cowper Cow per shoul not e onuse with Mr Cowper, onesetter in Leiester, who lso h elings with Cheselen n who my lso hve inspire him to unertke reer in surgery. It ws the ltter who, s Cheselen, wrote mny yers lter: Set and cured a racture o my own cubit (orearm) when I was a boy at school. His way was, ater putting the limb in a proper posture, to wrap it up in rags dipped in themixed; whites o and a little wheat four thiseggs drying, grew sti, and kept the limb in a good
17th 7th centur y 43 The 1
posture. And I think there th ere is no way better than this in ractures, or it preserves the position o the limb without strict bandage, which is the common cause caus e o mischie in ractures.
Oviously orerunner o plster o Pris! On the ontinent o Europe, perhps the est known surgeon ws Johnnes Shultes (1595–1645), ommonly lle Sultetus. He ws orn in Ulm, Ul m, n t the ge o 15, trvelle to Pu to stuy meiine. He prtise rst in Pu, then in Vienn, ut t the ge o 30, returne to Ulm n serve s ity physiin until the time o his eth. His me rests on his Armamentarium Chirurgicum , pulishe in Ulm er his eth y his nephew who ws lso his nmeske – Sultetus the Younger. Te Armamentarium Chirurgicum ws remrkle ook tht ontine omplete tlogue o ll known k nown surgil instruments, o ll the methos o nging n splinting, n o vst numer o opertive opert ive proeures, proeu res, ll o whih wh ih re illustrte n over the ull rnge o opertive proeures known in those ys – opertions on the mouth n ers, mputtions (Figure 5.8), nsl reonstrution er the mnner o gliozzi, mstetomy or ner o the rest n esren setion (Figure 5.9). Although the originl ws in Ltin, trnsltions into Frenh, English n Germn me the work ville to surgeons throughout Europe who lke the ility to re
Figure 5.9 A caesarian section. From the Armamentum Chirurgicum o Chirurgicum o Scultetus.
the originl Ltin. A sign o the importne n populrity o the ook is tht its illustrtions were reproue in mny other pulitions throughout Europe over the next two enturies. In Frne, Pierre Dionis (1643–1718) ws ppointe y Louis XIV in 1673 to rry rr y out puli ntomil issetions n opertions in the Jrin u Roi in Pris or the enet o stuents n without ee. Tis mrke the eginning o the importnt Frenh Shool o Surgery, whose inuene we will see over the next two enturies. Dionis himsel pulishe importnt textooks on ntomy n on surgil opertions. Te interest o Louis XIV in surgery ws no out ue to his own suerings rom
Figure 5.8 Amputations using a saw and a mas-
stul i n no. in Hisresorts physiins ptients to vrious helth to trysent outseverl the eets o onservtive tretment: our o them spent yer tking the sulphur wter o Brèges, our were sent to tke the sline wters o Bouronne-lesBins; ll ile to e ure. Tey then trie slve invente y Jesuit monk on urther ‘volunteers’ with no eet. Chrles Frnçois Félix (1650–1703), the ourt surgeon, ws lle into onsulttion. He himsel h never operte upon stul in no n promptly prtise on ptients with this isese ollete rom the hrity hospitls o Pris. He then onstrute silver istoury ( nrrow-le
sive chisel, together with a selection o cauterising irons. (From the Armamentum Chirurgicum o Chirurgicum o Scultetus.)
knie) or the opertion, in whih ws rrie outthe in the King’s ehmer Versilles erly in morning o 18 Novemer 1686. Present were three
44 The age o the surgeon-anatomist: Part 1
other surgeons n our potheries, whose uty ws to hol the ptient still, priest, the Minister o Wr n Mme e Mintenon (one o the King’s vourites). wo inisions were me with the knie with urther eight uts o sissors to ly the trk wiely open. Further opertions were rrie out on three osions in Deemer to prevent too rpi heling o the woun n, y 11 Jnury, the King ws well enough to wlk in the Orngerie. Full reovery took ple n Félix ws elevte to the noility, given ountry estte n mgnient ee o 300,000 livres. Surgery eme shionle n Félix, together with other populr surgeons, ws omre with requests or similr opertions rom memers o the ourt even i they h nothing wrong with them! I the 17th entury ws unremrkle in regr to signint surgil progress, it is importnt to note tht mjor vnes were me with knowlege o the untions o the oy. Inee, the 16th entury my e si to hve herle the renissne o ntomy, wheres the 17th entury sw the eginnings o moern physiologil knowlege. Sntorio Sntorio (1561–1636), lle Sntorius, stuie meiine t Pu, prtise meiine in Poln n nlly returne to Pu s proessor o meiine. He ws the rst to stuy the pulse rte in ierent iniviuls using penulum s timing instrument n the rst to use thermometer to mesure oy temperture in the stuy o iseses in humn ptients. He shione hir suspene rom weighing mhine, whih he use to stuy himsel uner ierent
Figure 5.10 William Harvey’s ingenious demonstration o the unction o the venous valves, using the supercial veins o the arm. (From De Motu Cordis , 1628.)
y Mrello Mlpighi (1628–1694) o Bologn, who emonstrte the pillries in the lmost
onitions resting n n e regreoseting, the ther o n the sleeping, moern stuy o metolism. Willim Hrvey (1578–1657), er eution t Cmrige, stuie in Pu n returne to Lonon to prtise s physiin in 1602. Aer mny yers o experimentl n linil stuies (Figure 5.10), he pulishe De Motu Cordis (Te Motion o the Heart ) in 1628, one o the most importnt works pulishe in the el o meiine. In this, Hrvey showe onlusively tht the irultion o the loo ws ontinuous n uniiretionl. Although A lthough he emonstrte the existene o irultion, he i not see the pil-
trnsprent lungout o extensive rog. Using his mirosope, he lso rrie investigtions o the minute struture o the skin, spleen n liver n me importnt investigtions in emryology. Te lymphtis were rst esrie y Gspre Aselli (1581–1626) o Cremon, who note ne uts lle with remy ui in the mesentery o the smll intestine o the og. Tese were esrie in his ook pulishe the yer er his eth, n his illustrtion o these so-lle ltels ws the rst time olour ws use in meil textook (Figure 5.11). Aselli 5.11). Aselli himsel hi msel elieve tht the ltels psse to the liver. Te mens y whih lymph
lry vessels through whih loo is onveye rom the terminl rnhes o the rteries to the smll triutries o the veins. Tis remine to e shown
returns to the irultion theisovere gret veinsyinJen the nek – the thori ut –vi ws Pequet (1622–1674) in 1647, n the onnetion
The 17th 17th centur y 45
Figure 5.11 Gaspare Aselli’s demonstration o the lymphatics in the mesentery o the small intestine o the dog (the lacteals). The rst demonstration o this system and the rst-time colour was used in a medical illustration. (Royal College o Surgeons o England.)
o the lymphtis o the gut with the thori ut ws emonstrte y Ol Ruek (1630–1702), Sninvin working t Pu. Te spirit o physiologil enquiry is well emonstrte y the experiment o imothy Clrk,
his nings in volume title Miscellanea Curiosa Medico-Physica, rst pulishe in 1663:
who stuie the eets o splenetomy in the he ws prtiulrly intereste in the eet o og; this proeure on the niml’s sex lie. He pulishe
the odog York, I excised theand spleen romDuke a stray o medium mediu m size not well nourished.
In March 1663, with the assistance o Master Pearse, a surgeon in ordinary to
46 The age o the surgeon-anatomist: Part 1
A trnsverse inision ws me roun the spleen, rom whih the enrge little reture extrue prt o its owel n intestines s well s the spleen itsel, whih we pulle out ompletely without ny ligture ut prtly y setion n prtly y igitl igitl seprtion. Ten, hving reple the other prts, we immeitely lose the woun with stithes n entruste the snrling niml to the re o n ssistnt who h to re-suture the woun shortly erwrs when the stithes were torn open y the enrge niml. From then on, however, the og reovere its helth, eme tmer thn eore, n ws susequently enthusisti in its pursuit o sexul tivity. In this mnner, the og live or yer muh hppier lie, n even put on esh. In the ollowing April, through wht use we o not know, t the ront o the oor, it ws oun e n rigi with ruise he. When we opene the ver we oserve tht the eshy prts were reer n the t everywhere whiter thn in other nimls. Te mesentery ws seen, in the spes etween the vessels, to e trnsluent, s one sees in the septum luium. Te rnhes o the t he vessels were, however, overe over where the t ws whitest. All the other re prts were more ori thn is usully seen in other nimls, n the white prts muh whiter, n this presente not isplesing pperne. But where the spleen h een exise, prt o the owel n spleni rtery were seen to e rmly here to the interior sr o the woun. In 1676, in the sme journl, Clrk reporte remrkle linilttempt: se o the eets o loss o the spleen in suiie
A butcher named William Willia m Panier, Panier, living in the village o Wayord, near Crookhome in the County o Somerset, being greatly in debt, and earing that lest he should be arrested, was constrained to go into hiding. The constables were about to capture him, and becoming desperate, and in order to avoid them, he drove a butcher’s knie into his abdomen on the let side, thus causing a great wound through which part o the omentum, and o the intestine, and also the spleen protruded. The constables were horried, and let the man or dead, as they believed. For three days the wound remained without a suture, but at last a surgeon was summoned. The surgeon replaced the intestines, and cut away part o the omentum, along with the spleen. The man rapidly recovered rom the eects o the wound, and or the whole o the ollowing year remained in good health and spirits. He soon aterward emigrated to New England, where not long ago he was so ar living a healthy lie. Doubeny Tuberville, M.D., a man renowned among our ellow-countrymen or his treatment o diseases o the eyes, has collaborated with me in communicating this observation.
Unortuntely, I n n no etils o imothy Clrk, who ws oviously keen experimentlist n linil oserver oserver..
6 The age of the surgeon-anatomist: surgeon-anatomist: Part 2 – from the beginning of the 18th century to the mid-19th century THE 18TH CENTURY Te 18th entury hs een terme the Age o Enlightenment. A wve o philnthropy n humnitrinism swept through Europe with the onept tht Soiety is olletively responsile or its epenents, its mentlly ill (in 1793 Phillipe Pinel, 1745–1826, ree rom their hins the luntis in the Biêtre Hospitl, Pris), its soliers n silors, the poor, women n hilren n the sik. In Britin, Briti n, it sw the estlishment o the gret voluntry hospitls to omplement the ol religious ountions. For exmple, in Lonon, the two originl hospitls oune y the monks, St Toms’ (1173) n St Brtholomew’s (1123), were e to y Westminster Hospitl in i n 1716 (Figure 6.1), Guy’s in 1726, St George’s in 1733, the Lonon in 1740 n the Milesex in 1745. Tere ws wkene onern with resusittion resu sittion o the rowne: rowne : in 1767, 1767, the Soiety or the Reovery o Drowne Persons ws oune in Amsterm; in 1771, Humne Soiety ws orme in Pris; P ris; n 3 yers lter, l ter, the Humne Soiety (lter to eome the Royl Humne Soiety) ws estlishe in Engln in 1774 y Dr Willim Hwes (1736–1808), Lonon pothery who otine his MD t the ge o 45. Hwes rst h to overome the reul superstition then urrent tht it ws unluky to resue, n espeilly to try tr y to revive, the pprently rowne.
Figure 6.1 Westminster Hospital, rst o the Voluntary Hospitals. Hospital s. Founded in 171 1716. 6. This print
shows third building, erected in 1735, Gate. at the corner the o James Street, now Buckingham
One wy in whih he i this ws to oer rewr o our guines or ny suessul resusittion. Te 18th entury lso sw stey growth in the tehnology n the stture o surgery, prtiulrly in the shools o surgery in Frne n Britin, n the ommenement o surgil trining in the newly inepenent Ameri. Still it ws the se tht the min enevours o the surgeon were irete to the tretment o rtures n other injuries, the ringe o lolise inetio in etions ns n removl o superil lesions. Only when the 47
Part 2 48 The age o the surgeon-anatomist: Part
ptient oul suer his miseries no longer woul he llow the surgeon to el with his gngrenous leg y mputtion, his strngulte herni y relie rom the knie or his ler stone y lithotomy (see Chpter 12), 12), y wht ws oen lethl opertion.
FRANCE
We hve lrey note the improve sttus o surgery uner the ptronge o Louis XIV. Tis ontinue in the reign o Louis Loui s XV, XV, whose personl surgeon, Georges Mreshl (1658–1736), suessor to Félix n surgeon t the Chrité Hospitl in Pris, persue the King to estlish L’Éole e Chirurgie (the Shool o Surgery) in Pris in 1724 enowe y government government grnt. gr nt. In 1775, this shool ws promote to the title o Collège e Chirurgie n house in spleni new uiling. Mreshl, together with his suessor t the Chrité Hospitl, Frnçois e L Peyronie (1678–1747), oune sienti soiety in 1731, whih eme the Royl Aemy o Surgery in 1748. Tis rought together the he surgeons uner the hirmnship o the King’s surgeon. Regulr meetings n nnul prize ompetitions were orgnise n regulr mémoires were pulishe. Suh mesures ensure tht surgery shoul hve sienti sis s well s eing prtil rt. Sujets tught t the Collège inlue physiology, pthology, hemistry n otny, s well s regulr letures on surgery n ntomy. In ition, the lmost lmos t ontinuous ontinentl wrs o the entury provie muh prtil
Figure 6.2 Jean-Louis Petit. (Royal College o Surgeons o England.)
o preoious innt who even s hil preerre issetion isse tion to plying with wit h his toys. By the ge o 17, he ws ssisting his teher, the ntomist n surgeon Alexis Littré (1658–1726), to teh ntomy. At the ge o 18, he eme n rmy r my surgeon eore
experiene mny young Anotheror importnt step surgeons. ws tht, in 1743, the surgeons t lst eme ivore rom the rers. A royl eree prohiite mster surgeons rom working, in ition, t the rers’ tre, with whom they h previously orme single guil. In 1768, the pprentieship system tht te k to the Mile Ages ws olishe or the Mster’s exmintion in surgery n reple y ompulsory ttenne t the Collège e Chirurgie. Tus, uring the entury, Pris eme one o the prinipl entres o surgery in Europe; mong its leing tehers were Petit, Choprt,
returningPetit to Pris, estlishing privte shool o surgery. ws one o the ouner memers o the Aémie e Chirurgie n eventully eme its iretor. He ws the rst to rin n inete mstoi (with suess), invente tourniquet with srew to e ple iretly over the rtery, n improve the tehnique o lim mputtion y inising the skin n musles more istlly to the one, whih llowe the ‘ps’ to ll over the stump n thus spee up the heling o the woun. In his reatise o the Diseases o Bones, Petit esries in etil the mehnis n tretment o rtures y extension. He etils the on-
Desult nws Biht. Jen-Louis surgeon Petit (1674–1750) (Figure 6.2) the outstning in Pris in the rst hl h l o the 18th entury. He ws something
strution o inline rture eHe tht ssiste trtion y using n plne. lso use overhe ropes to help the ptient in moving out the e.
France 49
In ontriution to the Mémoires o the Royl Aemy, he esries three ptients in whom the inme gll ler h een inise inise in the mistken ignosis o n sess. One o the ptients reovere n, rom the post-mortem stuy o the two tht ie, Petit onlue tht reovery ws ue to hesions tht h orme etween the gll ler n the ominl wll. Although he h proly not one this opertion himsel, he vise opening the inme gll ler n removing the stones; whih ws the opertion o holeystostomy, n ws not, in t, to e use until it ws perorme y John Bos in Inin in 1867 (see Roinson J O: Te Biliry rt. Austin, Silvergirl, 1985, p. 92). Petit’s 92). Petit’s ontriutions to the tretment o rest ner will e esrie in Chpter 11. Frnçois Choprt (1743–1795) pulishe with Desult the inuentil raité des Maladies Chirurgicaless et les Opérations qui leur Conviennent Chirurgicale in 1799 in two volumes. His nme is perpetute in the mputtion through the oreoot t the mitrsl joint using long p o the sole o the oot to over the stump. Pierre-Joseph Desult (1744–1795) (Figure 6.3) ws the most inuentil surgeon n eutor in Frne uring the seon hl o the entury, lthough his reer ws estroye n his eth ws hstene y the politil isturnes o the Frenh Revolution. Desult ws one o seven hilren o poor pesnt mily, ut he soon prove to e highly intelligent young mn n eme pprentie
Figure 6.3 Pierre-Joseph Desault. (From Zimmerman LM, Veith L: Great Ideas in the History of Surgery . New Ne w York, Dover, 1961.) 1961.)
est known were Xvier, Biht n DominiqueJen Lrrey, one o the most mous militry surgeons (see Chpter 9).
to lol the rer-surgeon. movee to Chirurgie. Pris n ttene letures t theHeCollège At the ge o 22, he egn to give privte lessons in ntomy n surgery n, lthough not goo leturer, he ttrte lrge numer o stuents y the lrity o his onepts. He insiste on the importne o prtil issetion n emphsise tht the untions o the prts uner stuy n their pthologil hnges were more importnt thn ry r y ntomil etils. Eventully, Eventully, he eme hie surgeon, rst t the Chrité n then t the Hôtel Dieu. Here he pioneere esie tehing rther thn orml letures n se emon-
Desult’s surgil ontriutions were n Among ingenious nging tehnique or rtures o the lvile (Figure (Figure 6.4) 6.4) n ligtion o the emorl rtery or poplitel neurysm in 1785, ew months eore John Hunter perorme this proeure, er whom it is nme. In 1791, he remove lrge right-sie thyroi mss, ve inhes in imeter, in emle ptient t the Hôtel Dieu. It ws perorme y metiulous issetion n ligtion o the superior n inerior thyroi rteries – remrkle proeure to perorm without nesthesi. Te woun hele slowly, n the ptient le the hospitl ompletely ure on the
strtions the newly mphithetre, whih wsinpke with onstrute oth omesti n oreign stuents. Among his mny surgil trinees, the
34th y.hievement, Desult’s lie, Atpost-opertive the height o his like tht o so mny others, ws interrupte y the
surgeon-anatomist: Part 2 50 The age o the surgeon-anatomist:
n opertive surgery. He eme ompletely engrosse in his sienti stuies n none surgery. His importnt ontriution ws to point out tht orgns were not homogeneous strutures ut were ompose o ierent tissues. He ie t the ge o 31, proly o tuerulous meningitis, hving suere or yers rom pulmonry isese.
ITALY
Figure 6.4 Desault’s method o bandaging or racture o the clavicle. (From Desault’s Oeuvres Chirurgicales .) .)
Itly, whih h plye suh n importnt prt in the evelopment o surgery rom the time o the Renissne, lost muh o its inuene in the 18th entury. Te exeption ly in one mn, Antonio Srp (1752–1832) (Figure 6.5). He me rom humle kgroun n ws tught y his unle, priest. By the ge o 15, he psse the entrne exmintion to the meil shool t Pu n me uner the inuene o Giovnni Morggni (1682–1771), the proessor o ntomy. Morggni li own the priniples o moern pthology, n in his mjor textook On the Sites and Causes o Diseases, he reully esrie eh ptient’s se history, the events leing to the nl illness n
Revolution. He ws tully rreste in 1793, ut ws relese, y populr outry, er ew ys in prison. By now, ll institutes o higher eution h een lose own, lthough he ws ppointe proessor o the new Éole e Snté in 1794; here, to his ismy,He surgery n meiine meii ne were e tught together. ws lle to tret the to9-yer-ol Duphin who ws ill in prison n evote lvish re to his young ptient, ut he himsel eme violently ill with wht might hve een some jil inetion n ie in 1795 t the ge o 51. Xvier Biht (1771–1802) h rie ut outstning reer. Te son o surgeon, he trine in Lyon; with the outrek o wr in 1793, he serve s militry surgeon. Te ollowing yer, he joine Desult t the Hôtel Dieu, where his hie relise tht he h n outstning young stuent. Biht ws tken into Desult’s home n eme his privte ssistnt the ge o23. On the ethn o his hie, Biht t estlishe privte shool lortory, where he tught ntomy, physiology
Figure 6.5 Antonio Scarpa. (Royal College o Surgeons o England.)
Germany 51
eth, n then the etile results o the postmortem exmintion with n ttempt to explin how the symptoms were the results o pthology. Srp eme Morggni’s ssistnt n personl seretry, n rom him evelope his gret interest in meil siene, espeilly pthologil ntomy, n his metiulous pproh to investigtions. Srp qulie t the ge o 20, n 2 yers lter l ter ws ppointe proessor o ntomy n linil surgery t the University o Moen, where he e to his uties tht o teher in ostetris n hie surgeon to the militry hospitl. He visite Pris n Lonon, where he eriene Perivl Pott n the rothers John n Willim Hunter, n returne to Itly to the post o proessor o ntomy t Pu in 1783. Srp’s tlents were mny; he ws rillint ntomist, surgeon with espeil tlents in ophthlmology n orthopeis, n outstning teher n n exellent rtist who illustrte his own numerous texts (Figure 6.6). His nme is eponymously ommemorte in Srp’s si, the rous lyer o onnetive tissue o the lower ominl wll, Srp’s tringle, the emorl tringle o the groin, n Srp’s gnglion on the eighth rnil nerve. He stuie the nerves o hering n o smell, esrie the roun winow n the lyrinthine ui o the er n gve the
rst etile esription o the innervtion o the hert. He gve n urte esription o sliing inguinl herni, illustrte, o ourse, y his own rwings, n evise shoe or lu oot, whih is the sis o the one use toy. Aginst ll these hievements must e ple his ruthless hrter, promoting his vourites n estroying his enemies. He never mrrie ut h severl illegitimte sons, whose reers he ostere. Soon er he ie, t the ge o 80, his reputtion ws ttke n the insription on his memoril tlet ws ee. However, his he, preserve in spirit, remins to the present y in the meil museum in Pu!
GERMANY Up until this perio, Germny h lgge ehin the other Western Europen ountries in surgery; itinernt one-setters, stone-utters n hrltns vie with rer-surgeons or the prtie o this rt. One Germn surgeon, however, stoo out s omprle in importne to ny other in the 18th entury, Lorenz Heister (1683–1758) (Figure ( Figure 6.7). 6.7). He ws orn in Frnkurt m m Min n prove to e gie stuent. He stuie rst rs t t the University University o Giessen, then Leyen n then Amsterm, where he st t the eet o two outstning surgeons n ntomists, Freerik Ruysh (1638–1731) n Johnnes Ru (1668–1719). In 1707, he went s surgeon to the Duth in their wr ginst the Frenh n then returne to Leyen or urther stuy uner Bernhr Bern hr Alinus A linus (1697– (1697–1770) 1770) n the gret
Figure 6.6 Anatomical illustration prepared by
Hermn Boerhve (1668–1738); otine otorte in 1708. Tt yer, he he returne to his his uties s n rmy surgeon. In 1710, Heister ws ppointe s proessor o ntomy n surgery in the University o Altor in the Repuli o Nürnerg, ut eore tking up his post, he me tour o surgil entres in Gret Britin. Briti n. It ws uring his time t Altor tht Heister pulishe the rst eition o his gret General System o Surgery (Figure 6.8). 6.8). Shortly er its pulition, he ws ppointe to the Chir o Antomy n Surgery t the University o Helmstt, in the Duhy o Brunswik. Lter, the proessorship o otny
Scarpa. (Saggio (Saggio di osservazioni e d’esperienze sulle principali mallattie degli occhi . Venice, Giannantonio Pizzani, 1802. 1802.))
ws e to his uties, he ws responsile or the estlishment o itsn mous otnil gren. Heister remine t Helmstt or the next
52 The age o the surgeon-anatomist: Part 2
rtures, luxtions, tumours n ulers o ll kins. O the severl opertions perorme on ll prts o the oy. O the severl nges pplie in ll opertions n isorers to whih is prexe n introution onerning the nture, origin, progress n improvements o surgery, with suh other preliminries s re neessry to e known y the younger surgeons’. Being work o 30 yers’ experiene, it is remrkle piee o work n oes, inee, over the whole o surgery known t tht time n inlues opertive miwiery. In eling with strngulte inguinl herni, Heister rst o ll gives etile ount o ttempting reution o the herni y mnipultion. However,
Figure 6.7 Lorenz Heister. (Royal College o Surgeons o England.)
When the surgeon perceives that it is impossible to return the intestine, and nds by the great infammation, pain and vomiting, that the disorder will be atal, he should acquaint his patient and his riends with the great necessity there is or him to undergo the operation, to prevent a mortication and consequent death… the integuments are next to be taken up on each side o the tumour by one hand o the surgeon and another o the assistant while he makes a longitudinal incision with the scalpel upon the middle o the tumour, ater which he is to dilate or remove the sides o the wound rom each other; but i the integuments cannot cann ot be thus elevated by
38 yers. Its shool o surgery hieve position o gret importne ue to his inuene, ut its eminene isppere rpily er Heister’s eth in 1758. Heister’s gret ontriution to tehing ws his surgil textook, rihly illustrte il lustrte with 38 opper pltes (Figure (Figure 6.9, n 6.9, n see Figure 11.3). It 11.3). It ws originlly written wr itten in Germn, in whih it ws pulishe in seven eitions, n ws lso trnslte into ten English n three Ltin eitions s well s eing trnslte into Spnish, Frenh, Itlin n Duth.
reason the violent infammation, the surgeonoshould then grasp the tumour between the thumb and orenger o his let hand, making the incision downward in a right line and with a light li ght hand but he may not divide deeper than the skin so as to injure the intestine. intestin e. A director is then to be introduced between the tumour and divided skin and the wound is to be enlarged upward and downward by an incision knie or scissors, ater which the sides o the wound are to be drawn asunder by hooks or
Imy hve o thethis; hitsEnglish o 1755 t sie opy s I write ull titleeition ontinues ‘ontining the t he otrine n mngemen mngementt o wouns,
the ngers and theadiposa remaining part o the membrana careully divided ‘til the intestine or its sacculus
Germany 53
Figure 6.8 Frontispiece o Heister’s Medical, Chirurgical and Anatomical Cases and Observations English English
edition, 1755.
54 The age o the surgeon-anatomist: Part 2
Figure 6.9 Copper plate illustration o amputations o arm and leg. (From Heister’s General System of Surgery . London, English, 5th edition, 1755.) 1755.)
o the peritoneum appear to view… to avoid the intestine a small opening may be made in the peritoneum with the point o the scalpel to introduce the nger and i the surgeon should meet with a quantity o water or lymph discharging itsel its el by the small aperture [sic] in that membrane, he should not be surprised, being no more than usual, but should proceed to divide that integument upwards with a pair o scissors or the scalpel ‘til he comes to the rings o the abdomen; and i any large blood vessels should be by accident divided, which would obscure the work, it should either be taken up with a needle and thread or compressed by the ngers o an assistant who should also draw out the blood with lint or a sponge. I the intestine then appears to be ound, it is to be returned by a gentle pressure through the ring o the abdominal muscles. But i any fatus or contained aeces prevents its return, they should be rst gradually pressed press ed out and i that also proves insucient the ring o the abdominal muscles should be divided…
when the ruptured part has been dilated and the intestine returned, the wound is to be dressed with linen compresses and retained by the bandage, though some scariy the ring o the abdomen to make a rmer cicatrix and prevent a return o the disorder. di sorder.
No surgil onition known t tht time ws too mjor or Heister not to vise thereon nor too minor to e overlooke; thus, he gives this vie or the tretment o n inete ingrowing toenil: The great toenail sometimes turns too much in on one side so as to enter the fesh and cause violent pain and infammation to such a degree that the patient cannot walk. The most general cause o this disorder is the wearing o too straight or narrow-toed shoes, which they will do well to avoid, who are desirous o being ree rom the complaint. But in order to set the nail at liberty rom the tender fesh into which it has xed itsel the patient’s oot is rst to be held or an hour ho ur in hot water, to molliy the indurated nail and skin, and that the water may penetrate the arther, it
Britain 55
may be proper to scrape o the outer surace every two or three minutes with a penknie or a piece o glass, ater which the inected nail is to be gently elevated with the ngers or a probe and a piece o sot dry lint interposed betwixt it and the fesh, and so bound up with a compress dipped in warm spirit o wine, which operation is to be repeated again the next day ‘til the pain and infammation disappear. I the method beore described proves insucient to remove the disorder, we must then have recourse to the knie. In order to which, the oot being macerated in warm water, as beore, is then to be placed and held in a convenient posture upon a chair by the hands o an assistant and the operator must insinuate the strong nail scissors gradually under the injurious part o the nail, to cut it o and then extract it, i it does not come away o itsel with a pair o pliers; and though the operation itsel itse l may give the patient no small pain or a short time, yet he will quickly perceive the advantage by a more lasting ease.
In ition to this mgnum opus, Heister wrote textook o ntomy tht ppere in 25 eitions in vriety o trnsltions, ooks on eye surgery, otny n other sujets s well s mgnient olletion o se reports. One o these, esriing the mngement o mssive tumour o the rest, will e esrie in Chpter 11.
BRITAIN It ws, however, in the Unite Kingom in prtiulr tht surgery ourishe in the 18th entury, espeilly Lonon, where oth the ol n the newly oune tehing hospitls were ttrting stuents rom ll over these islns n rom ro. A numer o nmes towere ove the rest, n their inuene in uene n e elt even toy; they inlue Willim Cheselen, Perivll Pott, John Hunter n Henry Cline. Willim Cheselen (1688–1752) (Figure 6.10), the son o Leiestershire rmer, me to Lonon
Figure 6.10 William Cheselden. Cheselden. (This ( This portrait hangs in the Council Room o the Royal College o Surgeons o England.)
s l o 15 n ws pprentie to Jmes Ferne (1672–1741), young surgeon reently ppointe to the st o St Toms’ Hospitl. He omplete his pprentieship in 1710, eoming Freemn o the Brer-surgeons’ Compny. At tht time, no one ws giving regulr letures in ntomy in Lonon, so the ollowing yer, t the ge o 23, he egn privte ourses in this sujet. In 1714, he ws reprimne Compny, y the Court o we Assistnts the Brer-surgeons’ n re inotheir minutes: Our master acquainted the Court that Mr Wm Cheselden a member o the Company did requently procure the dead bodies o maleactors rom the place o execution and dissect the same at his own house as well during duri ng the Company’s public lectures as at other times without the word o the Governors and contrary to the Company’s By-law in that behal by which means becomes more dicult or the beadles to bring away the Company’s bodies and likewise
surgeon-anatomist: Part 2 56 The age o the surgeon-anatomist:
drew away the members rom the public dissections and lectures at the Hall. The said Mr Cheselden thereupon called in but having submitted himsel to the pleasure o the Court with a promise never to dissect at the same time as the Company had the lectures at their Hall not without leave o the Governors or the time being the said Mr Cheselden was censured or what had passed with a reproo or the same pronounced by the Master at the desire o the Court.
Tis reprimn my well hve ise Cheselen ginst the Brer-surgeons; lter, he ws one o the instigtors, in 1745, o the rekup o the Compny, when the Compny o Surgeons ws orme s seprte oy with John Rny (1703–1773), Serjent Surgeon to George II, s its rst Mster. Cheselen, in turn, eme the seon Mster to the new Compny. Te Compny, s suh, h short lie sine in 1800 it eme the Royl College o Surgeons o Lonon whih, in turn, evolve into the Royl College o Surgeons o Engln in 1843. In pssing, we shoul note the iulties in prouring oies or issetion, usully exeute riminls, n n there ws risk tre or the ‘resurretionists’ in igging up reently urie orpses rom the grveyrs. Even the oy o eggr oun e rom hoking with re outsie St Toms’ Hospitl ws rrie into the hospitl y pssing strnger, who otine goo prie or ‘his rother’s oy’. A gruesome inient reore in the minutes o the Brer-surgeons’ Compny in 1740 use muh onsterntion. Te oy o youth ge 16 lle Duell, hnge or rpe, revive when li out or issetion. He ully reovere within ouple o hours ollowing looletting n glss o wrm wine. Constntly glning roun the thetre in terror, he muttere repetely ‘on’t, on’t, on’t’.. He ws returne on’t’ ret urne to Newgte Prison, P rison, ut ws ortuntely reprieve n trnsporte. It ws si tht he lter hnge his nme to Deverell, eme prosperous merhnt n presente gile lether sreen to the ompny or sving his lie. Young Cheselen relise the nee or goo, onise textook o ntomy in the English Engl ish lnguge
n pulishe Te Anatomy o the Human Body in 17133 when he ws 25. Tis 171 T is ook mintine minti ne his populrityy mong stuents or more thn entury, with ulrit the 13th eition ppering in 1792. It ws lso pulishe in Ameri, where seon eition ws pulishe in 1806. Te reson or its populrity ws tht it ontine the essentils o gross ntomy mingle with physiologil n linil isussions. Tus, he illustrtes the t tht n rtery rupture y trtion goes into spsm n oes not lee with the ollowing report: The gure o Samuel Wood, a miller, whose arm with the scapula was torn o rom his body by a rope winding round it, the other end being astened to the cogs o a mill (Figure 6.11). This happened in the year 1737. The vessels being thus stretched bled very little,
Figure 6.11 Case o avulsion o the shoulder. (Cheselden’s The Anatomy of the Human Body 1778, author’s copy.)
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the arteries and nerves were drawn out o the arm, the surgeon who was rst called placed them within the wound and dressed it supercially. Next day he was put under Mr Ferne’s care at St Thomas’ Hospital, but he did not remove the dressings or some days. The patient had no severe symptoms, and the wound was cured by supercial dressings only, the natural skin being let almost sucient to cover it.
Cheselen ws unoutely the oremost surgeon o his y in Lonon. He ontinue to insist on the importne o soun knowlege o ntomy or the meil stuents n on issetion to otin this. He serve on the st o St Toms’, Westminster n St George’s Hospitls n ws pioneer o ophthlmi surgery n mster o utting or the ler stone. We shll isuss more o this in Chpter 12. In his 50th yer, Cheselen gve up ll his positions to evote himsel entirely s surgeon to the Royl Hospitl Chelse, whih h een oune y King Chrles II or the re o ol n isle solier pensioners. He ie in 1752 on visit to Bth, n this notie ppere in the Gentleman’s Magazine in April o tht yer:
Perivll Pott (1714–1789) (Figure 6.12) ws okney, orn in Treneele Street in the City o Lonon, the son o greengroer. He ws pprentie to Willim Nourse (1701–1761), one o the two surgeons t St Brtholomew’s Hospitl, t the ge o 15 n otine his Freeom o the Brersurgeons Compny in 1736 t the ge o 22. Nine yers lter, he ws ppointe s n ssistnt surgeon to Brt’s n in 1749 eme ull surgeon. He ws highly intelligent person with rienly personlity n ws shrew linil oserver. He vise gentleness in tretment, eshewing the use o the utery, utery, ustis n irritting irritti ng meiments. At the ge o 42, riing to hospitl on rosty morning, he ws thrown rom his horse n suere ompoun rture o the tii. He relise the seriousness o the sitution, reuse to e move, n sent or two erers. When they rrive with their poles, he purhse oor rom nery shop, h this nile to the poles n n then h himsel rrie on this strether to his home. He ws vise y his surgeons to hve immeite mputtion, ut s the instruments were eing got rey, his ol hie, Willim Nourse, rrive n
William Cheselden Esq.; an eminent anatomist, lithotomist and surgeon to the Royal Hospital Chelsea; at Bath; he had drunk ale ater eating hot buns, upon which being very uneasy he sent or a physician who advised immediately, immediately , which advice, had vomiting he taken it might, it is thought, have saved his lie.
Te ignosis o this tstrophe is sujet or isussion. Cheselen ws urie in the grouns o the Royl Hospitl, n his tom n e seen there to this y. It ws my gret privilege to serve or mny yers s surgeon to this hospitl in very istnt line o esent rom Willim Cheselen. Tere remins one more inient o interest in the lie o this gret mn. In 1748–1749, he h s one o his pupils John Hunter, t tht time youth o 20. It my well e tht the vetern ntomist inspire the youth with some o his enthusism.
Figure 6.12 Percivall Pott. (Royal College o Surgeons o England.)
58 The age o the surgeon-anatomist: Part 2
vise onservtive tretment. Te rture ws reue, the woun hele n his leg ws sve. During his prolonge immoilistion, Pott use the time to ommene his series o texts tht re hrterise y their high literry qulity n welth o linil oservtion. His rst tretise, Ruptures, ws ollowe y others on ongenitl herni, lhryml stul, he injuries, hyroele, rtures n islotions, plsy o the lower lims n severl other onitions. Pott me numerous originl oservtions. Tus, he rst esrie ‘himney sweep’s ner’, n n thereore e regre s pioneer o ouptionl isese. Tis is ner o the srotum ue to rinogeni gents in soot. He wrote The ate o these people seems singularly hard; in their early inancy, they are most requently treated brutally, and also starved with cold and hunger; they are thrust up narrow and sometimes hot chimneys, where they are bruised, burned and almost suocated; when they get to puberty, pubert y, they become peculiarly liable to a most noisome, painul, and atal disease.
He esrie Pott’s puy tumour, the swelling o the slp over n extrurl sess, n enumerte the signs y whih it n e ierentite rom n extrurl hemtom. He lso reognise the lui perio tht n preee the om o extrurl hemorrhge n s tht the initil onussion uses loss o onsiousness tht my
Figure 6.13 Pott’s disease o the spine (tuberculosis). This specimen is in the Gordon Museum at Guy’s Hospital. It demonstrates the bodies o the third, ourth and th thoracic vertebrae have been destroyed. In ront o them is a thick-walled abscess cavity that is compressing the trachea. From a child aged three.
helthy iniviul. Inee, he relise tht pthologil proesses re ‘the perversion o the nturl
lenperio into tht o the rin ompression this o luiity. He vise the usewithout o trephine in he injuries n employe it muh s moern neurosurgeons o when the presene o umultion o loo eneth the skull nnot otherwise otherw ise e exlue. He gve lssi esription o tuerulous isese o the spine (Pott’s isese o the spine) (Figure 6.13) n etile esription o rture islotion islotion o the nkle, gin still sti ll to this y lle lle Pott’s Pott’s rture (Figure ( Figure 6.14). 6.14). John Hunter (1728–1793) (Figure (Figure 6.15) ws 6.15) ws the rst surgeon to pply the inutive system o oser vtion n experimenttion to the stuy o isese.
tions osthe He is rightully regre the niml ther oeonomy’. moern sienti surgery in the British Isles. His philosophy n e summe up y mous remrk he me in letter to his rien n pupil Ewr Jenner (1749–1823), o smllpox vintion me, opy o whih is reully preserve in the Hunterin Museum o the Royl College o Surgeons o Engln: ‘Why o you sk me question, y the wy o solving it. I think your solution is just; ut why think, why not try the t he experiment?’ experiment?’ Inee, n importnt prt o Hunter’s ontriution to surgery ws the wy he inspire mny
He relise tht,ontothe unerstn eets o the lso isese proess oy, it isthe rst neessry to stuy the orm n untion o the norml
o his surgil stuents thewith experimentl metho, whih they woulintke them n pss on in turn to their own stuents. Among his
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Figure 6.14 Pott’s racture. A specimen prepared by Sir Astley Cooper and preserved in the
Gordon Museum Guy’s Hospital. It demonstrates an obliqueatracture o the lower end o the bula with gross lateral dislocation o the ankle joint.
pupils, we must mke mention o: Benjmin Bell (1749–1806), Henry Cline (1750–1827), Everr Home (1756–1832), who eme Hunter’s rotherin-lw n lter Serjent Surgeon n Presient o the Royl College o Surgeons, John Aernethy (1764–1831), Anthony Crlisle (1768–1840), who lter serve on the st o Westminster Hospitl n lso eme e me presient o the Royl Royl College Col lege o Surgeons, n, most mous o ll, Astley Cooper (1768–1841). Severl o these, we shll see lter in this hpter. Stuents rom Ameri lso me to Hunter; they inlue John Morgn (1735–1789) n Willim Shippen (1736–1808) who were oouners o the rst meil shool in North Ameri, in Philelphi, n lso Philip Syng Physik (1768–1837), who is oen regre s the ther o Amerin surgery. John Hunter ws orn on rm on the outskirts o Est Kilrie ner Glsgow. He ws the lst o ten hilren n his rother Willim, who ws 10 yers his hi s senior, onsierly inuene his erly reer. John prove to e oy who islike his shool lessons ut who ws keen on nturl history, whih he stuie in the woos n els – story reminisent o the erly ys o Astley Cooper n o Chrles Drwin. At the ge o 20, John joine his rother Willim, who h estlishe himsel s populr ntomy teher in Lonon, s well s eing highly suessul ostetriin t the Milesex Hospitl; he ws lter to eliver Queen Chrlotte o the uture utu re King George G eorge IV. IV. John prove to hve rillint ir or ntomy n eme skille n energetisissetor. the ollowing yers, he worke ssistnt For to Willim, while 12 t the sme time stuying surgery uner Willim Cheselen n Perivll Pott. In 1760, Hunter joine the rmy; the ollowing yer, uring the Seven Yers’ Wr, he sw tive servie, rst in Belle Isle o the ost o Frne, n then in Portugl, gining onsierle experiene in treting wr wouns. He returne to Lonon in 1763, set up suessul surgil prtie n, in 1768, ws ppointe to the st o St George’s Hospitl. His rst episoe o wht ws unoutely ngin petoris ourre in 1773.
Figure 6.15 John Hunter (as a young man). (Royal College o Surgeons o England.)
He ie on 16while Otoer t the geggrvte o 65 o hert ttk eing1793 prtiulrly t or meeting t his hospitl. A post-mortem
Part 2 60 The age o the surgeon-anatomist: Part
perorme y Everr Home, his rother-in-lw, emonstrte severe lition o the rteries o the hert n o the rin. Originlly, Hunter ws urie in the rypt ry pt o the hurh o o St Mrtinin-the-Fiels, ut the on ws reinterre t Westminster Aey in 1859. Among the vst numer o Hunter’s experimentl ontriutions my e liste his stuies on esent o the testis, uring whih he esrie n nme the guernulum testis, the emonstrtion o t sorption y the ltels, the lymphtis o the smll intestine, the emonstrtion o the loo supply o the plent, the proo tht the seminl vesiles o not t s sperm reservoir, n his interesting stuies on gring. Tese ltter emonstrte wht toy we woul term n utogr, in whih Hunter trnsplnte the spur o ok into its om, n wht woul e terme toy n llogr, in whih he gre the testis o ok into the ominl vity o hen n, nlly, xenogr in moern terms, the trnsplnttion o humn tooth into ok’s om. Tese speimens n still e seen in the Hunterin Museum. Inee, mny woul regr Hunter’s gretest ontriution to e his museum; whih grew, in his lietime, to 13,682 speimens. Beore Hunter, museums o nturl history were olletions o uriosities, however Hunter rrnge his museum into ynmi tehing exerise. Te speimens were groupe into three min tegories; the rst emonstrte the inter-reltionship etween struture n untion, whether plnt, niml or humn. For exmple, the setion on the nervous
Certinly the most mous speimen is the skeleton o Chrles Byrne, ‘Orin the Irish Gint’ (Figure 6.16). Tis young mn erne his living eing exhiite s ‘the tllest tl lest mn in the worl’. His skeleton mesures 7 eet 8 inhes, so in lie he ws proly ouple o inhes tller thn this. He ws hevy gin rinker r inker n ie t the erly ge o 22. He gretly ere eing ‘ntomise’ ‘ntomise’ n n rrnge to e urie t se in leen on. However, Hunter’s ssoites rie the pll erers n
system emonstrte the evolutionry seriestorom the primitive nerve hin o the erthworm the highly evelope entrl nervous system o mn. Te seon group emonstrte the preservtion o the re n omprise the reproutive orgns n the evelopment o the oetus. Te thir series emonstrte pthologil hnges. Aer Hunter’s eth, the olletion eventully psse into the ustoy o the Royl College o Surgeons o Engln. On the night o 10 My 1941, the College ws extensively mge y oth ineniry n high explosive oms, n over hl the t he speimens were estroye. However, muh
Figure 6.16 The skeleton o Obrian, the Irish giant, in the Hunterian Museum o the Royal College o Surgeons. To the let is the (much smaller!) skeleton o the American giant and
o remins toyemny inspete toy nthe hsolletion een supplemente mgnient speimens.
between is seen the skeleton o the Sicilian dwar. All in their lietimes had been side-show exhibits.
Britain 61
rrie the oy o to Hunter’s ountry house t Erl’s Court, to e prepre s skeleton. Hrvey Cushing (see Figure 9.27) ske 9.27) ske to open the k o Byrne’s skull; this emonstrte very lrge pituitry oss oss (lter onrme onr me on X-ry), X-ry), whih shows tht the pthology ws romegly ue to mssive tumour o the nterior pituitry gln. Hunter’s most mous tehnil ontriution to surgery ws his opertion o ligtion o the emorl rtery in the susrtoril nl o the thigh, oen now lle Hunter’s nl, or neurysm o the poplitel rtery. Tis ws ommon in those ys in ohmen n horse riers, proly s result o repete pressure rom the upper ege o the high riing oot on the rtery. r tery. Up to the time o Hunter, surgeons either reuse to operte or tie the rtery immeitely ove the neurysm, where the vessel ws requently isese n oul esily rupture with onsequent eth rom hemorrhge. Aer niml stuies, in whih he showe tht there ws n exellent ollterl irultion er ligtion o the rtery in the thigh, Hunter rrie out this proeure in 1785 with gret suess. Tis ptient ws esrie y Sir Everr Home in 1793: Mr Hunter, rom having made these observations, was led to propose that in this operation the artery should be taken up in the anterior part o the thigh, some distance rom the diseased part, so as to diminish the risk o haemorrhage, and admit o the artery being more readily secured, should any such accident happen. The orce o the circulation being thus taken o rom the aneurismal sac, the progress o the disease would be stopped; and he thought it probable, that i the parts were let to themselves, the sac, with its contents, might be absorbed, and the whole o the tumour removed, which would render any opening into the sac unnecessary.
Dumries n stuie in Einurgh, Pris n Lonon, here s pupil o the Hunters, eore returning to join the st o the Einurgh Royl Inrmry. He wrote six-volume System o Surgery , whih ws esigne to eome omprehensive text in ompetition with Heister’s ook. It went through seven eitions n ws trnslte into Germn n Frenh. Bell lso wrote ook on venerel iseses in whih he orrete one o the errors me y John Hunter, who, s result o experimentl inoultions o venerel mtter, elieve tht syphilis n gonorrhoe were the sme isese. Te error proly rose euse the srpings o pus Hunter use were presumly tken rom ptient with oth iseses. Benjmin Bell’s two sons oth eme Einurgh surgeons, s i two o his grnsons. One o these, Joseph Bell (1837–1911), rillint teher o linil oservtion, h s one o his pupils Arthur Conn Doyle, who use him s the moel or the mous tionl etetive Sherlok Holmes. Wht woul it hve een like to hve een ptient with some serious illness who h to unergo the gonising n ngerous emergeny surgery o the 18th entury? How etter to illustrte this thn to use the se history o the rst ly o the ln in the Lonon o 1737. Croline o Ansh (Figure 6.17) ws orn in 1683 n mrrie George, Prine o Wles, in her erly 20s. She possesse mple Germni hrms: xen hir, sky-lue eyes, ir skin n voluptuous gure. She ws lso highly intelligent n
A numer o speimens o suessul Hunterin ligtions, in ptients who survive or yers er the opertion, n e seen toy in the Hunterin Museum. In Sotln, the leing surgeon o his time ws Benjmin Bell (1749–1806). He ws orn in
Figure 6.17 Caroline o Ansbach as a young woman.
62 The age o the surgeon-anatomist: Part 2
enjoye theologil speultion. Her husn, like his ther George I, ws, in ontrst, rther stupi, lthough he h pssion or the genelogy o Europen noility n n extensive knowlege o the uniorms o ll the regiments o Europe. On the eth o George I in 1727, George n Croline sene the throne, ut y now, seven hilren n innumerle nquets h on verte Croli Croline ne to n oese mile ge. Her sixt sixthh pregnny, in 1723, h lso le its mrk – lrge umilil herni – whih she suessully isguise rom her husn or mny yers. Te emergeny egn on Wenesy, 9 Novemer 1737. Croline ws seize with severe oliky pin n vomiting while t St Jmes’ Ple, Lonon. Dr George esier, physiin to the househol, n Dr Noel Broxolme o St George’s Hospitl were summone. Te usul polyphrmy o the erly 18th entury ws immeitely put into opertion; snke root n rny, Dy’s elixir, n Sir Wlter Rleigh’s oril were presrie n just s quikly vomite. Te Queen ws relieve o 12 ounes o loo n ws given n enem, whih, we re, ‘me rom her just s it went into her’. Muh to the Queen’s inonveniene, the King insiste on shring her e tht night, where neither oul he sleep nor oul she roll out s reily s she woul wish in her pin. On the next morning, Tursy, nother 12 ounes o loo were rwn rom the Queen n two more enems given, whih returne ‘immeitely n pure’. wo itionl physiins were lle in, Sir Hns Slone n Dr Hulse; they
pre-nestheti ys, n without the vntges o moern relxnt rugs, his vie ws proly soun. At 6 o’lok tht evening, Rny lne the swelling t the umilius n let out some mtter ut not enough to te the swelling to ny egree or to give ny hope o her reovery. On Suny, the lips o the woun were seen to hve mortie, n the surgeons, inee everyone in the royl househol, relise tht the prognosis ws now hopeless. Croline lle George to her sie n tol him tht on her eth he shoul mrry gin. George ws esie esie himsel in misery n with ters streming own his e, soing etween every wor, si ‘No, I will never mrry gin, I will simply hve mistresses’. Tis ws no out gret ompliment in the erly 18th entury, when so mny husns expete to outlive one or more o their wives. Dy er y, the poor womn’ wom n’ss suerings sueri ngs ontinue ut she ore them, together with repete pinul ressings o the woun, with w ith onsierle onsierle ourge n without omplint. On Tursy, the strngulte owel urst n exrement gushe out o the woun in immense quntities, ooing the e n owing ll over the oor. When her ompnions hope the relie woul o her goo, the Queen replie, very lmly, tht she hope so too, or tht ws ll the t he evutions she shoul ever hve. Hour y hour, hour, the Queen wekene, wekene , n inee the ystners elieve eh hour woul e her lst, ut pee i not ome until 10 o’lok on Suny night, 20 Novemer. Her lst wor ws to
orere listers n perients whih, gin, were vomite. On Friy morning, the poor womn ws le yet thir time. Erly on Stury morning, the Queen, no out y now wek rom loss o loo, onsente onsen te to the t he inignity o linil exmintio exmi ntion; n; John Rny, surgeon to the King, ws llowe to eel the royl omen. At one he relise the seriousness o the sitution n more surgil onsultnts were immeitely summone. Rny vise simple lning o the herni n oppose the suggestion o his ollegues tht the nek o the nvel shoul e ivie wie enough to thrust the
hilren; ‘Pry’. oy, how oen oes herptient ie itows strngulte umilil herni? Even the ol n eele n reily e resue y the surgil house st. Yet, in the 18th entury, the rst ly in the ln, oese ut otherwise t, oul not e given even the slightest relie y the most istinguishe oterie o physiins n surgeons tht Lonon oul muster. John Rny (1703–1773), who operte on the Queen, ws n interesting mn. He ws Lononer n ws only 34 yers o ge t the time o this royl opertion. He ontinue to serve the royl mily or mny yers n ws ppointe
gut k intoowel its ple, sying tht, tout this the strngulte woul prolpse ostge, the oy into the e. Tere is little out tht, in those
Serjent Surgeon 1740. In 1745, he eme the rst Mster o thein Compny o Surgeons t the rekup o the Unite Compny o Brers n
America 63
Figure 6.18 The Ranby Cup. (Royal College o Surgeons o England.)
Surgeons. Tis Compny o Surgeons lter eme the Royl College o Surgeons o Engln. Visitors to the College, to this y, will e shown one o its most preious possessions, mgnient silver‘John up (Figure 6.18) on whih is insrie in Ltin, Rny eites this memoril, suh s it is, to the very worshipul worsh ipul Compny o Surgeons on the rst rst y o July 1745, s token o regr or his rethren’. Surprisingly, there is no known portrit o this istinguishe mn.
oul get rom intelligent n intereste lymen. Tose surgeons who were to e oun were either immigrnts rom Europe or Amerins who woul trvel to Europe to stuy, espeilly to Lonon n Einurgh. Among these stuents, the most notle were Willim Shippen, John Morgn, Philip Syng Physik n John Collins Wrren. Willim Shippen (1736–1808) me to Lonon t the ge o 22 n stuie with John Hunter. He kept iry uring his sty, whih gives ler piture o meil stuent’s lie in those ys. A typil y is reore s ollows: ‘Rose t six, operting ‘til eight, rekst rekst t nine, issete issete ‘til two, ine ‘til three, issete ‘til ve, leture ‘til seven, operte ‘til nine, supper ‘til ten, then e’. Hospitls were visite ily n oen on Sunys. Shippen’s prtiulr plesure ws to sit lte into the night tlking to John Hunter, who stimulte his stuents to oserve, enquire n try the experiment. Shippen spent 2 yers in Lonon n yer in Einurgh, where he otine his MD or thesis on Attachment o the Placenta to the Uterus, n 6 months in Frne. He then returne to Philelphi n helpe John Morgn in the ountion o the rst meil shool, prt o the University o Pennsylvni, in 1765, n ws ppointe its rst proessor o ntomy n surgery. John Morgn (1735–1789) serve s n pprentie to Dr Remon in Philelphi, who then stuie with the Hunters in Lonon in 1760, ollowe y 2 yers in Einurgh, E inurgh, where he otine his MD MD Suppuration and the o or his on pointe . Inthesis this, he out tht pusFormation ws orme Pus
Surgery in Ameri egn to evelop towrs the en o the 18th entury. Te Amerin olonies roke wy rom the mother ountry in the Wr o
only in inme loo vessels n ws lwys preee y eviene o inmmtion. Morgn returne to Philelphi in 1763, helpe to oun the Shool o Meiine n ws ppointe its rst proessor o meiine. During the Amerin Wr o Inepenene, oth Shippen n Morgn hel high rnk in the meil servies. John Hunter’s lst Amerin stuent n the mn oen lle ‘the ther o Amerin surgery’ ws Philip Phi lip Syng Physik (1768–1 (1768–1837) 837) (Figure (Figure 6.19 6.19). ). Like so mny o the erly Amerin otors, he
Inepenene (1775– 1783). ). In the t he erly osurthe olonies, there (1775–1783 were ew otors n stil lys still ewer geons; most ptients epene on wht help they
hile rom nows one o the erly stuents t Philelphi the University Pennsylvni. He omplete omp lete his trining in Einurgh n Lonon,
AMERICA
64 The age o the surgeon-anatomist: Part 2
Figure 6.19 Philip Syng Physick. (Royal College o Surgeons o England.)
where he serve s s Hunter’s Hunter’s house pupil n helpe him with his issetions. He ws lso ppointe or yer s house surgeon t St George’s Hospitl. Physik returne to prtise in Philelphi, egn giving privte letures on surgery in 1800, n in 1805 ws ppointe s proessor o surgery t the university. For the rest o his lie, he ws the est known surgeon in tht ity n proly in the whole o the USA. Exept or ew reports in meil journls, he wrote little, lthough he introue numer o innovtions. Johns Collins Wrren Bostonin, serve resser t (1778–1856), Guy’s Hospitl in 1799, returne to Boston in 1802 n eme one o the ouners o the Msshusetts Generl Hospitl. He serve lter s proessor o surgery n ntomy t the Hrvr Meil Shool. We shll isuss him gin in the next hpter sine he h the honour to perorm the rst opertion uner ether nesthesi.
THE FIRST HALF OF THE 19TH CENTURY During the erly 19th entury, pioneering surgeons tookprt theo rtthe n siene o their su jet s r s, inee I onsier ur urther ther thn, one
might imgine possile with the onstrints they e. Tey h to ope with the sene o mens o relieving the pin o surgery, so tht spee ws o the essene, n the sene o knowlege o the teril nture o wouning sepsis, so tht ny opertion they perorme, no mtter how skillully, e the strong possiility o eing ollowe y suppurtion, oen with generlise spreing inetion, n with onsequent prolonge moriity n oen eth. Importnt vnes were me uring these ees. Tey sw the eginning o wht is now populrly lle ‘key-hole surgery’, when Jen Civile (1792–1867) (1792–1867) in Pris invente the lithotrite, l ithotrite, whih oul e psse long the urethr into the ler to rush ler stone without the neessity o open surgery. Tis remrkle vne will e etile in i n the hpter evote to ler stones (Chpter 12). Te 12). Te rst suesses were reporte or eletive, tht is to sy non-emergeny, opertions within the ominl vity; these were perorme or removl o mssive ovrin ysts n tumours. Vsulr surgery, with the exposure n ligtion o the mjor rteries o the oy or injury n neurysm, ws tken to its potentil limits. Ril surgery or rest ner, with removl even o inve jent lymph noes, ws rrie out (see Chpter 11) n 11) n mputtions through the hip joint n shouler joint or injury n isese were perorme with survivl o the ptients. An importnt tor tht ilitte surgil progress t this time ws the rpi issemintion o the news o importnt isoveries n o mjor vnesn in Ameri. the well-estlishe meil pressstill Europe Tus, the olest journl stilinl pulishe in the Unite Kingom, the Edinburgh (originlly the Edinburgh Medical Medical Journal (originlly ), rst ppere in 1805. Te and Surgical Journal ), Lancet , eite y Toms Wkley, generl prtitioner turne journlist, ommene pulition in 1823. Tis ws soon ollowe y the Glasgow Medical Journal in 1828 n the Dublin Medical Press in 1839. Let us now onsier some o these vnes in etil n omment upon the surgil pioneers responsile or them n upon their remrkly ourgeous ptients. It is inreile tht the rst suessul removl o n ominl tumour ws rrie out, not in
The rst hal o the 19th 19th century 65
some gret tehing hospitl in Europe, y n eminent proessor o surgery, ut in 1809 in Dnville, Kentuky. Te surgeon ws Ephrim MDowell (1771–1830) (Figure 6.20). MDowell ws orn in Virgini ut move to Kentuky s shooloy when his ther ws ppointe juge t Dnville, the rst pitl o tht stte. Like so mny Amerin stuents, he went to Einurgh; here he ttene the sessions o 1793 n 1794, where he ollowe the ntomy letures o Alexner Monro Seunus (1733–1817) n stuie surgery uner John Bell (1763–1820). Te ollowing yer he returne to Dnville s its only surgeon n uilt up n extensive prtie overing hunres o miles o rontier n where ll might men long rie on horsek n where Inins n wolves wolv es still pose thret. On 13 Deemer 1809, MDowell ws lle to see Mrs Jne o-Crwor, ly o 44, who live with her mily in log in some 60 miles rom Dnville (Figure 6.21). She ws thought to e in the lst stges o pregnny, n he ws ske to help in elivering her. When MDowell exmine the ptient, he oun tht the omen ws
Figure 6.20 Ephraim McDowell. (Royal College o Obstetricians and Gynaecologists.)
Figure 6.21 Mrs Craword’s house in Green County, Kentucky. (From Schachner A: Ephraim McDowell . Philadelphia, JB Lippincott, Lippi ncott, 1921.) 1921.)
onsierly enlrge n inee h the pperne o pregnny. However, the tumour ws inline to one sie n ws moile, n vginl exmintion showe nothing in the uterus n the ervix pushe to one sie; ll the initions were tht the mss ws ‘n enlrge ovrium’. He promise tht shoul she e le to trvel to Dnville, he ws prepre to perorm n experiment on her. Mrs Crwor ws tough rontier womn, n ew ys lter, she ppere t his home in Dnville, hving me the long, iult n ngerous journey y horsek. horsek. Interestingly Interesti ngly enough, when MDowell operte upon her, he oun tht the ominl wll ws goo el ruise, n this he srie to ‘the resting o the tumour on the horn o the sle uring her journey’. At this time, MDowell’s nephew Dr Jmes MDowell, who h grute ew months eore rom the new meil shool t Philelphi, joine the prtie s pr prtner. tner. Te young mn trie to issue his unle rom operting, ut MDowell n Mrs Crwor were etermine on the experiment. Te opertion ws perorme in the ront room o MDowell’s home (Figure ( Figure 6.22). 6.22). Nturlly, the opertion ws perorme without ny nestheti on the lssil ‘operting tle’ o the time, rought in rom the t he kithen (Figure (Figure 6.23) 6.2 3).. During the opertion, whih took 25 minutes, Mrs Crwor reite pslms n hymns. MDowell esries the opertion s ollows: Having her onand a table o ordinary height, placed on her back, removed all her dressing which might in any way impede
Part 2 66 The age o the surgeon-anatomist: Part
Figure 6.22 Ephraim McDowell’s house. The rst ovariotomy was perormed in the ront room. The building is careully preserved and is now a museum. (Royal College o Obstetricians and Gynaecologists.)
dirty gelatinous-looking substance, ater which we cut through the Fallopian tube and extracted the sack, which weighed 7 lbs and one-hal. As soon as the external opening was made the intestines rushed out upon the table and so completely was the abdomen lled by the tumour that they could not be replaced during the operation, which was terminated in about 25 minutes. We then turned her upon her let side, so as to permit the blood to escape, ater which we closed the external opening with the interrupted suture, leaving out at the lower end o the incision the ligature which surrounded the Fallopian tube.
Within 5 ys Mrs Crwor ws up n out mking her own e, n in i n 25 ys, she returne home in goo helth y the sme mens s she me.
Figure 6.23 The rst ovariotomy, painting by George Knapp. McDowell stands to the let o the patient. (From Schachner A: Ephraim McDowell . Philadelphia, JB Lippincott, Lippin cott, 1921.) 1921.)
the operation, I made an incision about three inches rom the musculus rectus abdominis, on the let side, continuing the same nine inches in length, parallel with the bres o the above-named muscle, extending into the cavity o the abdomen… The tumour then appeared ull in view, but was so large that we could not take it away entire. We put a strong ligature around the Fallopian tube near the uterus, and then cut open the tumour, which was the ovarium and mbrious part o the Fallopian tube very much enlarged. We took out 15 lbs o a
MDowell i not immeitely pulish this triumphnt result – the rst eletive lprotomy suessully rrie out or n urtely ignose intr-ominl pthology. Perhps he ws too ient, or perhps he i not relise the tremenous implitions o the se; possily his usy prtie gve him little time or the nieties o writing, n he ws ertinly not prtiulrly literry mn. Most likely, he relise tht omprtively unknown ountry surgeon, pulishing single se report, might e riiule unless urther ‘experiments’ were ttempte. Whtever the reson, MDowell wite until he h perorme two urther suessul opertions, in 1813 n 1816, eore pulishing report in 1817 o ll three suesses. His report ppere in the Eclectic Repertory and Analytical Review, pulishe in Philelphi. wo yers lter, MDowell’s seon ontriution ppere in the sme journl, reporting two urther ses. One ws suessul, ut the seon ptient ie o peritonel inmmtion on the thir post-opertive y. y. Although MDowell pulishe no more, he i ontinue with his experiments; etween 1822 n 1826, he operte on three more women. In one, the ovrin mss ws inise n rine, n the ptient live or onsierle perio o time. One opertion involve omplete exision, n the thir h to e none t lprotomy ue to extensive hesions. Tere is eviene
The rst hal o the 19th 19th century 67
rom orresponene tht MDowell perorme t lest 12 opertions or ovrin pthology, ut no etils exist o the lter ses. It ertinly took some time or MDowell’s suesses to e epte y the estlishment. A opy o the 1817 report ws sent to his ol teher, John Bell o Einurgh, who ws then in Rome, where he ie shortly thereer; thus John Lizrs (1783–1 (1 783–1860), 860), who lter eme eme proessor o surgery surger y t the Royl College o Surgeons o Einurgh, reeive the report. Lizrs i nothing out the pper until his own pulition, Observations on Extraction o Diseased Ovaria , ws pulishe in 1825, in whih he reporte our ses, ses , one o whih ws suessul in Ferury 1825. In his report, he quote MDowell’s pper, lthough y now two other Amerin surgeons h perorme suessul ovrietomies – Nthn Smith (1762–1829) o Connetiut in 1821, n A. G. Smith, nother Kentukin, in 1823. MDowell’s rst report reeive ynil reeption. Tus, n rtile in the London Medical and Chirurgical Review res
Danville. Two Two additional cases case s now published… are equally wonderul as those with which our readers are already acquainted.
Ephrim MDowell is knowlege s ther not only o ovriotomy ut lso o ominl surgery. His portrit ws immortlise s our-ent stmp y the Unite Sttes Postl Servie, n the most senior gyneologil soiety in the USA is nme er him. Over his grve in Dnville is ne memoril sh in Virgini grnite erete y the Kentuky Stte Meil Soiety (Figure 6.24).
Three cases o ovarian extirpation occurred, it would seem, some years ago in the practice o Dr McDowell o Kentucky, which were transmitted to the late John Bell and ell into the hands o Mr Lizars. We candidly coness that we are rather sceptical respecting these things, and we are rather surprised that Mr Lizars himsel should put implicit condence in them.
However, the pulition o MDowell’s However, MDowell ’s seon report me even the unelieving English repent, n in 1826, we re in the sme journl: A back-settlement o America – Kentucky – has beaten the mother country, nay, Europe itsel, with all the boasted surgeons thereo in the earul and ormidable operation o gastrotomy, with extraction o diseased ovaria… there was circumstances in the narrative o some o the rst three cases cas es that raised misgivings in our minds, or which uncharitableness we ask pardon o God and o Dr McDowell o
Figure 6.24 The memorial to McDowell in Danville. From Schachner A: Ephraim McDowell . Philadelphia, JB Lippincott Lippincott,, 1921. 1921.
68 The age o the surgeon-anatomist: Part 2
Te insription res: ‘Beneth this sh rests Ephrim MDowell MD, the ther o ovriotomy who y originting gret surgil opertion eme enetor o his re, known n honoure throughout the ivilise worl’. Mrs Crwor n her husn move to Inin, where Mr Crwor ws sustntil lnowner n representtive in the Inin legislture. Mrs Crwor ie in 1842 t the ge o 78 (Figure 6.25). Te lie o one surgeon n e use to illustrte the heights hieve in the erly 19th entury. Astley Cooper (1768–1841) (Figure 6.26), s well s his other ontriutions, must e regre s the ther o moern rteril surgery. I I (H.E.) spen gret el o spe upon him, it is euse I reely mit tht he is my surgil hero. Cooper ws orn in 1768, the son o Norolk ountry lergymn. At the ge o 16, he eme
Figure 6.26 Sir Astley Paston Cooper. (Royal College o Surgeons o England.)
rtile to his unle, Willim Cooper (1724–. (1724–. 1800), who ws the senior surgeon t Guy’s Hospitl. However,, Astley However Astle y live with wit h Henry Cline Cl ine (1750–1827), (1750–1827), surgeon t St Toms’. In those ys, the two hospitls were opposite eh other ross St Toms’ Street n were known s the Unite Hospitls (Figure 6.27). Meil stuents were tthe to
Figure 6.25 Daguerrotype o Jane Todd
Craword taken in either 1840 or 1841 at the age o 78. (From Schachner A: Ephraim McDowell . Philadelphia, JB Lippincot Lippincott, t, 1921.) 1921.)
Figure 6.27 Guy’s Hospital in 1734. The entrance is very much the same today. Gordon Museum, Guy’s Hospital.
century 69 The rst hal o the 19th century
oth institutions, their letures in meiine tking ple t Guy’s n those in surgery n ntomy t St Toms’ Tom s’.. Cline enourge young Cooper to tten the letures o John Hunter n, 6 months er rriving in Lonon, Astley trnserre his pprentieship to Cline. He now egn his lietime interest in ntomy. While still pupil, he ws ppointe, rst, emonstrtor in ntomy n then, t the ge o 23, helpe Cline with his ourse o letures. Cooper ws ppointe to the surgil st t Guy’s Hospitl in 1800, where he spent the rest o his proessionl lie. He must hve een one o the hrest working surgeons in history. At the height o his me, he woul rise every morning y six, oen y ve n sometimes s erly s our. He woul go stright to his isseting room, whih ws she t his own home, n there he woul experiment until rekst. From then until 1 o’lok, he gve ree onsulttions t his home. He then went to Guy’s Hospitl, where rows o stuents woul tten his wr rouns, linil letures n operting sessions. Visits to privte ptients n opertions in their homes woul ollow. He woul e home y seven, tke hurrie mel, n then go out gin to see more ptients or to leture, rrely rriving home eore minight. He use to sy tht y spent without issetion ws y wste. His monogrph on Hernia, pulishe in 1804, gives n ount o the ntomy o the groin tht n e re with prot to this y. It ontins the rst esription o the si trnsverslis, whih
stuies. He sought explntions or everything; in his monogrph on the testis, he notes tht the reson tht one testis is lower thn the other is so tht they o not eome squshe when we stn with our thighs together – s goo n ntomil reson s ny other. At the ge o 57, Astley Cooper resigne s senior surgeon to Guy’s Hospitl ut ontinue with his privte prtie n issetions. In 1827, he ws elete presient o the Royl College o Surgeons n in 1836 ws elete or seon term in oe. He ie in 1841 t the ge o 72, rom wht ws proly hypertensive ri ilure. We return now to Cooper’s ontriutions to vsulr vsul r surgery. He ws not simply ol surgeon, who ligte most o the mjor rteries o the oy; his work ws se on reul oservtion n experimentl stuies. While still stuen stuent, t, he investigte the ollterl irultion in the og ollowing emorl n rhil rtery ligtion. He me extensive stuies on ligtion o the roti n verterl rteries n h one og tht tully survive seril ligtion o ll our o these vessels. In 18 1811 11,, he reporte suessu suessull ligtion o the ominl ort in the t he og n emonstrte speimens to show the ollterl irultion tht ollows this. One o these speimens still survives in the Goron Museum t Guy’s n is well worth lose inspetion (Figure (Figure 6.28). Cooper ws the rst to ligte the ommon roti rtery or neurysm. His rst ptient, in 1805, ie o suppurtion o the s ut his seon se, mn ge 50, operte upon in 1808, ws
Fractures he soDislocations nme. His (1822), other monogrphs monogr phs were and Illustrations o Diseases o the Breast (1829), Observations on the Structure and Diseases o the estis (1830), Anatomy o the (1832) n On the Anatomy o the Tymus Gland (1832) Breast (1840). Te guiing priniple in Cooper’s
tehing is stte in the pree to his tretise on Hernia , in whih he writes: ‘I hve lmost uniormly in this work voie quoting the opinion o uthors on this prt o surgery… I hve thereore relte no se, n given g iven no remrk to the truth o whih I nnot vouh’. He leture with remrkle remrk le lrity – no woner
entirely suessu suessul, l, the ptient sur viving survivi ng 13onyers until ying o le ererl hemorrhge, the operte sie. Cooper ligte the externl ili rtery rtery or emorl neurysm on nine osions. One o these ws perorme on the sme y s the suessul se o roti ligtion, remrkle operting list even or toy ! Tis ptient ie 18 yers lter. When, in 1817, ptient presente t Guy’s Hospitl with rpily expning ili neurysm, whih ws oviously on the point o rupture, Cooper h the opportunity to put his erlier experimentll oservtions to the test. At this point, experiment
his lsses were rowe – n his se pulishe letures relwys well worth reing toy, s they were on reul linil n experimentl
he wentthe to the post-mo post-mortem rtem room t tempte to ttempte expose ort through lterln retroperitonel inision, oun this to e ‘utterly imprtile’
70 The age o the surgeon-anatomist: Part 2
Te ollowing is somewht shortene version o Cooper’s esription o the opertion: Charles Hutson, Hut son, a porter por ter,, at [sic] 38, was admitted into Guy’s Hospital, on the 9th o April 1817 1817, or an aneurys aneurysm m in the th e let le t groin, situated partly above and partly below Poupart’s ligament. The swelling was very much diused, and pressure upon it gave considerable pain. On the third day ater he had been in the Hospital, the swelling increased to double its ormer size, and extended rom three to our inches above Poupart’s ligament to an equal distance below it, and was o great magnitude. Just below the anterior and superior spinous process o the ilium, a distinct fuctuation could be elt in the aneurismal sac, so that the blood had not evidently yet coagulated; and the peritoneum was carried ar rom the lower part o the abdomen, in such a manner as to reach the common iliac artery, and to render an operation impracticable without opening the cavity o the peritoneum. I thereore was extremely averse to perorm an operation, and determined to wait and see i any eorts would be towards a spontaneous cure.
He ws osionlly le, kept peretly quiet, n pressure ws pplie on the tumour. On 19 June1817, slough ws oserve on the exterior
n prtise the trns-ominl pproh. His opertion o orti ligtion h thereore een ompletely stuie, oth rom its physiologil n ntomil spets. As the ollowing se report esries, the ollterl irultion ws inee suient on the norml sie, ut on the sie o the neurysm, where
prt o in theprt, swelling elowon Pouprt’s whih, seprte the 20th,ligment, n he h some leeing rom the s, ut it ws esily stoppe y ompress o lint, onne on the prt y hesive plster. On the 22n, er some slight exertion, he le gin, ut not prousely. On the 24th, the leeing gin reurre, ut stoppe spontneously. On the 25th, out hl-pst 2 o’lok, in onsequene o suen mentl gittion, he le prousely, n eme so muh exhuste tht his ees psse o involuntrily; ut Mr Key, then my pprentie, sueee in preventing immeite issolution
ollterl hnnels no out isrupte thromose, the legwere eme ishemi n n the ptient ie.
y pressure. At 9 him o’lok the sme evening Istte sw him, n oun in suh reue tht he oul not survive nother hemorrhge,
Figure 6.28 Injected specimen o a ligated dog’s aorta to show collateral channels, prepared by Astley Cooper. Gordon Museum, Guy’s Hospital.
The rst hal o the 19th 19th century 71
with whih he ws every moment thretene. Yet still nxious to voi opening the omen, to seure the ort ner to its iurtion, I me n inision into the neurisml s, ove Pouprt’s ligment, to sertin whether it ws prtile to pss ligture roun the rtery r tery rom thene. On introuing my nger, nger, I oun tht the rtery entere the s ove n quitte elow, without there eing n intervening portion o vessel; I, thereore, ws olige to non tht moe o opertion; n s the only hne whih remine o preventing his immeite issolution, y hemorrhge, ws y tying the ort, I etermine on oing it. Te opertion ws perorme s ollows: Te ptient’s shoulers were slightly elevte y pillows, in orer to relx, s muh s possile, the ominl musles. I then me n inision, 3 inhes long, into the line l, giving it slight urve, to voi the umilius: 1 inh n hl ws ove, n the reminer elow the nvel. Hving ivie the line l, I me smll perture into the peritoneum, n introue my nger into the omen; n then with proe-pointe istoury enlrge the opening into the peritoneum to nerly the sme extent s tht o the externl woun. During the progress o the opertion, only one smll onvolution o the intestine projete eyon the woun. Hving me suient opening to mit my nger into the omen, I psse it etween the intestines to the spine, n elt the ort gretly enlrge, n eting with exessive ore. By
o the intestine rom etween the thres: the ligture ws then tie, n its ens were le hnging out o the woun. Te omentum ws rwn ehin the opening s r s the ligture woul mit, so s to ilitte hesion; n the eges o the t he woun were rought rought together y mens o quille suture n hesive plster. He remine very omortle until the ollowing evening, when he vomite, n his ees psse o involuntrily. On the 27th, 7 o’lok .m., he h psse restless night n h vomite t intervls, intervls, pulse 104, wek n n smll; pin in he; gret nxiety o ountenne; very restless, n his urine rile rom him. He grully sunk, n n ie t 18 minutes er 1 o’lok, hving survive the opertion 40 hours.
mens o myonnger nil, I srthe through the peritoneum the le sie o the ort, n then grully psse my nger etween the ort n spine, n gin penetrte the peritoneum, on the right sie o the ort. I h now my nger uner the rtery, n y its sie I onveye the lunt neurisml neele, rme with single ligture ehin it; n Mr Key rew the ligture rom the eye o the neele to the externl woun, when the neele ws withrwn. Te next irumstne, whih require onsierle re, ws the exlusion o the intestine
theogulum. s, whih ws lle with w ith n immense quntity o Te speimen n e seen toy, reully preserve, in the Goron Museum t Guy’s (Figure 6.29). It ws not until over entury lter, in 1925, tht Ruolph Mts (1860–1957) o New Orlens ws le to report the rst suessul ligtion o the ominl ort (see Chpter 14). In ition to his work on rteril ligtion, Cooper ws one o the rst to rry out suessul isrtiultion t the hip joint. Tis ws perorme on 15 Jnury 1824, on solier who h
rom the t ligture, the ens together the woun, nothewhih ngerwere wsrought rrie own etween them, so s to remove every portion
h tng therom ttle o Wterloo in 1815. 18 15.his Heleg wsmputte now suering sueri hron hroni i osteomyelitis o the stump o the emur n ws oviously
Dissection No peritonel inmmtion, ut t the eges o the woun, whih were glue together y hesive mtter, exept the prt t whih the ligture protrue. Te thre h een psse roun the ort, out three qurters o n inh ove its iurtion, n rther more thn n inh elow the prt t whih the uoenum rosses the rtery; it h not inlue ny portion o omentum or intestine. Te neurisml s, whih ws o most enormous size, rehe rom the ommon ili rtery to elow Pouprt’s ligment, n extene to the outer outer prt o the thigh. t high. Te rtery ws eient rom the upper to the lower prt o
72 The age o the surgeon-anatomist: Part 2
Figure 6.30 Astley Cooper’s patient convalescing ater disarticulation at the hip joint in 1824. Guy’s Hospital Reports 1940–1941.
Figure 6.29 Drawing o the autopsy specimen o Cooper’s ligation o the abdominal aorta. Guy’s Hospital Reports 1940–1941. The original specimen can be seen in the Gordon Museum at Guy’s.
sinking uner the eets o the isese. Cooper rst tie the emorl rtery t the groin, n then me n elliptil inision rom elow the groin to out one-thir own the k o the thigh. Te he o the emur ws isrtiulte without iulty. Four loo vessels were tie n totl o out 12 ounes o loo ws lost. Te skin ps were rought together with stith n strips o hesive. Te opertion took totl o 35 minutes, the ptient eing given wine uring the ourse o the proeure. Te ptient ore the opertion with extreme ortitue. Reovery ws retre y inetion o the stump, whih ws relieve y loosening
the ressings n strpping n y inision o n sess. By 19 Mrh, he ws gining strength n h een wheele roun the squres o the Hospitl. By August, the ptient ws peretly reovere n ws living in the ountry resiene o his surgeon; it is n interesting light on Cooper’s hrter tht his interest in his welre o his ptient extene so r s to provie onvlesene or him in his own ountry house (Figure 6.30). Te ollowing yer, in Septemer 1825, Jmes Syme (1799–1870) (Figure (Figure 6.31 6.31), ), ssiste ssiste y Roert Liston (1794–1847), perorme n mputtion t the hip joint or tumour in Einurgh. Unlike Cooper’s opertion, this ws one t gret spee, the tul removl o the lim tking t king no more thn minute. Syme pi no ttention to leeing until the lim ws remove exept tht his ssistnt, Liston, ‘overe the numerous ut rteries with his le hn n ompresse the emorl in the groin y mens o his right’. rig ht’. As soon s the emorl rtery ws seure, Liston relese his hns n Syme writes
The rst hal o the 19th century 73
to convince us that the patient’s saety required all our expedition; and, in the course o a ew minutes, haemorrhage was eectually restrained by the application o ten or twelve ligatures.
Syme’s ptient snk n ie rom exhustion 7 weeks er er the opertion. opert ion. A report o the opertion, in the Edinburgh Medical and Surgical Journal, srstilly ompre the time oupie y Syme to tht y Cooper. Te Lancet , in Lonon, vigorously hmpione Cooper’s tehnique, sing its ritiism on the omprison etween Cooper’s metiulous re to seure the min vessels t rst step in the opertion in ontrst to Syme’s looy proeure. Te t tht Cooper’s ptient survive n Syme’s ptient ie ws lso not overlooke! Syme n Liston were leing surgeons in Einurgh t this time. Jmes Syme ws orn n trine in Einurgh, opene shool o ntomy
Figure 6.31 James Syme. (Royal College o Surgeons o England.)
And then had it not been or thorough seasoning in scenes o dreadul haemorrhage, I certainly should have been startled. It seemed, indeed, at rst sight, as i the vessels which supplied so many large and crossing jets o arterial blood could never all be closed. It may be imagined that we did not spend spe nd much time in admiring this alarming spectacle. A single instant was sucient
with Liston, n in 1833 eme the proessor o surgery in the University o Einurgh. He me numerous importnt ontriutions, inluing exision o the lower jw or tumour in 1828, the introution o his tehnique o mputtion o the oot using long heel p, whih still ers his nme, n voting, in monogrph he pulishe in 1839 1839,, the opertion opert ion o exision o the joint or hroni onitions suh s tuerulosis in preerene to mputtion. He ws lso pioneer in the use o hloroorm s n nestheti. Joseph Lister, the ther o ntisepti surgery (see Chpter 7), 7), ws his house surgeon n lter mrrie Syme’s ughter Agnes. Roert Liston ws ppointe s s proessor o surgery t the University College Hospitl, Lonon, in 1835 n will e enountere gin s the rst surgeon to use ether nesthesi in Europe (Chpter (Chpter 7).
7 The advent of anaesthesia and antisepsis In the mile o the 19th entury, over short perio o only two ees, the two most importnt vnes in the history o surgery took ple. Te rst ws the isovery o the eets o nestheti gents, whih olishe the gonies o surgil pro-
ple o estroying physil pin, it my proly e use with vntge uring surgil surg il opertions in whih no gret eusion o loo tkes ple.’ Tis ppers to e the t he rst suggestion tht pin
eures. Te seon ws the relistion tht woun suppurtion ws use y teri n thus tht the gretest hzr o open wouns proue y injury or y the surgeon’s knie oul e lrgely ovite y the introution o rst n ntisepti n, soon er, septi surgil tehniques.
From erliest times, ttempts hve een me to ull the pin o injuries n o surgery. Lrge oses o lohol, opium or lunum (tinture o opium n lohol) tken y mouth, or mnrgor
relie in suitle surgery vpour might e y inhltion o some or hieve gs. Nitrous oxie ws wiely use or its euphori eets in so-lle ‘rolis’ ut no one ppers to hve tken Dvy’s vie until u ntil Hore Wells (1815– (1815–1848), 1848), entist in in Hrtor, Connetiut, rrie out entl extrtions pinlessly using nitrous oxie ministere through wooen tue ple in the mouth rom n niml ler istene with the gs. Wells, in orer to populrise his isovery, went to Boston in 1845 n ws introue y his ormer prtner, Willim Morton, to the surgeons t the Msshusetts Generl Hospitl. A emonstrtion
Mandragora a (otine rom the mnrke plnt, Mandragor ofcinarum, whih ontins hyosine n other lkloi rugs), were use. Muh eort ws expene on the psyhologil preprtion o the ptient eore surgery, n some goo eets oul e otine y hypnotism, sine its introution s ‘mesmerism’ y Anton Mesmer (1734–1815). However, it ws the stuy o the eets o inhltion o vrious gses n vpours tht initite truly eetive metho o nesthesi. Humphrey Dvy Dv y (1778–1829 (1778–1829), ), who lter eme e me iretor o the Lortory o the Royl Institution, esrie the nlgesi eet o inhling nitrous
o entl ile, n Wells wsextrtion ooe outuner o thenitrous room. oxie He ontinue to use the gs in his own prtie, ut this ws soon reple y ether. It ws some time eore nitrous oxie returne s populr metho o nesthesi or entl extrtions n other reltively minor proeures. Ether (or, to give it its ull hemil nme, iethyl ether) ws rst prepre in 1540. Like nitrous oxie, it ws wiely use in Europe n Ameri s prty musement, so there is nothing new in the ehviour o our moern youngsters in their experiments with moo-hnging
oxie while still sti ll l o 19. Dvy himsel himsel gve it the nme ‘lughing gs’ n wrote, in 1800: ‘It ppers
sustnes. Crwor Long (1815–1878), who ws generl prtitioner in Jeerson, Georgi, h
ANAESTHESIA
75
76 The advent o anaesthesia and antisepsis
himsel inhle ether n notie tht he might ll n ruise himsel uner the inuene o the vpour without eeling ny pin. He thereore trie out inhltion o the sustne in 1842 to remove ouple o ysts rom the k o ptient’s nek n inee rrie out numer o minor opertions over the ollowing yers. However, he i not pulish his experienes until 1849, y whih time the use o ether ws well estlishe. It is not suient to mke isovery; it is lso neessry to let the worl know out it. Willim Toms Green Morton (1819–1868) (Figure 7.1) 7.1) n e regre s s the ther o moern nesthetis. He stuie t the Bltimore College o Dentl Surgery n eme pupil n then prtner o Hore Wells t Hrtor. He then move to Boston n ws present when Wells gve his unstistory emonstrtion o nitrous oxie. Ether ws n ovious lterntive, sine Morton h oserve its eets on his ptients when they rethe the vpour er pplying liqui ether to een pinul tooth
sokets. Morton trie the eets o ether on himsel, on og n on his ssistnts n then, on 30 Septemer 1846, on his rst ptient, Een Frost, who h tooth pulle out uner the inuene o ether sturte into hnkerhie. Te ptient testie s ollows:
Figu re 7.1 Figure 7.1 William Morton. (MacQuitty B: Battle for Oblivion. Oblivion. London, Harrap, 1969.)
Figure 7.2 John C. Warren. (From MacQuitty B: Battle for Oblivion. Oblivion. London, Harrap, 1969.)
This is to certiy that I applied to Doctor Morton at nine o’clock this evening suering under the most violent toothache; Doctor Morton took out his pocket handkerchie, saturated with a preparation o his, rom which I breathed or about hal a minute, and then was lost in sleep. In an instant more I awoke and saw my tooth lying upon the foor. I did not experience the slightest pain whatever. I remained 20 minutes in his oce aterward, and elt no unpleasant eects rom the operation operation..
Dr Henry Henr y Bigelow (1818–1 (1818–1890), 890), who h reently reent ly een ppointe to the st o the Msshusetts Generl Hospitl, hving re the newspper reports o Morton’s work, went to see him n ws impresse y wht he sw. He introue Morton to John Collins Wrren (1778–1856) (Figure 7.2), the proessor o surgery t the MGH, n ew ys
Anaesthesia 77
lter, Morton reeive the ollowing letter: ‘I write t the request o Dr John Collins Wrren to invite you to e present Friy morning Otoer 16, t 10 o’lok t the hospitl to minister to ptient who is then to e operte upon, the preprtion you hve invente to iminish the sensiility to pin.’ Te letter ws signe y the house surgeon, Dr Heywoo. It ws now only 2 weeks sine ether h een ministere to Frost, ut lrey Morton h progresse rom soke hnkerhie to simple nestheti mhine. Tis onsiste o twoneke glss gloe, one nek llowing the inow o ir, the other tte with wooen mouthpiee through whih the ptient inhle ir ross the sure o n ether – soke sponge in the ottom o the jr j r (Figure 7.3). All the nxieties o gret linil tril re summe up y Morton’s young wie, who wrote
husband would be ruined ruin ed by the world’s ridicule, or he would kill the patient and be tried or manslaughter. Thus I was drawn in two ways; or while I had unbounded condence in my husband, it did not seem possible that so young a man could be wiser than the learned and scientic men beore whom he proposed to make his demonstration.
The night beore the operation my hus-
Te operting thetre t the Msshusetts Generl Hospitl ws situte just elow the entrl ome o the ol uiling (Figure ( Figure 7.4). It 7.4). It is preserve to this y. One o the uthors (H.E.) hs h the privilege o leturing in wht is now lle the ‘Ether Dome,’ gret thrill or nyone intereste in surgil history. On the morning o 16 Otoer, it ws rowe with surgeons n meil stuents. Te uiene inlue oth Jo Bigelow n his son Henry.
band worked until 1 or 2 o’clock in the morning upon his inhaler. I assisted him nearly beside mysel with anxiety, anxie ty, or the strongest infuences had been brought to bear upon me to dissuade him rom making this attempt. I had been told that one o two things was sure to happen; either the test would ail and my
Te ptient ws Gilert Aott, 20 2 0 yers o ge, who h enign vsulr tumour o the nek. Petrie t the thought thoug ht o the pin o his opertion, he h reily gree to the experiment. Proessor Wrren expline to the uiene how muh he h lwys wishe to ree his ptients rom the pin o opertion, n or tht reson, h gree to the experiment. Te time o the opertion rrive n
Figure 7.3 A model o Morton’s ether inhaler. (The original is preserved in the Massachusetts General Hospital, Boston.)
78 The advent o anaesthesia and antisepsis
Figure 7.4onThe ‘Ether is still careully preserved and used today asbya the lecture theatre. Insetois the the table which theDome’ operation was perormed. (Photograph provided general director Massachusetts General Hospital, Boston.)
psse. By 10 minutes pst ten Proessor Wrren pike up his knie kn ie n si s i ‘As ‘As Dr Morton hs not rrive, I presume he is otherwise engge.’ Just s Aott ws eing strppe own on the operting hir, rethless n ustere Morton rrive; he h een moiying moiy ing his pprtus up to the very lst moment. Wrren si, ‘Well, sir, your ptient is rey.’ ‘Are you ri?’ Morton ske the ptient. ‘No, I eel onent tht I will o preisely wht you tell me.’ Morton pplie his ether, its smell ws isguise y ornge essene to prevent ystners reognising reognisi ng its nture. urning to Wrren, Morton ws now le to sy, ‘Your ptient ptient is rey, otor.’ Mny yers lter Mrs Morton esrie the sene:
but the stroke came with no accompanying cry. Then another and another, and still the patient lay silent, sleeping while the blood rom the severed artery spurted orth. The surgeon was doing his work, and the patient was ree rom pain. (Figure (Figure 7.5)
Te opertion took 30 minutes, n t the en,
Then in all parts o the ampitheatre there came a quick catching o breath, ollowed by a silence almost deathlike, as Dr Warren stepped orward and prepared to operate… The patient lay silent, with eyes closed as i i in sleep; but
Aottpin. gree tht the wholetoir een ree rom Wrren turne the h uiene n si, ‘Gentlemen, this is no humug.’ It took ew moments eore the senstionl importne o wht they h seen struk the uiene, who then rushe orwr to ongrtulte Morton, to exmine the ptient n to sk him over n over gin i the opertion h relly een pinless. Everyone in tht room must hve relise tht they h witnesse histori osion. It ws now neessry to proee to the ruil experiment. Te new gent might e eetive in the removl o suutneous lump rom the
everyone to knie hear a shriek opresent agony ully ringexpected out as the struck down into the sensitive nerves,
nek, ut woul it work in sheule, pitl opertion, n mputtion? A se ws uly thereore, or 7 Novemer. Beore this oul e put to the
Anaesthesia 79
test, urning ethil issue rose. Shoul Morton
Te ptient ws 21-yer-ol servnt girl, Alie Mohn, who h een in the hospitl sine the previous Mrh with tuerulosis o the knee joint. Dr George Hyw Hywr r ws to peror perorm m the mputtion, with Wrren n Bigelow in ttenne. Morton ministere the ether, n er some oughing, the ptient ell into eep sleep. Hywr stuk pin into her rm n, when there ws no retion, rpily mputte the leg. As he nishe, Alie egn to gron n move. Hywr ent over her n si, ‘I guess you’ve een sleep Alie.’ A lie.’ ‘I think I hve, sir,’ sir,’ she replie. ‘Well, you know why we rought you here; re you rey?’ ‘Yes sir, I m rey.’ Hywr then rehe own, pike up the mputte lim rom the swust, showe it to her n si, ‘It’s ll one, Alie.’ (Wht Alie si when she sw her leg hs not een reore.) Senes o intense exitement then took ple, with the meil uiene lpping n shouting with mzement. Morton esrie the ir moestly: ‘I ministere the ether with peret suess. Tis ws the rst se o mputtion.’ Te ptient i well n ws ishrge rom the hospitl in time or Christms. Te news o Morton’s isovery spre with mzing spee through the ivilise worl. In Deemer, Frnis Boott (1792–1863), meil prtitioner in Gower Street, Lonon, who h trine in Ameri, reeive letter written on 28 Novemer y Bigelow giving ull ount o the momentous events in Boston. Boott immeitely enourge entl surgeon, Jmes Roinson
e llowe to minister seret gent, eneil though it might e, or shoul its use e prohiite until its nture ws revele to the meil proession? Wrren ws prepre to go he, his only onern eing relie o pin, ut the Msshusetts Meil Soiety resolve unnimously – no ormul, no ptients. Even though Morton oere to supply the preprtion ree or use in the Boston hospitls, hospi tls, the otors remine mnt. mnt. On the very y o the opertion the rgument ontinue, with the ptient witing in the nteroom n the thetre pke to the eiling with expetnt otors n stuents. Unle to er the
(1813–1862), who h stuie t Guy’s n young ws in prtie in Gower Street, to give ether to womn or extrtion o molr tooth. Te site o this rst opertion uner nesthesi in the British Isles is toy ommemorte y plque (Figure 7.6). .6). Roinson Roinson went on to write the worl’s rst textook o nesthesi A reatise o the Inhalation o the Vapour o Ether the ollowing yer. So suessul ws this experiment tht Boott persue Roert Liston (1794–1847), proessor o surgery o the nery University College Hospitl (UCH), to try the eets o ether or
thought o the suering, Morton quietly nnoune thtptient’s his liqui ws inee sulphuri ether.
mjor pprtusn wsthe me y Peter Squire,surgery. neryTe phrmist, nesthetist ws his nephew, Willim Squire, meil stuent
Figure 7.5 Painting o the rst operation under ether. Morton holds his anaesthetic apparatus at the head o the table; Warren operates. (Photograph provided by the general director o the Massachusetts General Hospital, Boston.)
o anaesthesia and antisepsis 80 The advent o
Figure 7.6 Plaque to commemorate the rst operation under ether in Great Britain – a dental extraction in a house in Gower Street, London, along the road rom UCH. (Photograph by the author.)
t UCH ge 21. Te opertion ws rrie rr ie out just 2 ys er the entl extrtion, on 21 Deemer. Te ptient ws Freerik Churhill, utler, who h een mitte month previously with hroni osteomyelitis o the tii. At 2 o’lok, the
operting thetre t the UCH ws pke to pity. Squire lle or volunteer mong the otors n meil stuents present, sying tht he h only trie the pprtus ppr tus one eore n woul like one more rehersl eore sumitting ptient to its inuene or pitl opertion. No one move. Te thetre porter, Shellrke, ws thereore ske to sumit to the test. He ws not goo hoie to try out n nestheti s he ws t, plethori n h liver tht ws very ver y use to strong liquor. Aer ew eep reths o ether, Shellrke lepe o the tle n rn out o the room, ursing Squire n everyoy else t the top o his voie. Fieen minutes lter, Liston rrive, n Churhill ws rought into the thetre y the now soer n reovere Shellrke. Squire took the preution o hoosing two hey stuents to stn y in se the ptient repete the porter’s perormne. Wht hppene next hs een rillintly esrie y memer o the uiene, Dr Cok, n is illustrte in Figure 7.7: A rm step is heard, and Robert Liston enters – that magnicent gure o a man, six oot two inches in height, with
Figure 7.7 The rst ‘capital’ operation under ether at University College Hospital. Proessor Robert Liston operates in his shirt sleeves. The ether apparatus is placed on a small table; William Squire bends over the patient.
Anaesthesia 81
a most commanding expression o countenance. He nods quietly to Squire and, turning round to the packed crowd o onlookers, students, colleagues, old students and many o the neighbouring practitioners, says somewhat dryly, ‘We are going to try a Yankee dodge, to-day gentlemen, or making men insensible.’ He then takes rom a long narrow case one o the straight amputating knives o his own invention. It is evidently a avourite instrument, or on the handle are little notches showing the number o times he had used it beore… The patient is carried in on the stretcher and laid on the table. The tube is put into the mouth, William Squire holds it at the patient’s nostrils. A couple o dressers stand by, to hold the patient i necessary, but he never moves and blows and gurgles away quite quietly. William Squire looks at Liston and says, ‘I think he will do, sir.’ ‘Take the artery, Mr. Cadge,’ cries Liston. Ransome, the House Surgeon, holds the limb. ‘Now gentlemen, time me,’ he says to the students. A score o watches are pulled out in reply. A huge let hand grasps the thigh, a thrust o the long, straight knie, two or three rapid sawing movements, and the upper fap is made; under go his ngers, and the fap is held back; back ; another
dressed. The patient, trying to raise himsel, says, ‘When are you going to begin? Take me back, I can’t have it done.’’ He is shown the elevated done. el evated stump, drops back and weeps a little, lit tle, then the porters come in and he is taken back to bed. Five minutes have elapsed since he let it. As he goes out, Liston turns again to his audience, so excited that he almost stammers and hesitates, and exclaims, ‘This Yankee dodge, gentlemen, beats mesmerism mes merism hollow.’
Te originl pinting is in UCH, ourtesy o University College, Lonon. Liston oul hrly hve relise t tht moment tht the nee or rpi surgery, whih his skill h rought to suh pith o peretion, ws now to e reple y the new er, when nesthesi woul llow lm n n unhurrie opertions. As or Morton, the rest o his short lie ws not hppy one, lthough he h the ompenstion o using ether with gret suess uring the Amerin Civil Wr (see Chpter 9). 9). He ie in 1868 t 48 yers o ge. Te itizens o Boston erete monument over his grve (Figure ( Figure 7.8), 7.8), the insription insript ion o whih ws ompose y Dr Jo Bigelow: Inventor and revealer o anaesthetic inhalation By whom pain in surgery was averted and annulled Beore whom in all time surgery was
thrust, andangle the point o the knie comes out in the o the upper fap; two or three more lightning-like movements and the lower fap is cut, under goes the great thumb and holds it back also; the dresser, holding the saw by its end, yields it to the surgeon and takes the knie in return – hal a dozen strokes, and Ransome places the limb in the sawdust. sawdus t. ‘Twenty-eight ‘Twenty-eight seconds,’ says William Squire. The emoral artery is taken upon a tenaculum and tied with two stout ligatures, and ve or
agony Since whom has controlled the pain.
Te wor ‘nesthesi’ ws suggeste y Oliver Wenell Holmes (1809–1894), (1809–1894), proessor o ntomy n tomy n physiology t the Hrvr Meil Shool. He i so in Novemer 1846, 1846, ew weeks er the t he rst use o ether, in letter to Morton, lthough the wor nesthesi h ppere in Bailey’s English in 1721 to men loss o senstion. Te Dictionary in wor nesthesi psse into the English lnguge, wor lthough the term ‘etheriztion’ ws wiely use in the erly yers.
six vessels with orceps andmore single thread, a the stripbow o wet lint put between the faps, and the stump
ws 1846, proly given y in sSotln on 19 Ether Deemer the sme the entl extrtion y Roinson in Lonon. Tis ws t
82 The advent o anaesthesia and antisepsis
Figure 7.9 James Young Simpson. (Royal College o Surgeons o England.) Figure 7.8 The memorial over Morton’s Mor ton’s grave, Mount Auburn cemetery, Boston. (Photograph by the author. au thor.))
the Dumries n Gllowy Royl Inrmry. Te news o Morton’s suess ws tken there y Willim Frser (1819–1863), ship’s surgeon who rrive in Liverpool rom Boston. TeMlgigne surgeon ws Willim Sott (1820–1887). Joseph (1806–1865) ws le to report his rst ve ses o ether nesthesi t the Aémie e Méeine in Pris on 12 Jnury 1847. Te rst nestheti in the southern hemisphere ws given y generl prtitioner, Dr Willim Russ Pugh (1805–1897) in Luneston, smni, on 7 June 1847. Te rst mjor wr in whih nesthetis were employe ws the Crimen Wr o 1854–1855. Jmes Young Simpson (1811–1870) (Figure 7.9), proessor o miwiery in Einurgh, use ether in his ostetril prtie on 19 Jnury 1847, ut the gent h the isvntge slow n ssoite vomiting. He nohis twoinution young ssistnts experimente y inhling vrious rugs in
Simpson’s house n were impresse y the spee o tion n plesntness o hloroorm in prouing unonsiousness. It ws esy to use, simply y pouring rop o the gent on piee o guze or hnkerhie hel ner the e o the ptient eh time the sujet rethe (Figure 7.10). By 10 Novemer 1847, Simpson ws le to report the use o hloroorm in ostetri prtie in pper re to the Einurgh Meil n Chirurgil Soiety. Simpson ws ttke or using pin relie or women in lour, ut the use o ostetril
Figure 7.10 The simple ‘rag and bottle’ method o administration o chloroorm used by Simpson.
Anaesthesia 83
nesthesi ws gretly strengthene when Queen Vitori h hloroorm ministere to her y John Snow (1813–1858) t the irth o her eighth hil in 1853. It is hrly surprising tht the mens o relieving the pin o surgery ws so quikly opte throughout the worl. Te story o the spre o knowlege o the use o woun inetion n its prevention ws muh slower proess. O ourse, the erly nestheti gents h their isvntges, even though their use ws wiespre well into the seon hl o the 20th entury. Te senior uthor, or exmple, s young otor, eme quite expert in the ministrtion o oth nitrous oxie n ether. Nitrous oxie is only suitle or short nestheti, or exmple, entl extrtion. Ether requires long time to inue the ptient, proues goo el o nuse n is highly inmmle when mixe with oxygen. Chloroorm, lthough esy to use, is ssoite with osionl inients o suen eth rom ri irregulrity. Numerous inhltion gents, use lone or in omintion, were evelope in the 20th entury: ylopropne ylopropne n hlothne, or exmple, were ser n more plesnt or the ptient. Intrvenous nestheti rugs, suh s pentothl n ketmine, mke the inution o nesthesi rpi n resonly plesnt. Lol nesthesi ws reltively lte evelopment. It egn when Crl Koller (1857–1944), young ophthlmologist in Vienn, on the suggestion o his rien, Sigmun Freu, use
Figure 7.11 William Stewart Halsted. (From MacCullum WG: William Stewart Halsted, Surgeon.. Baltimore, Johns Hopkins Press, 1930.) Surgeon
it is prole tht Hlste never overme his morphine ition. We shll meet Hlste gin in Chpter 11 s 11 s he plye n importnt prt in the evelopment o surgery or ner o the rest, ut he ws then hnge person. From eing ol, rther moynt personlity, he eme
oine pplieonsthe eyeeye rops s Itlol or opertions in 1884. wsnestheti soon tken up y surgeons in Lonon, Pris n Berlin s lol inltrtion or surgil proeures. In the sme yer s Koller’s pioneering work, Willim Stewrt Hlste (1852–1922) (Figure 7.11), surgeon t the Roosevelt Hospitl, New York, egn to experiment on himsel n three o his young ollegues with oine or nerve loke, inltrting nerves o the e, jws n lims to proue regionl nesthesi. He i not relise tht oine is ngerously itive rug; his three ollegues ll ie n Hlste himsel,
the Fountion o Surgery the Johns Hopkins HospitlProessor in Bltimore, slow,tmetiulous introvert; n unwitting mrtyr in the evelopment o nesthesi. Fortuntely, sustitutes or the ngerous gent oine were soon evelope, in prtiulr, novoine, or proine, in 1905. More reently, whole series o gents suh s ligno lignoine ine (1943) (1943) hve een synthesise n n re in use toy. Not only re these gents use to inltrte skin or to lok peripherl nerves, ut they my e injete into the url s to lok the spinl nerves (spinl nlgesi) or inltrte roun the spinl nerves outsie the
y 1886,re. require hospitl mission orepsyhitri Te tretment ppere to to wen him rom oine on to morphine, n
ur the) in verterl n l (epiurl (epin urlostetril or extrurlwithin n lgesi) nlgesi moernnl surgil prtie.
84 The advent o anaesthesia and antisepsis
THE DEVELOPMENT OF ANTISEPTIC SURGERY Few, i ny, isoveries in siene re suen irs; irs; there is so oen series o steps, slow relistion, leing to the importnt rillint suess. Tere re numerous exmples o this throughout this ook: or exmple, the evolution o eetive surgery or missile wouns, ler stone n rest surgery. Nowhere is this etter illustrte thn the evolution o the ontrol o surgil woun inetion. We hve seen (Chpter (Chpter 4) 4) tht Teoori (1205–1298) (1 205–1298) enie tht suppurtion ws n n essentil prt o woun heling n wrote: ‘It is not neessry tht pus shoul e generte in wouns. No error n e greter thn this. Suh prtie is inee to hiner nture, to prolong the isese n to prevent the onsolition o the woun.’ Most surgeons, however, oth eore n er him, onsiere suppurtion n pus ormtion to e norml ompniment o wouning. Bteri were rst oserve y remrkle mn who h no meil or sienti trining whtsoever. Tis ws Anton vn Leeuwenhoek (1632–1723) (1632–1723),, rper in Leyen, Holln, who n e regre s the ther o mirosopy. He groun the lenses o his own mirosopes, whih were relly no more thn sophistite mgniying glsses, n illustrte teri rom his own mouth in 1683. It ws nerly two enturies eore their signine in the ustion o iseses ws estlishe. Mny oservers postulte role or hypotheti-
other y the ttening miwie or otor; he onsiere tht it ws putri mtter rom the uterus tht use the inetion n vise lenliness on the prt o the ttening otor. Chrles White (1728–18 (1 728–1813) 13) o Mnhester emphsise the t he importne o lenliness in ostetril prtie, while Oliver Wenell Holmes (1809–1894) o Boston, in pper On the Contagiousness o Puerperal Fever in 1843, rgue tht women in lour shoul not e trete y otor who h reently onute n utopsy or who h trete ptient with puerperl ever. He quote tht ollegue h een le to hlt n epiemi o puerperl ever in his prtie simply y wshing his hns in solution o lium hlorie er ttening ny ptient inete y this isese. Importnt oservtions were me y Ignz Semmelweiss (1818–1865) (Figure 7.12), Hungrin who ws ppointe rst ssistnt to the proessor o ostetris t the Allgemeines Krnkenhus in Vienn in 1846. Te ostetril lini ws ivie into two ivisions: the rst ws evote to tehing postgrute otors n
l ‘efuvi’ ‘misms’ in the spre o inetious iseses.orTe wor ‘mlri’ omes rom the Itlin mal aria (‘ ir’), lthough we know tht it is the mlri protozol prsite, rrie y the Anopheles mosquito, whih uses the illness n not the ‘ ir’ o the mrshlns tht re home to this inset. Erly importnt oservtions were me y ostetriins on the ontgiousness o puerperl or hile ever. Tis ws the ree n n oen tl inetion o the irth nl n peritonel vity, usully ssoite with generlise sepsis n pyemi (inetion o the loostrem) in women er hilirth. Alexner in Aereen pulishe ookGoron in 1795,(1752–1799) initing tht puerperl ever ws rrie rom one ptient to the
Figure 7.12 Ignaz Semmelweiss. (Royal College o Surgeons o England.)
development o antiseptic The development antiseptic surgery 85
meil stuents, n Semmelweiss oun tht this h n pplling mternl mortlity, whih oul e s high s 18% o the ptients. In ontrst, the seon ivision, whih ws ste y miwives, h mternl eth rte o roun 2%. Moreover, he note tht while hile ever rge in the wrs, no suh epiemi existe in women elivere in their homes or even those who selelivere in the streets o Vienn. Te ollowing yer, his ollegue, the pthologist Jo Kolletshk, ie er perorming post-mortem exmintion uring whih he h prike his nger. Semmelweiss note tht the post-mortem hnges seen t the utopsy on his ollegue were similr to those o the women ying o hile ever. Te use o the ierene in mortlity etween the two ivisions o the hospitl ws now ler. Te otors n stuents in Division One woul perorm post-mortems n prtise ostetril opertions in the utopsy room, then go stright to the elivery wr ering with them invisile ‘ver prtiles,’ reognisle only y their hrteristi n unplesnt smell, rom the e women to the irth nl o the women in lour. Te miwives, who h nothing to o with post-mortems, were protete rom this ontgion. Semmelweiss immeitely institute ritul o hn-wshing, whih omprise sruing with sop n hot wter ollowe y wsh in hlorinte wter until the smell o the post-mortem room h een ompletely eliminte. At the sme time, t ime, instruments, sins, linen n ressings were lso lene. Te results were
hands o the midwives and ward attendants that come into contact with the discharges o other ill patients [sic]… in a word the carrier is anything contaminated with decomposed animal organic-material that comes into contact with the vaginal tract.
By 1862, Semmelweiss ws showing ovious etures o mentl eteriortion, n in 1865, he ws mitte to privte sylum in Vienn, where he ie. Tere is some poignny in the te o his eth, sine this ws the yer in whih Joseph Lister rrie out his rst opertion using the ntisepti tehnique. Te importnt link in the hin, the proo tht miro-orgnisms re the use o woun inetion, remine to e emonstrte. Tis vitl eviene ws proue, not y meil reserher, ut y n orgni hemist. Louis Psteur (1822–1895) (Figure 7.13) stuie t the Éole Normle in Pris, worke t the University o Lille n ws lter ppointe s proessor o hemistry t the
soonregion pprent, the o 1%.with mternl mortlity lling to Semmelweiss returne to Bupest in 1850 n eme proessor o ostetris there, hieving mternl mortlity rte o 0.85% t the Rohus Hospitl. Unortuntely, Semmelweiss i not pulish his work until 1860. His Aetiology, Concept and Prevention o Puerperal Fever ws iult to ollow, wory n repetitious; it ws not trnslte into English until 1941. In it he sttes The carrier o the decomposed animalorganic materialhand, is the th e instruments, examining nger, the operating bed linen, atmospheric air, sponges, the
Figure 7.13 Louis Pasteur. (From William Osler: Evolution of Modern Medicine. Medicine. New Haven, Yale Universityy Press, 192 Universit 1921. 1.))
86 The advent o anaesthesia and antisepsis
Soronne, Pris. His stuies on ermenttion o wine n putretion o milk, utter n roth emonstrte tht this putretion proess ws proue y wht he lle ‘erments,’ miroorgnisms whih he oul emonstrte uner the mirosope. In series o rillint, ut simple, experiments, Psteur ws le to show tht roth sterilise y oiling woul remin remi n so i ple in sk plugge y sterilise otton ot ton wool, whih woul woul llow l low ess to the tmospheri ir ut not to orgnisms in the ir, whih woul e ltere y the wool. Remove the plug, n the roth woul eome putri er ouple o ys. A roth inusion, sterilise y oiling, oul e le open to the ir inenitely i the nek o the sk ws rwn out into urve whose onvexity pointe upwrs. Tis enle the roth to e in ontt with the outsie ir, ut teri were prevente y grvity rom oing so n were eposite in the oule en o the
nek. By reking o the nek lose to the top o the sk, ir n its ontine orgnisms now hve iret ess n proue rpi inetion o the roth (Figure 7.14). Psteur’s stuies on ermenttion prove to e the tlyst to the work o Joseph Lister on the uses n prevention o surgil woun inetion. Few oul eny tht Joseph Lister (1827–1912) (Figure 7.15) ws the gretest surgil enetor to mnkin. He ws orn in Upton, Essex. His ther Joseph Jkson Lister, evout Quker, ws wine merhnt n lso istinguishe istingu ishe mirosopist. Lister ommene his meil stuies t the ge o 17 t University College, Lonon, n ws si to hve een present t Liston’s histori mputtion o leg while the ptient ws nesthetise with ether (see erlier). In 1853, Lister eme house surgeon n then n ssistnt to Jmes Syme (1799–1870) in Einurgh, mrrie his ughter Agnes n ws ppointe s n ssistnt surgeon t the Einurgh Royl Inrmry. In 1860, he ws ppointe s Regius Proessor o Surgery t Glsgow, n it ws here tht he li the ountion or his lie’s work. Lister ws
Figure 7.14 Pasteur’s experiment with broth, illustrated in the lecture notes o Anderson, a medical student attending Lister’s surgical
lectures in Glasgow. (From Guthrie D: Lord Lister,, His Life and Doctrine. Lister Doctrine . Edinburgh, Livingstone, 1949.)
Figure 7.15 Lord Lister. (Royal College o Surgeons o England.)
o antiseptic surgery 87 The development o
intereste in inmmtion n woun heling; he h lrey rrie out importnt stuies on the inmmtory proess y oserving the vsulr hnges tht tke ple in the loo vessels o the rog’s oot we uner the mirosope. Like so mny surgeons eore him, Lister ws puzzle y the oservtion tht lose rture, no mtter how severe, woul hel without inetion. In ontrst, ompoun rture, omplite y perhps only minor punture woun, oul suppurte n the vitim woul e luky to get wy with his lie, let lone his lim. In some wy, the exposure o the rture to ir oul e lethl, n mny surgeons vise urgent u rgent pking o the woun to prevent suh ontmintion. In 1865, Toms Anerson, the proessor o hemistry in Glsgow University, tol Lister o Louis Psteur’s pulitions etween 1857 n 1860, whih prove onlusively tht putretion ws ue to teri n not merely ue to exposure to ir. At one it eme ovious to Lister tht it ws not the ir ut the orgnisms ontine in it n rrie into the woun tht resulte in the suppurtion, the pus n the gngrene tht plgue the surgil wrs o his ys. It ws oviously impossile to kill miroes y mens o het, s Psteur h one in his experiments; some hemil sustne must e use. He wrote
tuerulosis n the seon on ptient ge 22 with ompoun rture o the leg. In oth ses, suppurtion ourre. Te rst suessul use took ple on 12 August 1865, n opertion tht might e regre s the wtershe etween two ers o surgery, the primitive n the moern. O this ptient, Lister wrote On the 12th o August 1865, a boy named James Greenlees, aged 11 years, was admitted to the Glasgow Royal Inrmary (Figures 7.16 and 7.17) with compound racture o the let leg, caused by the
Figure 7.16 The Royal Inrmary, Inrmar y, Glasgow, in 1865. (From Guthrie D: Lord Lister, Lister, His Hi s Life and Doctrine.. Edinburgh, Doctrine Edinbu rgh, Livingstone, Liv ingstone, 1949.) 1949.)
When it had been shown by the researches o Pasteur that the septic property o the atmosphere depended, not upon the oxygen or any gaseous constituent, but on minute organisms suspended in it, which owed their energy to their vitality, vitalit y, it occurred to me that decomposition o the injured part might be avoided without excluding the air, by applying as a dressing some material capable o destroying the lie o the foating particles.
Lister trie numer o ierent sustnes suh s zin hlorie n sulphite o potsh with little suess. sues s. He then her or re out the pplition o roli i in the eetive tretment o sewge in Crlisle n otine smple o the
Figure 7.17 The room in the Glasgow Royal Inrmary where the rst compound racture was treated by the antiseptic method. Photograph taken beore this part o the hospital was pulled
rue ihis rom ollegue, proessor In 1865, rsthistwo experiments withAnerson. roli i were ilures: rst, n exision o the wrist or
down or rebuilding. (From Guthrie D: Lord Lister, His Life and Doctrine. Doctrine. Edinburgh, Livingstone, 1949.)
88 The advent o anaesthesia and antisepsis
wheel o an empty cart passing pas sing over the limb a little below its it s middle. The wound, which was about an inch and a hal long and three quarters o an inch broad, was close to, but not exactly over over,, the line o racture o the tibia. A probe, however, could be passed beneath the skin over the seat o the racture and or some inches beyond it.
Te tretment onsiste o the reul pplition o unilute roli i to ll prts o the woun, whih ws then resse with lint soke in the sme ui. Te lint ws overe with sheet o tinoil to prevent evportion, n the leg ws then reully splinte. Uner the ressing, the loo n roli i orme protetive rust, eneth whih, mirle o mirles, the woun egn to hel sounly. Aer 4 ys, the t he rst ressing ws remove. Although the woun ws sore, no out rom the rue roli, there t here ws none o o the usul horrile smell o hospitl inetion or the other milir signs o putretion, whih woul hve een expete in the norml ourse o events within 3–4 ys. Lister resse the woun gin in i n the sme wy n le it untouhe or nother 5 ys. Te ptient remine omortle. Te skin roun the woun h een urne y the roli i, so Lister hnge the ressing to guze soke in solution o roli i in olive oil. Six weeks er his ient, Jmes Greenlees wlke out o the hospitl.
Te outome o the seon se ws less hppy. Tis ws 32-yer-ol lourer, whose ompoun rture o the tii proue only smll externl woun. He ws mitte to the hospitl uner Lister’s re on 11 Septemer, n n ientil tretment ws employe. Aer 11 ys, progress seeme to e exellent n Lister went or short holiy, leving the house surgeon in hrge. Unortuntely, gngrene evelope n the leg h to e mputte. Tere ws now erth o ompoun rtures on Lister’s unit, ut he spent the time experimenting with roli i in the tretment o leg ulers n in the use o the ntisepti ntise pti tehnique in removing isese ones rom the wrist o young girl nme Jnet Forgie. At lst, thir ptient with ompoun rture ws mitte on 19 My 1866, 21-yer-ol mn whose leg h een smshe y hevy iron ox t work. retment ws suessul, s ws tht t ht o ourth se, nsty ompoun rture o the orerm in 10-yer-ol oy. Lister elye pulishing his results until totl o 11 ptients h een mnge y the ntisepti tehnique. On a new method o treating compound racture, abscesses, etc., with observations on the conditions o suppuration ws pulishe in Te Lancet in in ve suessive issues rom
16 Mrh 16to 27 July 1867 (le 7.1). O the 11 ses o ompoun rture, Lister reporte only one eth, the sixth in the series. John Cmpell ws 57-yer-ol qurrymn with ompoun rture o the thigh resulting rom lrge lling
Table 7.1 7 .1 Lister – the rst 11 cases o compound racture treated by the antiseptic method
No. 1 2 3 4 5 6 7 8 9 10 11
Sex
Age
Site and injury
Result
M M M M M M F M M M M
11 32 21 10 7 57 62 13 33 52 55
Tibia – cart wheel Tibia – horse kick Tibia – heavy box Radius and ulna – machine strap Tibia – omnibus wheel Femur – quarry Radius and ulna – all Femur – engine governor Tibia – omnibus wheel Tibia – waggon wheel Tibia – jump rom window
Recovery Hospital gangrene amputation Recovery Recovery Recovery Death – haemorrhage Recovery Recovery Recovery Recovery Recovery
The development o antiseptic surgery 89
rok. Tere ws 6-hour ely n onsierle loss o loo eore he ws mitte to the hospitl. Aer mking m king goo progress or severl weeks, he ie rom hemorrhge ollowing the perortion o the emorl rtery y shrp rgment o the rture. It must e rememere tht, t this time, mny ompoun rtures require mputtion, n this proeure ws oen tl. Te improvement in the sttistis on Lister’s own servie, er the option o his ntisepti metho, is emonstrte y his pulishe gures. Between 1864 n 1866, there were 35 mputtions with 16 eths, 46% mortlity. Between 1867 n 1870, when mputtions were rrie out using the ntisepti tehnique, 40 opertions were perorme with only 6 eths, 15% mortlity. Suh results were quite extrorinry in those ys. Beore Lister, surgeons hesitte to init n inision through the intt skin euse o the extreme risk o woun inetion, whih ws oen tl. Even the simplest proeure, suh s removl o seeous yst, might e ollowe y lethl erysipels. However, y 12 Deemer 1870, Lister ws suiently onent to operte on mn whose gross mlunion o the uln h le the lim more or less useless. Uner ntisepti preutions n with the ition o roli spry, Lister perorme n open osteotomy on the mlligne one, whih o ourse involve trnsorming the sitution into wht mounte to ompoun rture. In those ys, this oul lmost e onsiere mlprtie. Te woun hele y some-
woun suppurte, the ligtures woul grully ome wy, oen helpe y tug rom the surgeon n oen ompnie y seonry hemorrhge. It is interesting tht Sir Astley Cooper (see Chpter 6) in 6) in se o poplitel neurysm tie the emorl rtery using tgut n ut the ens short; the woun hele y rst intention. Tis ws k in 1817. Lister elieve tht teri-ree ligtures might e le sely within the woun, n in 1867, he tie the roti rtery o horse with piee o silk soke in roli i. Te ens o the ligture were ut short n the woun lose. First intention heling took ple, n t utopsy, the silk ws oun to e unhnge n emee in rous tissue. Following this, Lister ligte l igte the externl ili rtery in 51-yer-ol womn with n neurysm neur ysm o the emorl emorl rtery. r tery. Agin, he use silk soke in roli i, n the opertion ws suessul. He still worrie tht, even without suppurtion, the unsore silk might use irrittion lter, n so he turne to tgut prepre rom sheep’s intestines s more suitle gent. During the Christms o 1886, he rrie out his lssil experiment on l, tying the roti rtery with tgut sterilise in roli roli i. Te opertion ws omplete suess; when the woun ws explore month lter, the originl tgut h een entirely reple. For the rest o his lie, Lister remine intereste in the est mens o sterilising tgut, n some o his originl tues n e seen to this y in the Hunterin Museum t the Royl College o Surgeons o
thing rrely seen eore Lister – heling y rst intention ! Enormous new vists o surgery now ly open. Lister perorme n open reution o rture ptell, ring to open the intt knee joint n wire the two rgments together; the woun hele. He wire together isple rture o the olernon, with se rture union (see Figure Figure 10.5). Suess 10.5). Suess ollowe suess s the new ntisepti metho eme rmly estlishe. While these experiments were going on, Lister ws lso eeply involve in the prolems o rteril ligtion. Te stnr prtie or enturies
Engln in Lonon. Dougls Guthrie gives vivi ount o Lister t work:
h to ligte mjor vessels, usully with een silk, n then to leveloo the ens o the ligture long n ngling out o the woun. As the
his the patient the neck. handsThe o skin the ooperator and and his assistants were treated with carbolic
The technique o an operation by Lister… was very simple. He never wore a white gown and requently did not even remove his coat, but simply rolled back his sleeves and turned up his coat collar to protect his starched collar rom the cloud o carbolic spray in which he operated. Sometimes he would pin an ordinary towel around
90 The advent o anaesthesia and antisepsis
solution (1 in 20). Towels soaked in the solution were placed around the wound. Instruments and sponges were steeped in the same fuid. Neither the operating theatre nor its urnishing were specially adapted or the purpose. The rough wooden foor bore the marks o previous operations, the table was a plain deal board padded with leather, while gas or candles supplied articial light when required. requi red. One advantage o so simple a method was that the student who saw it practised in hospital could reproduce it when he commenced practice and had occasion to operate in the homes o his patients. It has been alleged that he was a poor operator, but that is not true. He may have been slow; he had none o the dramatic dash and haste o the surgeon o previous times. But there was now no need or rapid operating. The introduction o anaesthetics allowed the surgeon to proceed with his work calmly, deliberately and careully. On the occasion when rapid action was demanded, Lister showed that his dexterity was equal to that o other surgeons. As he told his students, ‘anaesthetics have abolished the need or operative speed and they allow time or careul procedure,’ and he would oten add a avourite maxim,
regre roli i s just nother o the mny sustnes tht h een vise s woun pplitions, n inee, surgeons h experimente with this very ompoun in the pst. Without ll the other junts o the metho, it is not surprising tht Lister’s results uner these irumstnes woul not hve een repete. Still other surgeons oul not elieve tht invisile miroes oul proue woun inetion. Lwson it (1845–1899) 1845–1899),, one o the thers t hers o moern omi ominl surgery, or exmple, erie Lister’s ies. It is interesting tht it’s own exellent results were ue to his metiulous lenliness; he ws, in t, prtising n erly orm o aseptic surgery. A ull two ees o ptient experiment, emonstrtions, letures n lerne rtiles in the journls were require eore surgeons were entirely won over to Lister’s ies. In 1869, Lister trnserre rom Glsgow to eome proessor o lini linill surgery in Einurgh, Einurg h, n in 1877, he epte n invittion to the Chir o Surgery t King’s College, Lonon. It ws proly the very resistne o the Lonon surgeons tht persue Lister to leve Einurgh. He wrote to rien tht his new ppointment woul: ‘Enle me to rry out the two ojets whih I shoul in relity hve in view, viz., the thorough working o the ntisepti system with view to its iusion in the metropolis n the introution o more eient eie nt metho o linil surgil tehing thn hs hitherto previle in Lonon.’ Lister ie in 1912, hving een rete ronet in 1883 n eing the rst surgeon to otin
‘success detail.’ depends upon attention to
One might hve expete tht Lister’s results o wht we n ll the ntisepti tehnique o surgery woul hve spoken or themselves n tht his methos woul hve een epte rpily throughout the ivilise worl. Tose surgeons who visite him n lerne his metiulo metiulous us ritul o woun re were impresse n reproue his results in their own prties. Tis pplie prtiulrly to ontinentl visitors, so erly supporters inlue Sxtorph o Copenhgen (1870),
peerge, in 1897.oHe serve n on the o the Royl College Surgeons wsCounil one o the rst reipients o the Orer o Merit. He shres the honour o eing one o the three surgeons in the Unite Kingom who hs puli monument. It stns or ll to see in Portln Ple in Lonon, just south o Prk Cresent, where he live or mny yers when he ws proessor o surgery t King’s n where plque ommemortes his resiene. His monument ers two wors; on one sie ‘Surgery’ n on the other ‘Lister’ (Figu (Figure re 7.18) .18).. Te other sttues, sttues , y the wy, re to John Hunter,
Volkmnn Hlle (1874) n oth Nussum o Munih noTiersh o Leipzig, in 1875. However,, mny others, espeilly However espei lly in Britin, Briti n, simply
n is to esurgeon, oun inSir Leiester Squre, Lonon, n this the plsti Arhil MInoe, in Est Grinste, West Sussex.
The development o aseptic surgery 91
surgery. His tehnique inlue srupulous preprtion o the ptient’s skin, o his own hns n rms n those o his ssistnts n nurses. It ws he who introue the sterilisle surgeon’s gown n his speilly esigne ll-steel instruments sterilise y oiling. It ws Mewen who rrie out the rst suessul removl o n intrrnil tumour in 1879. With his other ontriutions, inluing the tretment o intrrnil n intrspinl sess n intrrnil hemt hemtom, om, he n e regre s one o the ther gures o neurosurgery (see Chpters 8 n 8 n 10 10 n n Figure 10.16). In reent times, Sir John Chrnley (1911–1982) (Figure 10.18), one o the pioneers o joint replement surgery, who well knew the isster is ster o woun inetion in this type o proeure, introue wht might e thought o s ‘super sepsis’. In ition to the stnr preutions, the surgeon n his tem operte in lminr ow tent in
Figure 7.18 Statue to Lister in Portland Place, London. (Photograph by the author.)
THE DEVELOPMENT OF ASEPTIC SURGERY Lister onstntly worke t pereting his surgil tehnique, hiey in the iretion o using miler ntiseptis ntisept is n pting het or the sterilistion sterilis tion o his instruments n ressings. He none the use o roli spry (Figure 7.19) when he relise tht the risk o woun inetion ws gretest rom the surgeon’s hns,ininstruments sws thn rom teri the ir. Tisn me s rther gret relie to the surgeon n his ssistnts who h to work or some yers uner the isomort o n erosol o irritting roli i. Te use o stem sterilistion o instruments, ressings n gowns, the wering o msks, ps n gloves, ir ltrtion ltrtion n the other rituls o the operting thetre toy were introue over the next ouple o ees. Among the pioneers must e mentione Gustv von Neuer (1850–1923) o Kiel, Kurt Shimmelush (1860–1895) o Berlin n Ernst von Bergmn (1836–1907) o the sme
Figure 7.19 Lister’s carbolic spray; nicknamed ‘the donkey,’ it produced an aerosol o carbolic in the room, much to the discomort o the
ity. Mewen (1848–1924) stuent o ListerWillim t Glsgow, who eme proessor o surgery t tht university, i muh to populrise septi
surgeon and his assistants. (This is preserved in the Hunterian Museum at the Royal College o Surgeons o England.)
92 The advent o o anaesthesia and antisepsis
strem o ltere ir n wer wht look like spe suits to ensure tht their exhle reth is shunte wy rom the ptient. It is interesting tht sterile ruer gloves, now regre s n essentil prt o the operting thetre ritul, were introue initilly not to protet the ptient rom the surgeon’s teri, ut to gur the surgeon n his st rom rom the irritting eets o ntiseptis. Inee, even eore the er o ntisepti surgery, surger y, gloves me rom otton, silk, lether n, nlly, ruer were employe to protet the hns rom injury uring opertions n utopsies – when trivil ut in septi se might prove lethl to the opertor. Ruer eme the mteril o hoie ollowing the invention o the vulnistion proess y Chrles Gooyer in 1844 to stilise the ruer. Willim Hlste (1852–1922), proessor o surgery t the Johns Hopkins Hospitl Bltimore (see Figure 7.11), 7.11), ws most isture when, in 1889, his thetre sister, Miss Croline Hmpton, nnoune tht she ws going to hve to retire euse she oul no longer tolerte the intense irrittion o her hns proue y onstntly ipping them into the ntisepti solution then use, orrosive sulimte. Hlste rrnge or ruer gloves to e me y the Gooyer Ruer Compny n rought them k or Miss Hmpton to use; the skin irrittion isppere. It ws only susequent to this tht t ht the use
Figure 7.20 An operation in 1893. Only the surgeon is wearing rubber gloves. His assistants are barehanded.
o gloves slowly eme routine, ut now s n ntiteril rrier etween the surgeon’s hns n the ptient (Figure 7.20). Te ening o the Hlste–Hmpton story is romnti one; the ollowing yer they mrrie! Although Hlste never puliise the use o gloves, his trinees no out spre the ie. Johnnes von Mikuliz o Breslu (1850–1905) oserve Hlste t work n helpe to populrise the use o gloves in Germny. Te rst pulition on the use o oile sterilise ruer gloves in surgery ppers to hve een y Werner von Mnteuel in 1897, proessor o surgery t rtu, Estoni. ‘o wer oile gloves is s i to operte with oile hns,’ he wrote!
8 The birth of modern surgery – from Lister to the 20th century Te yers rom the 1860s to the outrek o the Gret Wr in 1914 sw n extrorinry urgeoning o surgery. surger y. At lst, surgeons were le to operte untroule y the nee or spee, unisture y the srems o their ptients n without the high
(see Figure 6.2) 6.2) in Pris in 1743 esrie ly who h her istene gll ler rine uner the impression tht it ws n sess. Severl months lter, he ws le to extrt stone the size o pigeon’s egg rom the epths o the persistent
risks oen tlstnr post-opertive inetion. Te gret o ulk o the opertive proeures o toy ws li own; or exmple, the routine surgery o the ominl orgns, o the urinry trt, the enorine glns, ones n joints, the nervous system, herni repir n er, nose n throt surgery. Te rst ttempts were me in the el o hest surgery. Only the surgery o the hert, the reonstrutive surgery o rteries, the trnsplnttion o orgns n joint-replement proeures were to remin s mjor els o surgil evelopment, n these will e onsiere in lter hpters.
stul. However, wsout physiin whoopertion enourge surgeons to it rry elierte or gllstones. John Tuihum (1829–1901) o St Toms’ Hospitl, Lonon, pulishe tretise on the hemil omposition o gllstones, n in 1859, he vise tht the surgeon oul x the gll ler to the ominl wll wl l through smll inision n then, hving llowe hesions to orm, oul open the gll ler, extrt the stones n then llow the resultnt stul to hel spontneously. It It ws not until unti l 1867 tht John Stough Bos B os (1809–1870), proessor o surgery in Ininpolis (Figure 8.1) 8.1) who ws pprently unwre o
will men e illustrte ingTis out remrkle some o theergret n someyopikthe importnt evelopments tht still shine out o tht remrkle hl entury o rpi hnge.
Gllstones hve een oun in Anient Egyptin mummies n hve presumly troule the humn re sine the erliest ys. Certinly ‘inmmtion o the liver’ ws reognise y the Greeks n esrie y Pulus Aegint, who ourishe in the 7th entury. Giovnni Morggni (1682–1771)
Tuihum’s pper, perorme the proeure n pulishe it the ollowing yer. Te opertion ws rrie rr ie out uner hloroorm in thir-oor room ove rug store, where Bos h rente the room or his opertion. Te proeure ws perorme, o ourse, without ntisepti preutions – Lister’s pper on ntisepsis ws pulishe in this sme yer (see Chpter 7). Te 7). Te ptient ws ly ge 30 who presente with lrge ominl mss tht ws thought proly to e n ovrin yst. When the mss ws opene, limpi ui espe uner onsierle ore, together with numer o gllstones. Aprt rom woun ine-
reporte 20 post-mortem exmintions in whih he oun gll stones. Jen-Louis Petit (1674–1750)
tion, the ptient me goo reovery n outlive not only her surgeon ut lso six o the eight
GALLSTONE SURGERY
93
94 The birth o modern surgery
Figure 8. 8.1 1 John Stough Bobbs. (From Robinson JO: The Biliary Tract . Austin, Silvergirl, 1985.)
Figure 8.2 Carl Langenbuch. (Photograph provided by Dr Busso Maska, Lazarus Hospital, Berlin.)
meil witnesses o the opertion. Bos ws Pennsylvnin o Duth extrtion. He trine t Jeerson Meil College in his home stte n serve s meil oer in the Civil Wr. He went on to eome Fountion Proessor o Surgery in Ininpolis. It ws not or nother ee tht urther oper-
its university. At the ge o 27, he ws ppointe surgeon t the Lzrus Hosp Hospitl itl in Berlin n n ie in hrness in 1901 rom peritonitis ue to rupture ppenix. Lngenuh tkle the prolem o extirption o the gll ler in sienti mnner in the post-mortem room. He note tht elephnts n
tions to remove stones rom(1813–1883), the gll ler were reporte y Mrion Sims Teoor Koher (1841–1917) o Berne, Willim Willims Keen (1837–1932) in Philelphi n Lwson it (1845–1899) in Birminghm. It ws only er mny yers tht John Bos reeive the worlwie ole o surgil rst. Te opertion o holeystotomy, lthough simple n se n, inee, osionlly rrie out toy, h the isvntges isv ntges o reurrent inetion, resiul stones n oen persistent ishrging iliry stul. Te rst surgeon to remove remove the gll ler ws Crl Johnn Lngenuh (1846–1901)
horses o not thereore possess this orgn (nor rtstoo, or pigeons onlue tht o mn, !), n oul o without it! Te opertion he evise in his ver experiments ws rrie out through -shpe inision; the trnsverse lim ws ple long the inerior mrgin o the liver n ws joine to the longituin longituinll inision long the lterl mrgin o the retus musle. Te ysti ut ws ligte with silk si lk 1–2 m rom the t he gll gl l ler, whih ws then issete ree rom the liver e. On stisying himsel with these preliminry stuies, the time me or the living experiment. Te ptient ws mn ge 43 suering rom
(Figure 8.2) in 1882. or He h lrey perorme the rst nephretomy kiney tumour in 1877. Lngenuh ws orn in Kiel n grute rom
severe gllstone symptoms intense ttks o pin n junie or mnywith yers; inee, he h rehe the stge where he oul no longer mnge
Gastric surgery 95
without morphine. Te opertion ws perorme extly in the mnner o the proeure evise in the utopsy room, n the inme gll ler with its ontine two smll holesterol stones ws remove. Te ptient me stistory reovery, n er ouple o months h gine nerly 14 kg. He h require no morphine morph ine sine si ne the t he opertion. Lngenuh rgue strongly in vour o removl removl o the gll gl l ler rther thn rining it. He wrote I believe, thereore, that I may state that the extirpation o the gall bladder, perormed by me or insidious cholelithiasis, ater preceding ligation o the cysticc duct, may be regarded as the less cysti dangerous and more eective method, as well as or most other diseased processes o this organ.
Removl or ringe o the gll ler, o ourse, oul not el with the prolem o luli in the ile ut itsel. Lwson it reommene rushing the stones with oreps overe with ruer tuing, while Koher vise rushing them with the ngers, rgments eing llowe to pss into the uoenum. However, there woul e ovious isvntges tht smll rgments o stones oul e le ehin n orm nius or reurrent luli. In 1889, two surgeons, on either sie o the Atlnti n within 3 weeks o eh other, opene the ommon ile ut n remove the stones. Roert Ae (1851–1928), n ttening surgeon t St Luke’s Hospitl, New York, remove
he h never lost ptient er ny opertion or gllstones in the sene o mlignnt isese or the eep junie o holngitis. His mortlity when operting on eeply junie ptients with holngitis ws only 1.7%.
GASTRIC SURGERY oy, ner o the stomh is the ourth most ommon killing mlignny in Europe, n in the 19th entury, it le the el. Te rst ttempt to reset tumour t the pylorus ws rrie out in 1879 y Jules Pén (1830–1898) (1830–1898) (Figure 8.3) o Pris. His ptient ie on the h post-opertive y. In 1880, Luwig Ryigier Ryig ier (1850–1920) (1850–1920) o Culm, Poln (Figure 8.4), 8.4), perorme the seon gstretomy in history, ut his ptient ie ie 12 hours post-opertively. Menwhile, in Vienn t the Surgil University Clini o the Allgemeines Krnkenhus, Teoor Billroth (1829–1894) (Figure (Figure 8.5) 8.5) h his ssistnts work out the tehnil etils o the proeure o gstri resetion in the niml lortory. Tey were le to emonstrte tht survivl ws unoutely
n impte stone through in struture ommon ut, whih he rine seprte inision in the hepti ut. Te ptient, ly ge 36 who ws eeply junie, me peretly smooth reovery n n 4 yers lter elivere son. Tree Tre e weeks er Ae’s opertion, Knowsley Tornton in Lonon remove two impte stones rom the ommon ut, gin with reovery o the ptient. Te opertion o holeohotomy ws thus estlishe. By the eginning o the 20th entury, gll ler surgery ws eoming routine proeure. Arthur Myo Roson (1853–1933), surgeon t the Generl Inrmry t Lees, who lter move to Lonon n whose mous Berkeley Moynihn (seemost Figure 8.16), protegé 8.16), ws lews to report in the British Medical Journal o o 1903 tht
Figure 8.3 Jules Péan. (Photograph provided by Proessor Louis Hollender, Strasbourg.)
96 The birth o modern surgery
Figure 8.4 Ludwig Rydigier. (Photograph by the author o the portrait in the Surgical Clinic, Copernicus Academy o Medicine, Cracow.)
Figure 8.5 Theodor Billroth. (Royal College o Surgeons o England.)
possile n eliminte the question whether or not the gstri juie woul issolve the sutures or the heling tissues t the nstomosis etween the gstri stump n the uoenum. Billroth wrote: ‘No insurmountle ostles to prtil exision o the stomh exist either on ntomil, physiologil or opertive grouns. It must suee’ suee ’. In Jnury 1881, Billroth’s ssistnt Anton Wöler (1850–191 (1850–1917) 7) (Figure 8.6), 8. 6), Czehoslovkin Czehoslovk in who lter eme proessor o surgery in the University o Prgue, ske his hie to see 43-yer-ol ptient, Térèse Heller, who h ll the etures o mlignnt ostrution o the gstri outlet. She ws erien, wste n ontinuously tinuous ly vomiting, with thin t hin rpi pulse n n n ovious tumour to eel in the upper omen. Te ptient knew only too well tht, untrete, her en oul not long e elye, n she reily gree to wht ws, in t, n experiment. Billroth knew o Pén’s unsuessul ttempt t gstretomy, ut, t this stge, h not her o Ryigier’s ilure. Te opertion ws plnne in gret etil. Te stomh ws reully lvge n nutrient peptone enems were given. Te opertion ws rrie out on 29 Jnury uner hloroorm nesthesi n strit ntisepti tehnique. Wöler ws the ssistnt. Te omen ws opene through trnsverse inision n lrge inltrting rinom ws revele, whih involve more thn one-thir o the istl portion o the stomh (Figure (Figure 8.7). Te 8.7). Te loo vessels long the greter n lesser orers
Figure 8.6 Anton Wölfer. (From Herwitz A, Degenshein G: Milestones in Modern Surgery . Philadelphia, Harper Ha rper and Row, 1958.) 1958.)
Gastric surgery 97
Figure 8.7 The gastrectomy on Frau Heller. (From Billroth T: Clinical Surgery. Extracts from the Reports of Surgical Practice Between the Years 1860–1876. 1860–1876. London, The New Sydenham Society, 1891.) 1891.)
o the stomh were ligte. A gret nxiety ws whether or not the stump o the stomh woul pull over suiently to reh the uoenum, ut one the helthy tissues were ivie out 1 inh long the stomh sie o the growth, the ut ens oul inee e rought together. Te olique
the indications, and to develop the technique to suit all kinds o cases. I hope we have taken another good step orward towards securing unortunate people hitherto regarded as incurable or, i there should be recurrences o
woun in the stomh ws suture rom elow upwrs until the opening ws just ig enough to t the uoenum, n ltogether, some 50 sutures o silk were employe. Te opertion lste 1½ hours, n exmintion o the exise speimen revele tht the pylorus ws so nrrowe y the growthh tht it oul just growt just mit the sh o ether (Figure 8.8). Muh 8.8). Muh to everyone’s elight, there ws no wekness or vomiting n very little pin er the opertion. Te woun hele well, n Billroth wrote his report on 4 Ferury:
cancer, at least alleviating their suerings or a time.
The course so ar is already sucient
Te rve ly ie o iuse metstses in the liver l iver n omentum only 4 months lter, ut the news tht suessul prtil pr til gstretomy h een perorme serve s n immense stimulus to the surgery o the limentry limentry trt, whih lossome rpily rom tht te. By 1890, Billroth n his tem h perorme 41 gstri resetions or ner with 19 suesses. Teoor Billroth ws one o the gret surgil gints o ll time. Quliying t the University o
proo thatcare, the and operation is possible. Our next the subject o our next studies, must be to determine
Berlin, he trine Bernr VonoLngenek (1810–1887), who uner is regre s one the ouners o moern Germn surgery. At the ge o 31,
98 The birth o modern surgery
Billroth eme proessor o surgery t Zurih, n 7 yers lter took up his ppointment in Vienn. Here, he oune one o the gretest shools o surgery, where he rrie out his pioneering work in experimentl stuies, surgil pthology n opertive surgery. He pioneere exision o tumours o the ler n the owel, rrie out the rst lryngetomy or ner in 1873 n perorme hinqurter mputtion. He oune the moern onept o reporting the totl linil experiene o the eprtment to inlue opertive mortlity, omplitions n 5-yer ollow-up.
oesophgosope in 1881 n evise tehnique or reonstrution o the oesophgus er reseting its ervil portion or ner. We hve lrey note tht Anton Wöler, Billroth’s rst ssistnt t the time o the erly gstretomies, eme proessor o surgery in Prgue n pioneere the opertion o gstroenterostomy. Anton von Eiselerg (1860–1939), Billroth’s lst gret pupil, eme proessor o surgery in Vienn in 1901. He himsel ws gret teher n proue no less thn 19 hies o surgil eprtments. Another et to Billroth, whih is perhps less well known, ws his lielong ssoition with musi. As stuent, his only tlent ws or musi, whih he wishe to pursue proessionlly. However, his mother, wiow o Luthern pstor, insiste tht he stuy meiine, lthough he ontinue to ply the pino n ompose. In Zurih, Billroth rst eme rienly with Johnnes Brhms, n this ontinue when oth move to live in Vienn. Nerly ll Brhms’ ompositions were rst trie out t the home o Billroth. Who knows wht he might hve hieve i his mother h not me him stuy meiine! Billroth is urie in the Centrl Cemetery in Vienn, not r rom the grves o Beethoven n Shuert n the t he monument to Mozrt. Wht o the two surgeons whose pioneer gstretomies ene in ilure? Jules Pén, surgeon t the St Louis Hospitl in Pris, ws verstile surgeon who h lrey pulishe the rst suessul eletive removl o the spleen. Tis ws rrie out in 1867 t n explortory opertion in girl o
However, he soune note: n ‘Sttistis re like women, mirrors owrning purest virtue truth or like whores, to use s one pleses!’ Billroth’s protégés inlue Vinenz Czerny, Crl Gussenuer n Johnnes von Mikuliz. Vinenz Czerny (1842–1916), who eme proessor o surgery t Heielerg, perorme the rst totl hysteretomy y the vginl vgin l route in 1879 1879 n evelope tehnique o intestinl nstomosis. Crl Gussenuer Gus senuer (1842–1903 (1842–1903)) helpe with the og experiments on gstri resetion n sueee Billroth to his Chir in Vienn. Johnnes von Mikuliz (1850–1905) eme proessor o sur-
20, enormous whose suspete tumour prove to e n spleniovrin yst. Pén evise oreps or the ompression o rteries tht inorporte in the hnles rthet to lok them in position. Tese were lter moie y Spener Wells, ut in Frne, these instruments re still terme ‘les pines e Pén’. Pén ie suenly o pneumoni while still usily engge in his enormous privte prtie. Luwig Ryigier went on to eome proessor o surgery t Crow n is regre s the ther gure o moern Polish surgery, ouning its Assoition Asso ition o Surgeons. In Novemer 1881, 1881, he perorme the rst suessul gstretomy or
gery in Breslu. He evelope tehniques o pyloroplsty, oletomy s two-stge proeure n thyroietomy. He ws the rst to use the eletri
initions enign gstri uler resetion n wentinon to etil the or gstri ses o pylori stenosis, hemorrhge n ner.
Figure 8.8 The resected specimen o stomach. Note that only a ne probe can be passed through the obstructing tumour. (From Billroth T: Clinical Surgery. Extracts from the Reports of Surgical Practice Between the Years 1860–1876. 1860–1876. London, The New Sydenham Society, Societ y, 1891. 1891.))
Surgery o the large intestine 99
Te rst suessul totl removl o the stomh or ner ws perorme y Crl Shltter (1864–1934) o Zurih in 1897 n ws reporte the ollowing yer in Te Lancet . Te uoenum ws lose, n loop o smll intestine rought up n nstomose to the oesophgus. Te ptient ie o metstses in the lymph noes n pleur yer lter. Te now quite ommonly ignose onition o hypertrophi pylori stenosis o innts ws poorly reognise until the Dnish peitriin, Hrl Hirshsprung (1830–1916), esrie postmortem exmintions exmi ntions on two innts who h ie o this isese. In spite o its lmost ertin tlity, physiins were relutnt, i not vehemently oppose, to vise opertion or its relie. Over the yers, reports ppere rom time to time o ttempts to relieve the ostrution y vrious tehniques using vrious orms o pyloroplsty or gstrojejunostomy.. In trojejunostomy I n 1907, Pierre Freet (1870–1946) (1870–1946) o the Pitié Hospitl, Pris suggeste new opertion in whih the serous n musulr ots o the pylorus lone were ut longituinlly, the muos eing le intt, n the musle ws then suture together. Tis proeure ws tken up y Wilhelm Weer (1872–1928) o Dresen. In 1911, Conr Rmstet Rmste t (1867– (1867–1963) 1963),, Germn militr mi litryy surgeon, gretly simplie the opertion. He wrote in his report o his rst se: When in September Se ptember 1911 1911 I was rst rs t conronted with an operation or pyloric stenosis, I decided to perorm a par-
Figure 8.9 Ramstedt’s pyloromyotomy operation. (From Sir Frederick Treves, The Student’s Handbook of Surgical Operations . London, Cassell, 1930 1930.) .)
cured. Today, about one year ater the operation, he had developed as well as any child o his age.
In the seon se, Rmstet eie to leve the inision gping; it ws omplete suess. Tis simple proeure o merely iviing the thikene musle ring t the pylorus (pyloromyotomy) remins the stnr opertion toy (Figure 8.9). Sine the introution o the Rmstet opertion, the mortlity o this onition hs llen l len to prtilly prtil ly zero. However, However, in spite o muh reserh, the etiology o the onition remins something o mystery n is proly multitoril, involving geneti n environmentl tors.
tial pyloroplasty according to Weber. During the operation I noticed, ater section o the rmly contracted, almost bloodless and hypertrophied muscular ring, that the wound edges gaped markedly. I had the impression that the stenosis was already overcome. Nevertheless I sutured the incision transversely in order to complete the Weber pyloroplasty. The tension o the wound edges was, however, very great and the sutures cut through so that the union o the wound edges in the oppo-
SURGERY OF THE LARGE SURGERY INTESTINE
site wassuture incomplete. I thereore direction covered the area with a tag o omentum or protection. The child is
olletionolon o sules long thetht orers the sigmoi in the ver he wso isseting. He pointe these out to his proessor o
It is interesting tht two o the most ommon iseses o the lrge owel in the Western worl toy – ivertiul o the olon n its omplitions n ulertive olitis – were rrities up to the erly yers o the 20th entury. Divertiul o the olon re esy enough to reognise (Figure (Figure 8.10). 8.10). Inee, s rst-yer meil stuent in 1943, with no knowlege o pthology, the senior uthor note peulir
100 The birth o modern surgery
Hershon (1825–1889), physiin t Guy’s Hospitl, who wrote Pouches o the colon sometimes become o considerable size… these pouches are the result o constipation, the muscular bres become hypertrophied, but their eort to propel onward their contents leads to these minute hernial protrusions.
Figure 8.10 Maxwell Telling’s illustration o diverticula o the sigmoid colon. (British (British Journal of Surgery , 1917.)
ntomy, Sir Wilre Le Gros Clrk (1895–1971), who si ‘those re lle ivertiul; ivertiulum mens wy-sie house o ill repute n well o they eserve the nme’. He ws thereore ol mze when to some lter he looke up the textooks nyers no esription o this ovious onition until tht o Jen Cruveilhier (1791–1874), proessor o esriptive ntomy in Pris, who wrote in 1849:
He note lso tht these pouhes o not pper to proue ny symptoms or le to ny ngerous results. o the liniins n pthologists o the 19th entury, these ivertiul were uriosities n, inee, Sir Arthur Keith (1866–1955) just eore the First Worl Wr oul ollet only seven speimens in the museum o the Royl College o Surgeons in Lonon n the museums o the Lonon Meil Shools. However, y 1917, Mxwell elling (1874–1938), physiin t the Generl Inrmry, Lees, ws le to review no less thn 324 exmples o oloni ivertiul n gve goo ount o the omplitions o this onition. Te rst resetion o the sigmoi olon or ivertiulitis ppers to hve een perorme y Jmes Rutheror Morison (1853–1939 (1853–1939), ), proessor o surgery t the University o Durhm Durh m in 1903. Te ptient ws mle ge 60 who ws thought to e suering rom ostrution o the olon ue to rinom. Te resete speimen showe wht Morison terme ‘sulitis’. Te nstomosis leke, n n the ptient ie 2 ys post-opertively.
Cruveilhier note tht these ss oul e irri-
in the Western worl, ivertiul o theoy, olon represent the ommonest pthologil onition o the lrge owel n t present et up to 60% o the elerly popultion. We n only onlue tht this onition is ssoite with the low roughge roughge iet o the t he moern so-lle ivilise ivil ise worl. In muh o Ari n Asi, in popultions who still mintin high-ulk iet, the t he onition onition remins rrity. Non-ontgious irrhoe o hroni type hs een reognise or enturies lthough the nme ‘ulertive olitis’ tes only rom the mile o the 19th entury. Toms Syenhm (1624–1689),
tte y el n mtter n tht this le to inmmtion perortion. Te might rst ount in the English lnguge ws given y Smuel
who s eore vlryeoming oer uner Cromwell in theserve Civil Wr Lonon physiin, esrie the ‘looy ux’ in 1666. Prine
We not inrequently nd between the bands o longitudinal muscle bres in the sigmoid a series o small, dark, pear-shaped tubers, which are ormed by herniae o the mucous membrane through the gaps in the muscle coat.
Cancer o the large bowel 101
Chrles, the Young Pretener, evelope looy irrhoe ollowing his eet t the Bttle o Culloen in 1746; surely t tht woul elight those psyhitrists who elieve in psyhosomti use or olitis. However, the rst goo esription o ulertive olitis ws given y Smuel Wilks (1824–1911) n Wlter Moxon (1836–1886) o Guy’s Hospitl Hospitl in their t heir Pathological Anatomy . Tey lerly ierentite this onition rom erile epiemi ysentery n wrote We have seen a case attended by discharge o mucus and blood where, ater ate r death, the whole internal surace o the colon presented a highly vascular, sot, red surace, covered with tenacious mucus or adherent lymph, and here and there showing a ew minute points o ulceration; the coats were also much swollen by exudation into the mucous and submucous tissues. In other examples there has been excessive ulceration, commencing in the ollicles, spreading rom them to destroy the tissues around, thus producing a ragged, ulcerated surace.
In the stnr textook o the lte 19th entury, Willim Osler’s (1849–1919) Te Principles and Practice o Medicine pulishe rst in 1892, there re only three prgrphs eling with ulertive olitis n the esription is poor – thus he sttes ‘Tere is never loo or pus in the stools’. (Divertiul o the olon, y the wy, re not even
Figure 8.11 A Brooke spout ileostomy. ileos tomy. The patient had undergone numerous previous operations or infammatory bowel disease (patient o H.E at Westminster Hospital.)
totl el iversion ut ws ssoite with high mortlity sine it ws so oen rrie out only when the ptient ws lmost moriun. moriun . It ws lso oun tht, even er prolonge rest, losing the ileostomy ws lmost invrily ollowe y re up o the olitis. Moreover, until Bryn Brooke (1915–1998) o Birminghm introue his spout ileostomy n eient pplines were evise, the lie o the ileostomy ptient ws miserle one inee (Figure 8.11). As with eient meil tretment, it ws only uring the 1940s tht the onept o resetion o the isese olon, rst s stge n then s one-stge oletomy, together with exision o the retum, egn to e perorme. In reent yers, wie vriety v riety o proeures hve een introue to ovite the nee or
mentione.) Te erly tretment o ulertive olitis ws entirely non-spei n omprise wie vriety o nti-irrhoel meitions. It ws not until the 1940s tht the rst spei rug tretment, sulphslzine, ws introue, n ollowe y the use o ortiosterois in the 1950s. Erly surgil ttempts t tretment inlue ppeniostomy, rst perorme y Roert Weir (1838–1927) t the Roosevelt Hospitl, New York, s mens o irrigtion o the oliti owel, n inee, this proeure ws rrie out right up to the Seon Worl Wr using wie vriety o irrigtion uis. Attempts
permnent inontinentthe stom. the ileoretl nstomosis, KohTese pouhinlue n now the ileo-nl nstomos nstomosis is with pouh. Te uture must lie with etermintion o the etiology (or etiologies) o ulertive olitis n its prevention or spei tretment. No out uture genertions will e just s mze tht the surgeons o toy hve to remove the whole o the lrge owel euse its muos is inme, inme , s present young surgeons view the surgil tretment o pulmonry tuerulosis in the pre-ntiioti er.
to putrst theuse olon restYoung y mens o n ileostomy were ytoJohn Brown (1865–1919) o St Louis in 1913. Ileostomy ertinly provie
In the pre-nestheti er, the most tht oul e oere to ptient with lrge owel ner ws to
CANCER OF THE LARGE BOWEL
102 The birth o modern surgery
relieve ostrution y mens o proximl stom. Te rst ttempt t this ws perorme y Pillore o Rouen in 1776; the ptient ws wine merhnt with lrge owel ostrution ue to sirrhous tumour t the oloretl juntion. Te istene eum ws expose through trnsverse t rnsverse inision, inision, opene n xe to the mrgins mrg ins o the woun with ouple o sutures. Te opertion proue gret relie o the ostrution, ostrut ion, ut the ptient ie on the 28th post-opertive y euse o nerosis o loop o jejunum proue y the lrge mounts o merury, mounting to 2 l in weight, whih h een given in the originl onservtive ttempts to overome the ostrut ostrution. ion. Pierre Pier re Fine (1760–1 1760–181 814) 4) o Genev rrie out the rst suessul trnsverse tr nsverse olostomy in 1797. Te ptient, womn ge 63 with retosigmoi ostruting growth, live or 3½ months eore ying o sites. A numer o suesses were reporte o the ormtion o n ‘rtiil nus’ in innts with imperorte nus, ut the next suessul se in n ult ws reporte rom the Unite Kingom y Dniel Pring Pr ing (1789–185 (1789–1859), 9), surgeon o Bth. His ptient ws womn ge 64 who h omplete ostrution ue to growth in the upper retum. He operte on 7 July 1820 n reore the se in the Medical and Physical Journal the ollowing Jour nal the yer. Beore reourse to the opertion, he rrie out every other mesure he oul think o, n n ount o these mkes n interesting re: All the medical resources o art were aterwards exhausted in ruitless attempts to procure evacuations. Salts, senna, aloes, colocynth, jalap, scammony, gamboge, elaterium, calomel were given in their largest doses and variously combined; castor oil was also given in doses o three ounces and as vomiting was by no means requent, these medicines were commonly retained. Injections o every sort and by dierent means were also administered; they were sometimes retained or about hal an hour to the amount o our to six ounces and were then orcibly expelled. It was attempted to pass a fexible catheter beyond the obstruction, through which clysters might be thrown into
the bowels above the seat o it… she was once bled without any relie to her symptoms and when all other means had ailed, some large doses o laudanum were given, without any reasonable expectation on the supposed possibility o the existence o spasm.
With regr to the inonveniene o olostomy, Pring wrote It may be worthwhile to observe that the inconveniences o an anus in this situation are not such as to have any cause to regret or having to submit to the operation; on the contrary, so ar rom her having any reason to lament this circumstance, I believe mysel that it has aorded her o a moral as well as a physical advantage; or she is now at no loss or an interest, and is provided or something to think o or the rest o her lie.
Col omort, inee, even or phlegmti English womn!
CANCER OF THE COLON Jen Frnis Reyr (1790–1863) o Lyon inreily perorme suessul resetion o sigmoi oloni growth with immeite nstomosis o the ens o the owel in 1823 without n nestheti; the ptient, mn o 29, survive or yer. However, it wite the evelopment o generl nesthesi n the introution o ntisepti surgery eore oo o reports o resetions o lrge owel tumours ws reporte. In 1879, Vinenz Czerny (1842–1916), protégé o Bilroth, suessully resete oloni growth with ento-en nstomosis, n in the sme yer, Teoor Billroth (Figure (Figure 8.5) perorme 8.5) perorme oloni resetion n rought the proximl en o the owel out o the ominl woun s olostomy. By the en o 1899, the numer o reporte resetions h risen to 57, with 19 opertive eths, mortlity o 37%. Te mjority o these tlities were ue to peritonitis, the inetion tking ple either uring the onut o the opertion or rom lekge or nerosis o the suture line some 5–10 ys er
Cancer o the rectum 103
surgery. It ws soon ppreite tht resetion n nstomosis o the olon, espeilly its le hl, ws muh more ngerous thn the sme proeure elsewhere long the limentry nl n surgeons turne their ttention to the solution o this nger nger.. An erly pproh ws exision o the tumour with exterioristion. Initilly, this omprise exterioristion o the loop o olon ontining the tumour. At the seon stge, the protruing growth ws remove, n t the thir t hir opertion, the resulting olostomy ws lose. Te rst suessul se ws reporte y Wlter Heineke (1834–1901) o Erlngen, Germny. In 1895, Frnk Toms Pul (1851–1941), o Liverpool, pulishe his tehnique in whih he exteriorise the ete loop, suture glss tue into the owel ove n elow the site o the tumour n then immeitely exise the growth (Figure 8.12), thus reuing the opertion to two-stge proeure. Johnnes von MikulizReki (1850–1905), proessor o surgery in Breslu, populrise this proeure on the ontinent o Europe n ws le to show reution in opertive mortlity in his own se se rom 43%, when he ttempte primry nstomosis, to 12.5% or the exterioristion tehnique, whih susequently me to e terme the Pul–Mikuliz opertion. Frnk Pul h reer tht ws typil o the surgeons o his er, who ommene their work in pre-Listerin ys n went on to experiene
the lmost mirulous ierenes proue y ntisepti n septi methos. When he ws ppointe s resient meil oer t the Liverpool Royl Inrmry in 1875, he esrie his hospitl work thus: ‘Erysipels, septiemi, pyemi n hospitl n gs gngrene were rmpnt. One out o three ovriotomies n exisions o the rest ie o sepsis. Most o the surgeons o tht time operte in irty rok ot’. Aer serving 20 yers on the st o the Royl Inrmry, he wrote, in ontrst to his erly experienes: ‘It ws very wonerul 20 yers in whih the sety o opertions inrese stouningly. In my lst yers I i over 1,000 onseutive rest ses without eth n in ppenix ses, with the exlusion o ve hopeless ses lrey suering rom generl peritonitis, lso 1,000 onseutive reoveries’. Unoutely, the Pul–Mikuliz opertion represente onsierle vne in mking oloni surgery se. Its isvntges were iulty o the proeure when pplie to ulky tumours or growths in the non-moile segments o the lrge owel, n the t tht equte resetion o the res o lymphti ringe ws impossile. Inee, lol reurrene in the woun ws not unommon. Se moern surgery, o primry resetion with immeite nstomosis o the lrge owel, epene rst on the evelopment o eient tehniques o owel suture, then on the importne o operting on eompresse owel ow el with, s n nillry, nil lry, knowlege o the risks o primry resetion in the e o lrge owel ostrution, n the importne o loo supply t the nstomosis.
CANCER OF THE RECTUM
Figure 8.12 Insertion o a Paul’s tube into the large intestine.
With its vivi lol symptoms n its rey etetion y the insertion o the nger into the unment, retl ner ws well known to the Anients ut, o ourse, until omprtively reent times its tretment ws entirely pllitive – wrm ths, emollient enems, n ilttions o the mlignnt tumour with ougies were employe. Te rst surgeon to mputte the retum or ner ner ws Jques Lisrn (1790–1847), surgeon t L Pitié Hospitl in Pris Pr is in 1826; 3 yers lter, he h perorme p erorme
104 The birth o modern surgery
nine suh opertions. His proeure omprise n ovl perinl inision, issetion o the istl retum n its mputtion ove the growth. Tis resulte, o ourse, in the ormtion o n unontrollle perinel olostomy. In 1874, now with the vntge o septi tehnique n nesthesi, Teoor Koher (1841–1917) (see Figure 13.2) 13.2) o Berne perorme preliminry losure o the nus with purse-string suture to prevent el ontmintion o the woun. He ws lso le to inrese the extent o the opertion y opening the peritonel vity rom elow with more equte moilistion o the retum. In 1885, Pul Krske (1 (1851 851–1 –1930) 930) introue his h is opertion o srl resetion o the retum, exposure eing hieve y removing the oyx n lower srum. Te peritoneum ws reely opene rom elow, the pelvi olon moilise n rought roug ht own n, ollowing removl o the tumour, n en-to-en nstomosis ws rrie out to the retl stump. I the growth ws too low to mke this possile, srl olostomy ws estlishe. Te Krske opertion eme extremely populr on the ontinent o Europe. It h the isvntge o high rte o nstomoti rekown ut h the vntge o reltively low mortlity n resonle survivl results. One review o nerly 1,000 suh opertions gve mortlity o 11.6% n 30% survivl er 5 yers. yers. It ws JP Lokh L okhrt-Mummery rt-Mummery (1875–1957) (1875–1957) o St Mrk’s Hospitl, Lonon, who ws responsile or the evelopment o n eetive tehnique o perinel resetion o the retum in 1907. A preliminry
olostomy tht might lek, ut it ws reltively equte ner opertion n h the vntge, in the ys o irly irly primitive nesthesi nesthesi n rrr rity o loo trnsusion, o eing reltively simple to perorm n with low mortlity, in the region o 10%. Up to the 1930s, it ws proly the most ommonly employe tehnique in the Unite Sttes n the Unite Kingom. Removl o the retum y omine ominl n perinel opertion opertion ws rst rst perorme y Czerny ((1842–19 ((1842–1916) 16) in 1884. Tis T is ws not plnne pln ne proeure ut h to e rrie out euse n ttempte srl exision ws oun to e impossile to omplete rom elow. It ws Ernest Miles (1869–1947) o the Royl Cner Hospitl (lter the Royl Mrsen) n the Goron Hospitl, who rst perorme this proeure eletively in 1907. Miles (Figure 8.13) ws isture y the high rte o erly reurrene in his own experiene o the perinel metho o retl exision. Creul post-mortem exmintions o ptients ying with this isese onvine him o the importne o wie n extensive exision o the retum, nl nl, the levtor ni musles n the rining lymph noes. Te rst ptient ws house pinter
lprotomyTe wsperinel perorme loop olostomy shione. stgen oul e perorme t one ut ws more usully elye or 10 ys n ws rrie out in the semi-prone position. Te retum ws moilise, the peritoneum opene rom elow n the superior retl vessels were tie n ivie s high s possile. Te olon ws then ivie in the upper prt o the woun n the lin stump lose. Te peritoneum ws suture with tgut, leving the stump o sigmoi olon on the woun sie o the pelvi iphrgm. Te uthor stte tht the opertion shoul not tke more thn 45 minutes, the ptient shoul e out e inTe 14 ys n eh lethe to isvntge returnvntge home in 3o weeks. opertion t he is o leving lin stump o olon istl to the
Figure 8.13 Ernest Miles. (Royal College o Surgeons o England.)
Appendicitis 105
ge 55. Aer the ominl prt o the opertion h een perorme, the ptient ws turne on the right sie or the perinel proeure. Te vity o the pelvis ws pke with guze, n smll tue rin ws ple in the lower prt o the woun. Te isvntge o this proeure t rst ws the high mortlity. In Miles’ rst 62 ses, there were no less thn 22 eths, lthough this ws reue in his thir 100 ses to 13 tlities. Tis mortlity ws gretly reue with the introution o moern nesthesi, routine loo trnsusion n ntiiotis. Te penlty o these proeures, o ourse, is the permnent olostomy. Nowys, tumours other thn those t the istl en o the retum or o the nl nl itsel re trete y resetion with nstomosis s low own s the noretl ring. Te introution o the stpling gun hs gretly inrese the populrity o this opertion.
THE ACUTE ABDOMEN Until surgery oul e rrie out without unue hste n in omprtive sety, most o the uses o ute ominl pin remine something o mystery n were lelle ‘ileus’ or ‘ominl pssion’. When ptients ie with vne peritonitis, the extensive hnges oun t utopsy oen isguise the ext lous o the originl isese. One the omen oul e opene surgilly, surgi lly, in wht Berkeley Moynihn Moynih n (1865–1936) (1865–1936) (see Figure 8.16 8.16)) l lle le ‘the pthology o the living’, the pthology revele in the operting thetre eluite the uses n, in mny thesome ure o mny o these emergenies. In thisses, hpter, o the highlights o this perio will e esrie.
APPENDICITIS Lorenz Heister (1683–1758) (see Figure 6.7) 6.7) must e given the reit o eing the rst to reognise the ppenix s the site o ute inmmtion. In 1755, he he esrie these t hese hnges t post-mortem: I ound the vermiorm process o the caecum praeternaturally black, adhering closer to the peritoneum than usual. As I was now about to separate it by gently pulling it asunder the membranes
o the process broke… and discharged two or three spoonuls o matter… this instance may stand as a proo o the possibility o infammation arising and abscesses orming in the appendicula as well as in other parts o the body.
For more thn entury ollowing this, there were osionl utopsy reports o gngrene n perortion o the ppenix with lol sess or with generl peritonitis, ut most ses remine unreognise or were given the vgue ignosis o ‘typhlitis’, ‘perityphlitis’ or ‘ili pssion’. Te rst person to report removl o t lest prt o the ppenix ws Cluius Amyn (1680–17 1680–1740), 40), surgeon rst r st t Westminster n n then t St George’s Hospitls. Tis se ws reporte t the Royl Soiety in 1736; the ptient, oy o 11, h right srotl herni ssoite with ishrging sinus. Tis ws explore n oun to ontin the ppenix perorte y pin. A ligture ws ple roun the sh o the ppenix, the perorte portion n the imprisone pin mputte n the ptient me stistory reovery. Te rst suessul opertion or ringe or n ppenix sess ws perorme in 1848 y Henry Hnok (1809–1880) o Chring Cross Hospitl, Lonon. His ptient ws ly o 30 in her eighth month o pregnny. She evelope ominl pin, misrrie on the ourth y n evelope tener mss in the lower right omen. She ws seen y Hnok on the 12th y o the illness when she h istene, tener omen, the symptoms n signs eing prtiulrly mrke in the right lower qurnt. Hnok suspete inmmtory troule roun the eum or ppenix n presrie opium n poulties. wo ys lter, her onition ws muh worse n there ws istint mss to eel. By now her onition ws esperte. An nestheti ws given, n n inision ws me ‘inwrs rom the spine o the ilium just ove Pouprt’s ligment’. When the omen ws opene, very oensive pus n ules o gs espe, ollowe ouple o weeks lter y two eoliths tht Hnok postulte h espe y ulertion rom the isese ppenix. From tht time, her improvement ws rpi n she me goo reovery. Hnok wrote
106 The birth o modern surgery
I know o no instance on record where the abdomen has been opened under the circumstances detailed above, or it should be borne in mind that in this case there was neither redness nor fuctuation nor any external signs indicative o circumscribed abscess o the part… it may be premature to argue rom the results o one case, but I trust that the time will come when this plan will be successully employed in other cases o peritonitis terminating in eusion, and which usually end atally.
However, so xe ws the ie tht it ws hopeless to interere one peritonitis ws estlishe within the ominl vity tht Hnok’s vie ws ignore or some 40 yers. yers. Surprisingly, it ws physiin n not surgeon whose tehings le to the erly tretment o ute ppeniitis. Reginl Fitz (1843–1913) (Figure 8.14) pulishe review o 257 ses o perorting inmmtion o the ppenix in 1886
in whih he showe quite lerly tht sesses in the right ili oss were in the min ue to ppeniitis n not to inmmtion roun the eum. Not only i he give ler esription o the pthologil n linil etures o ppeniitis ut he lso pointe out the importne o surgil tretment. His summry is s true toy s when it ws rst written: In conclusion the ollowing statements seem warranted; the vital importance o the early recognition o perorating appendicitis is unmistakable. Its diagnosis, in most cases, is comparatively compar atively easy. Its eventual treatment by laparotomy is generally indispensable. Urgent symptoms demand immediate exposure o the perorated appendix, ater recovery rom the shock, and its treatment according to surgical principles. I delay seems warranted, the resulting abscess, as a rule, intraperitoneal, should be incised as it becomes evident. This is usually on the third day ater a ter the appearance o the rst characteristic symptom o the disease.
Fitz ws grute o Hrvr n rrie out postgrute stuies in Vienn n Berlin. By the ge o 35, he eme proessor o pthologil ntomy t Hrvr, ws lter visiting physiin t the Msshusetts Generl Hospitl n, t the ge o 49, ws ppointe proessor o Meiine t Hrvr. oy, he shoul e rememere not onlyvlule or his work work on on the ppeniitis ut orn his eqully linil etures pthologil hnges o ute pnretitis. Fitz’s vie ws tken up rpily in the Unite Sttes. Although Roert Lwson it (1845–1899) o Birminghm s erly s 1880 operte on ptient with gngrenous ppeniitis n remove the ppenix with suessul result, he i not reor the se until 1890. It remine or Toms Morton (1835–1903) o Philelphi to e the rst to orretly ignose ppeniitis, rin the sess n remove the ppenix with reovery n to pulish the se in 1887. Figure 8.14 Reginald Fitz. (From Ellis H: The 100th birthday o appendicitis. British Medical Journal 1986; 1986; 293, 1617.)
suentretment gret vne in the erlyinignosis nTe opertive o ppeniitis Ameri ws lrgely ue to the exmple n tehings
Perorat ed peptic ulcer 107 Perorated
o numer o surgeons, prtiulrly Chrles MBurney n John Murphy. Chrles MBurney (1845–1913), surgeon in hie t the Roosevelt Hospitl, New York, esrie ‘MBurney’s point’, the point o mximum tenerness in ute ppeniitis, thir o the wy long the line joining the nterior–superior ili spine to the umilius, n evise the musle-splitting inision tht is still toy employe or ppenietomy more oen thn ny other pproh. John B. Murphy (1857–1916) (see Figure 14.22) o 14.22) o Chigo, who ws inientlly the rst surgeon to perorm the suessul suture o ivie emorl rtery, me speil point o insist tht there is regulr sequene o symptoms in typil se o ppeniitis: pin roun the umilius, vomiting, n pin shiing to the right ili oss (Murphy’s sequene). On the ontinent o Europe n in the Unite Kingom, the opertion or removl o the inme ppenix ws slower in eing opte. Freerik reves (1853–1923) (Figure 8.15) o the Lonon Hospitl i muh to populrise the opertion in Engln, n y 1901, he h perorme 1,000 ppenietomies. On 24 June 1902, 2 ys eore the t he orontion, reves rine r ine the ppenix sess o King Ewr VII. Te ptient reovere n went through the ull eremony o his elye rowning 7 weeks lter. reves, the ser jent surgeon, surge on, ws me ronet. As A s n e well imgine, this royl opertion i muh to rw the generl puli’s ttention to the isese.
Figure 8.15 Sir Frederick Treves. (Cartoon by ‘Spy’.)
require ringe. Five months lter, Hstings Gilor (1861–1941) o Reing operte on
Perortion o gstri or uoenl uler into the peritonel vity gives rise to suen severe symptoms n usully les to tl peritonitis unless the perortion is lose. Unsuessul ttempts t repir were me y Mikuliz in 1884, Czerny in 1885 n susequently y numer o other surgeons. Te rst suess ws hieve in 1892 y Luwig Heusner (1846–1916), uner onsierle iulties n y nlelight, in Brmen (now Wuppertl), Germny. Te ptient, mn ge 41, h perorte 16 hours previously; prev iously; the t he hole
ptient withIn perorte uler, who only or week. 1893, Gilor operte on survive seon ptient who survive er stormy onvlesene. Te se ws not immeitely pulishe, so the reit or the rst pulishe suessul opertion or perorte gstri uler in Engln must go to Toms Herert Morse (1877–1921) o Norwih who reporte the suessul repir o perorte gstri uler ner the ri in girl o 20 in 1894. Te suesses o Heusner n Morse quikly eme known, n opertion or suture o perorte uler ws lmost t one opte t every mjor entre. When opertions or perorte
ws only oun er serh upreovlong the lesser urve o thereul stomh. Te high ptient ere, lthough susequently le-sie empyem
gstri uler egn to e perorme, uoenl uler wsrst omprtively rre onition. It ws Berkeley Moynihn (1865–1936) (Figure (Figure 8.16) 8.16)
PERFORATED PEPTIC ULCER
108 The birth o modern surgery
to hve remrke ‘Is then your English loo so preious?’ Moynihn rete the Assoition o Surgeons o Gret Britin n Ireln, lunhe the British Journal o Surgery n ws n eetive presient o the Royl College o Surgeons. He ws rete s Bron Moynihn o Lees in 1929 when, until then, the only other surgeon to hve een elevte to the peerge ws Joseph Lister (see Figure 7.15). 7.15).
INTUSSUSCEPTION With its vivi mniesttions o loo-stine muus psse per retum, plple ominl mss n, in lte ses, prolpsing mss to e elt in the retum or even to e seen extruing ex truing through the nl verge, it is not surprising tht intussuseption in hilren ws one o the erliest orms o intestinl ostrution to e speilly reognise. retment ws expetnt, with eorts to reue Figure 8.16 Sir Berkeley (later Lord) Moynihan photographed in bloodstained operating clothes at the General Inrmary at Leeds. (Institute o Orthopaedics, London.)
who rst me the onition o uoenl uler well known in 1901 in his ook on Diseases o the Stomach, written jointly with Myo Roson. In this, he ws le to ollet only 51 ses o opertion or perorte uoenl uler, o whih re nine h reovere. O his two personl ses, one wsgret suessul. Moynihn to time. eome o the tehers o surgeryws o his Hisone ther h won the Vitori Cross in the Crimen Wr s sergent n, most unusully in those ys, ws ommissione ommissione rom the rnks. He ws trine n spent the whole o his reer t the Generl Inrmry t Lees n ws ppointe to its st in 1896. He pioneere mny o the moern opertions o the stomh, iliry system, intestines n pnres, n his textook Abdominal Operations, whih rst ppere in 1904, me his nme known on oth sies o the Atlnti. More thn nyone else t the time, he prehe the importne o gentle, unhurrie ut purposeul purposeul rsmnship. A visiting Frenh surgeon,surgil er wthing Moynihn’s metiulous hemostsis, is reporte
the intussuseption y enems or y the pssge o retl ougies. Surgeons were enourge to ontinue these eorts y osionl reports o suesses n y still rrer exmples where spontneous ure o the innt resulte rom the pssge ps sge per retum o the gngrenous segment o strngulte owel. Te rst suessul opertion or reution o n intussuseption in n innt ws perorme in 1871 y Jonthn Huthinson (1828–1913) (Figure 8.17) who 8.17) who pulishe etile report o se in 1874. In this pper, he metiulously tulte 131 previous se reports, whih mkes s reing inee. His ptient ws emle hil ge two, who presente with ll the lssil etures o the onition. He wrote My experience o several other somewhat similar cases, all o which have resulted in death, ater patient and repeated attempts by the injection method, did not encourage me to expect success in this. It was very evident rom the child’s condition, that unless relie were aorded she would not live long and I thereore elt justied in telling the parents that although an operation be, inthat itselit very dangerous, yetwould I thought aorded the only chance. They begged me to
Intussusception 109
excellent health about 3 weeks ater a ter the operation.
Nowys, the tretment o hoie in stle innt or hil is non-opertive reution using liqui (ontrst or sline) sl ine) or ir enem uner X-ry or ultrsoun ontrol. Tis is suessul in 70%– 85% o ses. While the opertive tretment toy remins the sme s tht esrie y Jonthn Huthinson, it is reserve or ses where nonopertive reution is unsuessul or in unstle ptients with eviene o omplitions suh s peritonitis. Sir Jonthn Huthinson, surgeon t the Lonon Hospitl, ws remrkle linil oserver. He esrie the stigmt o ongenitl syphilis, whih inlue the peg-top inisor teeth (Huthinson’ss teeth), n he esrie (Huthinson’ esrie the inresinres ing ilttion o the pupil in ses o extrurl hemorrhge (Huthinson’s pupils), the msk-like il pperne o tes orslis (Huthinson’s Figure 8.17 Jonathan Hutchinson as a young surgeon. (Royal College o Surgeons o England.)
give the child a chance i I thought it was one, and we accordingly determined to lose no time. The child having been taken up into the operating theatre, chloroorm was administered and I then opened the abdomen in the median line below the umbilicus and to an extent admitting o the easy introduction o two or three
ies) n hl ozen ermtologil onitions. He pulishe ten volumes o Archives o Surgery etween 1889 n 1900, the entire ontents o whih were written y him. In the volume pulishe in 1891 is remrkle report n illustrtion o ientil twin sisters ge nine, who, t the ge o three, h evelope ientil lk pigment spots on their lips n insie the mouth (Figure 8.18). In 1919, Freerik Prkes-Weer (1863–1962), Lonon physiin, note ollow-up on these girls, one o whom h ie ollowing n opertion opert ion or intussusept intussuseption ion 11 yers er Huthinson’ Huthinson’ss
ngers. I nowthe very readily drew out o the wound intussuscepted mass, which was about six inches long. lon g. I ound that the serous suraces did not adhere, and that there was no diculty whatever in drawing the intussuscepted part out o that into which it had passed… Having completed the reduction I put the bowel back into the abdomen, and closed the wound with harelip pins and interrupted sutures. The operation had been an extremely simple one, and had not occupied more than 2 or 3 minutes… The child recovered without having ever showed the slightest symptom o peritonitis, and let the hospital in
Figure 8.18 Identical twins with pigmented cutaneous spots. (From Hutchinson’s Archives of Surgery o o 1891.)
110 The birth o modern surgery surger y
originl oservtion. Perhps Huthinson’s nme shoul e given eponymously to the synrome o utneous pigment spots ssoite with intestinl polyps n intussuseption esrie y the Duthmn John Peutz (1886–1957) in 1921 n y Hrol Jeghers (1904–1990), proessor o meiine, New Jersey, USA, in 1949.
THE RUPTURED SPLEEN Te spleen is the visus most ommonly mge in lose ominl injuries, prtiulrly with severe rushing rush ing low to the le lower lower hest or the omen. Although spontneous heling my osionlly our, untrete the mjority o ptients with this injury will ie o exsnguintion. Rther surprisingly, thereore, there seeme in the pioneer ys o ominl surgery to e iene y surgeons to open the omen in this onition n to remove the rupture spleen. Tis ws in spite o the t tht Jules Pén (see Figure (see Figure 8.3) h 8.3) h perorme suessul eletive splenetomy in 1867 in girl o 20 suering rom n enormous spleni yst. Te rst two t wo unsuessul ttempts to e reore reore were reporte in 1892 y Sir Willim Aruthnot Lne (1856–1943) (see Figure 10.8) 10.8) o Guy’s Hospitl. Te rst ws oy o 15 who ell o roughm, lne on its pole n ws operte on y Lne shortly erwrs. Te pulpe spleen ws remove, ut the ptient ie 5 hours lter. Te seon ws oy o 4 who reeive low on the omen rom the pole o rrige. Splenetomy ws perorme or the ompletely rupture spleen, ut the hil sur-
the le nk. At opertion out one n hl litres o loo poure out o the omen, n the spleen ws oun to hve een ompletely severe, its lower hl lying ree within the omen. Te spleni vessels were tie n the upper hl o the spleen exise. In the ys eore loo trnsusion, norml sline ws inuse suutneously into eh o the rms n thighs. His reovery ws omplite y gngrene o the le oot, whih require mputtion, ut he le hospitl, omplete with n rtiil lim, 5 months months er surgery. It ws not until unti l 2 yers lter l ter tht Sir Chrles Alre Bllne (1865–1936) rrie out the seon reporte suessul splenetomy or lose trum (Figure 8.19). Tis took ple t St Toms’ Hospitl in Lonon on shooloy ge ten, who h een struk y riket ll on the le sie o the t he omen 5 ys eore mission. mission. oy, o ourse, elye rupture o the spleen is well
vive only ew(1844–1924), hours. Te ollowing ollowing yeroFrierih renelenurg proessor surgery in Leipzig, reporte urther ur ther unsuessul splenetomy or trum n inee pulishe two urther tl ses. Reing these t hese se reports suggests tht, h loo trnsusion een ville, these ptien ptients ts might well hve survive. It ell to Oskr Riegner (1844–1910), the hie surgeon t the All Sints Hospitl in Breslu, to hve the istintion o perorming the rst suessul splenetomy or lose spleni trum in 1893. His ptient ws 14-yer-ol lourer who ell two oors rom soling, striking his o-
Figure 8.19 Ballance’s rst successul
men on or. the next he h inresingly ple By with pulsey, o 120 neome with istene pinul omen, whih ws ull in
splenectomy or trauma; rupture o the spleen rom a cricket ball. (From Trans Clin Soc 1896; 1896; 29, 77–104.)
Ruptured ectopic pregnancy 111
reognise. Bllne esrie the shiing ullness in the right nk n xe ullness in the t he le, whih he lime resulte in hemorrhge rom the spleen. Tis rther outul physil sign is oen reerre to s ‘Bl ‘Bllne’s lne’s sign’. sign’. We hve never eliite it.
RUPTURED ECTOPIC PREGNANCY
Until 1883, rupture etopi pregnny ws eth sentene. In his ook on extruterine pregnny pulishe in 1876, Dr John Prry wrote: ‘Here is n ient whih my hppen to ny wie in the most useul perio o her existene, whih goo uthorities hve si is never ure; n or whih, even in this ge when siene n rt ost o suh high ttinments, no remey either meil or surgil hs een trie with single suess’. When we re tht eminent uthorities were vising the use o eletri shoks, the injetion o nroti mterils into the s, n opious n requent leeing, one is hrly surprise t the rte o ilure. Prry himsel went on to suggest tht the only remey woul e to open the omen n either to tie the leeing vessels or to remove the s entirely. Te rst surgeon to perorm suessul opertion o the kin reommene y Prry ws Roert Lwson it (1845–1899) (Figure 8.20) o
Birminghm, n it is interesting tht the suggestion tht he shoul operte me rom generl prtitioner. Te rmti story involves three suessive ses esrie vivily in it’s own wors: In the summer o 1881 I was asked by Mr. Hallwright to see with him in consultation a patient who had arrived by train rom London in a condition o serious illness diagnosed by Mr. Hallwright as probably haemorrhage into the peritoneal cavity rom a ruptured tubal pregnancy. The patient was blanched and collapsed, the uterus was xed by a doughy mass in the pelvis and there was clearly a considerable amount o eusion in the peritoneum. I agreed with Mr. Hallwright as to the nature o the lesion. This gentleman made the bold suggestion that I should open the abdomen and remove the ruptured tube. The suggestion staggered me and I am ashamed to say that I did not receive it avourably… I declined to act on Mr. Hallwright’s request and a urther haemorrhage killed the patient. A post mortem examination revealed the perect accuracy o the diagnosis. I careully inspected the specimen which was removed and I ound that i I had tied the broad ligament and removed the ruptured tube I should have completely arrested the haemorrhage and I now believe that had I done this the patient’s lie would be saved.
Te seon opportunity me 18 months lter, in the summer o 1883, when it ws onsulte y Mr Spkmn o nery Wolverhmpton with similr se. Te ptient ws lerly ying, ut it operte; it ws the rst osion when n tive surgil ttempt ws me to sve lie uner suh irumstnes. As it reors:
Figure 8.20 Robert Lawson Tait. (Royal College o Surgeons o England.)
We got her to bed alive and that is all that can be said… I thought very much about this case or it was a bitter disappointment. I thought I should achieve a triumph and I had only a ailure.
112 The birth o modern surgery surger y
He resolve then tht in ny uture se he woul ignore the leeing, go or the soure o the hemorrhge, the ro ligment, tie it t its se n then remove eris n lots t leisure. Te next ptient presente hersel on 1 Mrh 1883. it ws onsulte y Dr Pge o Solihull, suur o Birminghm, with ptient who h xe mss in the pelvis n whose menstrution h een rreste or out 3 months. She h high pulse, n elevte temperture n ws in gret pin. it writes I advised abdominal section and ound the abdomen ull o clot. The right allopian tube was ruptured and rom it a placenta was protruding. I tied the tube and removed it. I searched or, but could not nd, the oetus and I suppose it got lost among the olds o intestine and there was absorbed… The patient made a very protracted convalescence but she is now perectly well. Within yer, it h operte on three itionl ptients; pt ients; 4 yers lter, in 1888, he ws le to report 39 ses with only two eths, inluing his rst ttempt. it, remrkle mn, ws one o the thers o ominl surgery. We hve lrey note erlier in this hpter tht he ws the seon surgeon to rry out holeystotomy (1879) n the rst to ignose n suessully remove n utely inme ppenix (1880). He ws pupil o the gret Sir Jmes Young Simpson, proessor
pulition in 1886 o 137 onseutive ses o ovriotomy perorme without eth. it ws short, stout mn with mgnient he, thik ull nek, orpulent oy, pugy legs n smll hns n eet; he ws esrie s hving the oy o Bhus n the he o Jove. His voie oul e so n musil; he woul sing sweetly n yet, when in rge, woul ror like lion. Mny oservers ommente on his mrvellous rpiity n exterity s surgeon. His tehnique ws simpliity itsel. He operte in smll nursing homes with the ptient li on plin wooen tle. He woul remove his jket, roll up his sleeves, n srupulously prepre his hns with sop n wter. Te ptient’s omen woul e reully lense, rst with turpentine n then with sop n wter, n the instruments were sterilise y oiling; it ws thus one o the pioneers o septi rther thn ntisepti surgery n inee he ttke Listerism s not only unneessry ut ngerous. Te ontriutions o this surgeon re est summe up y Willim Myo, who si: ‘Te vities o the oy were sele ook until the t he ther o moern ominl surgery, Lwson it, rrie the t he sense o sight into the ominl vity’.
OBSTRUCTION DUE TO POSTOPERATIVE ADHESIONS Tere ws ownsie to the new ominl surgery – novel ominl omin l emergeny. Ahesions Ahesions re lmost invrile ollowing lprotomy n,
o ostetris in Einurgh, introue roorm into miwiery nwho surgery in 1847hlo(see Figure 7.9). it 7.9). it ore striking resemlne to his proessor, n inee there were rumours tht he ws Simpson’s nturl son. Aprt rom the resemlne, there seems to e little eviene to support this gossip, whih seretly muse it. He qulie in 1866, move to Birminghm t 25 yers o ge, n spent the rest o his tive lie there until his eth rom uremi ue to renl stones t the erly ge o 54. Aprt rom his work on etopi pregnny, it pioneere the surgery o ovrin ysts n tumours, losely ollowing
one eore ominl surgery ommene, it ws long ses o smll owel ostrution uenot to post-opertive ns n hesions were reporte. Toms Brynt (1828–1914) o Guy’s Hospitl reporte the rst exmple in 1872 – tl se ollowing removl removl o n ovrin yst. Willim Will im Bttle (1855–1936) reporte seon tl se in 1883; this ourre 4 yers er n ovriotomy. oy, post-opertive hesions ount or some threequrters o ll ses o smll owel ostrution in the Western worl.
on the erly o work Sir Toms Spener Wells (1818–1897) the oSmritn Hospitl, Lonon, in this el. His surgil skill is shown y the
Now tht inspetion o the ominl viser ws possile t opertion, surgeons oun, to their
‘VISCEROPTOSIS’
Urological surgery 113
surprise, tht the position o the orgns ws oen quite ierent to the nings in the ver, espeilly in the preserve oies o the isseting room. A still urther surprise ollowe the isovery o X-rys y Wilhelm Roentgen (1845–1923), proessor o physis t Wurzurg, in 1895 n then the X-ry visulistion o the ominl orgns y ontrst mteril, rst y using ismuth sulphte introue y Wlter B. Cnnon (1871–1945) t Hrvr Meil Shool, in 1897. Te spleen, kineys n, in prtiulr, the stomh n intestines were oen situte in lower plne thn esrie in the ntomil textooks. Some o these ppernes, in t, were rought out y the weight o the ontrst mteril in the stomh n owel, with the ptient in the upright position ut the rest, s we now know, simply represente norml iologil vrition. However, wht n only e esrie s ‘non-isese’ me into existene – ‘viseroptosis’. Even tht shrew liniin, Berkeley Moynihn (see Figure 8.16) wrote 8.16) wrote in his textook Abdominal Operations: The circumstances which are generally present are these; there is a weakening o all the natural supports o the viscera; the peritoneal ligaments are long, lax, and unequal to their burden, and the abdominal wall in its lower part is pushed orwards, bulging in characteristic ashion; a passive dilatation o any part, or o all parts o the alimentary canal may be present. The patient complains chiefy o a sense o a heavy weight, o dragging and o weariness in the abdomen. There is oten nausea and sometimes vomiting; there are ullness, fatulence, eructations. The bowels act irregularly, and constipation is always a prominent eature. The patient is almost always a neurasthenic o a most pronounced type. An examination will disclose the circumstances mentioned above – a laxity o the supports and consequently an undue mobility o all the organs in the abdomen.
He i, however, point out lter in the hpter: ‘Te existene o these vrious orms o ptosis oes
Figure 8.21 Rovsing’s gastropexy or ‘ptosis o the stomach’. (Thorkild Rovsing 1862–1927, proessor o surgery, Copenhagen.)
not lwys, oes not inee oen, entil the ssoition with them o ny isturne o helth’. Lrge numers o ptients were tte with ptosis orsets to support the viser. I this ile, however, thousns o ptients, mostly neuroti women, were sujete to mjor ominl opertions in whih the stomh, liver, kineys n owel were hithe up (gstropexy, heptopexy, nephropexy, et.) n vrious peritonel ns, whih we now know re peretly norml, reully ivie. ivie. Menwhile, the gyneologists were usy ‘norml’ t work putting pelvi orgns k into their position.the Tese opertions persiste well into the 1920s 1920s n n still sti ll e seen in illustrtions o textooks o those times (Figure 8.21).
UROLOGICAL SURGERY Te new er sw mjor vnes in the surgery o the urinry trt (see lso Chpter 12). An 12). An importnt lnmrk ws the rst suessul plnne nephretomy rrie out y Gustv Symon (1824–1876) in Heielerg in 1869. However, this ws not the rst time the kiney h een remove; in the smeh ee, lest our invertent nephretomies eentperorme, ll with tl results, on the mistken ignosis o the mss
surger y 114 The birth o modern surgery
eing ovrin in three ses n n liver yst in the ourth. Symon’s ptient ws womn o 46 who h unergone removl remov l o n ovry ov ry 18 months pre viously y nother surgeon, who invertently exise length o le ureter. Te ptient evelope n ominl urinry stul n lso ureterovginl stul, so her lie with oule inontinene together with urinry inetion ws eoming intolerle. Symon me our ttempts to improve her onition y onservtive surgery, ll o whih ile. He relise tht only removl o the kiney woul ure her. Beore oing so, he perorme the opertion on 30 ogs to ssure himsel tht the proeure ws omptile with peret helth, n he lso prtise the opertion in the post-mortem room, in prtiulr, to stuy eient ligtion o the renl peile. Post-opertively, the ptient evelope ileus, woun inetion n pneumoni, n the woun took months to hel ompletely,, ut ortuntely, she ws restore to ull ompletely u ll helth. Following this, the opertion o nephretomy eme omprtively ommon or wie vriety o initions, inluing stone, tumour n tuerulosis, ut it remine ormile opertion. Tus, Smuel Gross (1837–1889) o Jeerson Meil College, Philelphi, in review o 233 ollete ses in 1885, oun oun n overll mortlity o 45%: tht o the lumr pproh ws w s 37% while tht o the ominl route ws 51%. By the wy, er his untimely eth, Gross’ wiow mrrie Sir Willim Osler, lter Regius Proessor o Meiine
nek. Tis he remove with sissors, with relie o the ptient’s ostrutive symptoms; this opertion proly represente the rst prtil prosttetomy. However, the er o suprpui prosttetomy wite the twin enets o nesthesi n ntisepsis. Erly pioneers were Willim Belel (1856–1929) o Cook County Hospitl, Chigo, who, in 1886, perorme the rst plnne opertion when he vulse peunulte mile loe y this pproh. In 1887 Arthur Fergusson MGill (1850–1890) o the Lees Generl Inrmry ws le to report report three ses o suprpui prosttetomy esrie s ‘removing with sissors n oreps tht portion o n enlrge prostte whih prevents the ow o urine’. O some interest ws tht his ssistnt t his rst opertion ws young stuent, Berkeley Moynihn (see Figure 8.16). By 8.16). By 1890, MGill ws le to reor 33 suh opertions perorme y himsel n his ollegues in Lees. In 1895, Eugene Fuller (1858–1930) o New York reporte six suessul ses o prosttetomy in whih there is no out tht t ht he ttempte omplete enuletion o ll isese tissues. A suprpui tue ws ple in the ler, n seon so ruer tue ws psse through the perineum into the ler, or ringe. Despite the work o Belel, MGill n Fuller, the opertion o suprpui prosttetomy gine reltively little support, n it remine or Sir Peter Freyer (1852–1921) (Figure (Figure 8.22) 8.22) to populrise the opertion in series o ppers n monogrphs, so tht toy, suprpui enuletion o
in Oxor.
Cses o urinry retention h een trete y theteristion y the Anient Chinese n Egyptins Egy ptins n y the Inin surgeons Susrut n Chrk. Prior to the vent o prosttetomy, the ptient with retention rom prostti isese ws onemne to lie o sel-theteristion, sel-theteristion, eing tught to rry out the proeure himsel three or our times ily. In 1827, er removl o stone y suprpui ystotomy, Jen Amusst
the prosttetue with (proly ler ringe lrge suprpui one o through the resons or Freyer’ss unoutely goo results) is eponymously Freyer’ title ‘the Freyer prosttetomy’ (Figure (Figure 8.23). 8.23). Freyer lime, quite wrongly, tht he n only he h introue totl removl o the gln n inee lime tht the essentil eture o his opertion ws tht he remove the whole prostte n its psule rom its ventitil sheth. Both these lims were ptently not true, n the journls o the time were lle with the rimonious lims n ounterlims o Freyer, Fuller o New York, the Lees Group n others. However, the
(1796–1856) in Pris rm roune mss, whih must hveoserve een the enlrge mile loe o the prostte, projeting rom the ler
puliity to the opert ion opertion y the ontroversy, ontroversy s well sgiven Freyer’s numerous letures, rtiles n, ooks, me the opertion wiely known n i
PROSTATECTOMY
Prostatectomy 115
Figure 8.22 Sir Peter Freyer. (Portrait at the Institute o Urology and Nephrology, London.)
Freyer himsel little hrm. Inee, uring the Freyer t he ontroversy, he quote Siney Smith, who wrote ‘tht mn is not the isoverer o ny rt who rst sys the things; ut he who sys it so long n so lou n so lerly tht he ompels mnkin to her him’. Freyer ws olourul hrter. He qulie rom Queen’s University, Belst, in 1874 with gol mel, serve in the Inin Meil Servie s olonel olonel n eme prtiulrly skille ski lle in the use o lithotrite (see Chpter 12) 12) in the rushing o ler stones. Suessul opertions with this instrument upon Bhur Ali Khn, the Rjh o Rmpur, were rewre with lkh o rupees n mgnient present o jewellery. He returne to Lonon in 1896 n ws soon ppointe to the st o St Peter’s Hospitl, Lonon, then, s toy, the only speilise urologil hospitl in the Unite Kingom, now the Institute o Urology. He ws skilul skil ul n n speey surgeon, surgeon, n his exellen exellentt results ttrte lrge privte prtie. In 1920, he reporte series o 1,625 prosttetomies with mortlity o only 5%.
Figure 8.23 (a) Upper aspect o an enormous prostate, weighing 10 ½ ounces, removed rom a patient aged 75. The catheter indicates indic ates the position occupied occupi ed by the urethra. Portion Porti on A, A1, A1, B, B1, B1, lay in the bladder; B, B1, C, C1 outside the bladder between the pubic arch and the rectum. (b) Showing under
aspect o the same prostate, with, below it, an adenoma detached rom the prostate. (From Freyer PJ: Clinical Lectures on Stricture of the Urethra and Enlargement of the Prostate. Prostate. London, Baillière, Tindall and Cox, 1902.)
surger y 116 The birth o modern surgery
Te Freyer prosttetomy remine populr until quite reently; inee, s house surgeon in Oxor in 1948, I ssiste s siste my hie t mny o these opertions. Although Hugh Young (1870–1945) o Bltimore perete the perinel prosttetomy in 1903, the opertion, lthough quite populr in the Unite Sttes, i not ompete with the suprpui pproh elsewhere in the worl. It remine or erene Millin (1903–1980) to ring in his opertion o retropui prosttetomy, whih he rst perorme in 1945, to reple the trnsvesil pproh. It h the ovious vntges o leving the ler intt, eient losure n goo heling o the prostti psule n n muh shorter n more omortle post-opertive ourse. Give surgeons their ue: they rpily pt vnes in tehnology to their rmmentrium. Te isovery o X-rys, or exmple, ws pplie within weeks to the ignosis o rtures n lolistion o oreign oies. Te evelopment o n eetive smll eletri light ul enle one o the thers o moern urology, Mx Nitze (1848–1906), proessor o urology in Berlin, to onstrut n eletrilly lighte ystosope in 1877 tht revolutionise urologil ignosis (Figure 8.24). By 8.24). By 1911, Hugh Young use ystosope with punh tthment to perorm trnsurethrl prosttetomy. Control o leeing ws prolem until John Culk (1881–1938) sustitute the eletri utery or the knie so tht leeing oul e ontrolle y ogultion o ivie loo vessels. Nowys, the use o reopti instruments hs seen the lmost entire reple-
oul e evelope. It ws Sir Willim Mewen (1848–1924) (see Figure 10.16) o 10.16) o Glsgow who rst suessully remove ererl tumour in 1879. Te ptient ws girl g irl o 14 who presente with le suproritl mss n evelope severe right-sie Jksonin ts while eing oserve on the wr. At opertion, meningiom rising rom the ur, herent to the skull n extening into the oritl vity, ws remove. Post-opertively, the ptient h urther onvulsions on the h y, ut er tht, me smooth reovery. Mewen must e regre s s one o the ouning thers o neurosurgery. In 1876, he ignose ererl sess in the le rontl loe o oy o seven n vise surgery. Tis ws reuse, ut t utopsy the ignosis n lolistion were rillintly onrme. Tree yers lter, n in the sme yer tht he perorme his suessul exision o the rin tumour, he urtely lolise n suessully evute suurl hemtom. By 1893, he h operte on 24 ses o ererl sess with no less thn 23 reoveries, mrvellous reor tht n hrly e equlle toy. Sir Vitor Horsley (1857–1916) ws the rst surgeon to remove spinl tumour. Te yer ws 1887; the ptient, retire rmy oer, ws mitte to the Ntionl Hospitl or Nervous Diseses, Queen Squre, Lonon, uner the re o the neurologist Sir Willim Gowers (1845–1915) with prplegi, retention o urine n severe pinul exion spsms o the lower lims. Gowers ignose spinl tumour ompressing the or t the level o the h thori verter. Horsley,
ment o openopertion prosttetomy y the trnsurethrl ystosopi (the trnsurethrl prosttetomy or UR), with its low moriity n short ptient sty st y..
We hve lrey note in the rst hpter o this ook tht trephintion o the skull ws mong the erliest opertions n ws rrie out in wiely ierent loi throughout the worl. We hve esrie the eorts o oth ivilin n militry surgeons to el with he wouns n skull r-
whothe hyer onlyeore, een put the st the hospitl wson lle into tonsulttion n operte within 3 hours o seeing the ptient euse o the ovious urgeny o the onition. A lminetomy o the ourth to the sixth thori vertere ws perorme n revele nothing, nothing , ut higher explortion n opening the ur emonstrte n lmon-size tumour tht ws inenting the spinl or n ws ompletely remove. Te ptient me ull reovery n ie o other uses 20 yers lter. l ter. Te pthology report on the speimen esrie it s ‘romyxom’. Horsley (Figure (Figure 8.25) 8.25) lso pioneere the iult
tures. However, in so mny other o surgery, eletive s opertions upon the rnhes entrl ner vous system h to wit the moern er eore they
rnil o exision o the trigeminl gnglionopertion in the tretment o trigeminl neurlgi (‘ti oloureux’) – ttks o reul il pin
NEUROSURGERY
Neurosurgery 117
Figure 8.24 Max Nitze’s cytoscope cy toscope and accessories accessorie s (patented in Vienna 1877 and published 1879.) 1879.)
lolise to one or other o res o istriution o the ivisions o the h rnil nerve. At Queen Squre, he rrie out surgery or rin tumours, ererl sesses sess es n ol epilepsy. epileps y. Horsley ws remrkle mn. A rillint grute o University
physiology n puli helth – he ws strong vote o stinene rom lohol. In the First Worl Wr, Wr, he ws ppointe onsultnt surgeon su rgeon in the Mile Est n ie suenly while serving in Mesopotmi, perhps rom het stroke or
College Hospitl, Lonon, he wstosoon to its surgil st in ition his ppointe uties t Queen Squre. He h wie interests in surgery,
else ever, ws rmpnt t tht time.prtyphoi He lies urie in whih the British wr emetry t Amr.
surger y 118 The birth o modern surgery
Figure 8.25 Sir Victor Horsley (as Colonel in the RAMC). (Royal College o Surgeons o England.)
Te ouner o neurosurgery in the Unite Sttes is reognise to hve een Hrvey Cushing (1869 (1 869–1939) –1939) (Figure (Figure 8.27 n 8.27 n see lso Figure 9.27), 9.27), n his ontriutions to the surgery o he injuries in the First Worl Wr re etile in Chpter Chpter 9. rine 9. rine y Willim Hlste t Bltimore, where he ommene his neurosurgil work, Cushing ws ppointe s surgeon-in-hie t the newly
Figure 8.26 An example o Harvey Cushing’s artistic skill. The exposed motor area o the brain in a man with ocal epilepsy secondary to a bullet wound in the speech area. (From Cushing’s chapter in Keen’s System of Surgery , published in 1908.)
renline omine with trtion with series o rtery oreps pplie to the skin eges. In 1910, he introue silver lips, to whih his nme is still pplie, whih oul e use to olue meningel n ererl vessels. Sution ws introue to
uilt Peter Brighm Hospitl in Boston in 1912. Here,Bent he evelope his metiulous tehnique, whih psse into stnr neurosurgil prtie. Beore the First Worl Wr, he pulishe n importnt work on the surgery o trigeminl neurlgi n tumours o the rin n o the pituitry. Cushing ws n omplishe rtist; his ooks n rtiles were illustrte y his own super rwings (Figure 8.26). On his return to ivilin lie er the wr, he went on to proue mssive stuies on rin tumours. From his erliest ys in neurosurgery, Cushing relise the vitl importne o hemostsis in
elrin with sustne. severe leeing, espeilly eep within the However, it ws his introution o the use o ithermy in 1926 tht ws the most importnt o these innovtions. Te rst osion on whih Cushing use ithermy (operting on highly vsulr meningiom) hs prt prtiulr iulr sintion sintion or me euse his ssistnt t the time inte. Tis ws none other thn Hugh Cirns (1896–1952), who lter ws my proessor o surgery t Oxor. At tht time he ws young Austrlin vetern o the Gllipoli lnings in the First Worl Wr, where he h ought ginst the urks s privte in the Austrlin
eling tissues o the skull nwith the the rinvsulr itsel. He showe tht slp, slp leeing oul e ontrolle y inltrtion with
rmy. lter serve Frne junior meil oer.He Oviously, theinsmell osogulting rin tissue prove too muh or him t tht historil
Caesarian section 119
opertion in 1926. Inee, Cirns use to sy tht Gllipoli n the t he Bttle o the Mrne were nothing ompre to working s Cushing’s ssistnt. One o Cushing’s right young men in his h is ys t the Johns Hopkins ws Wlter Dny (1886–1946) (Figure 8.27). Dny serve s Cushing’s reserh ssistnt in 1910, then s his ssistnt resient rom 1911 to 1912, ut their very ierent personlities lshe then, s they i or the rest o the reers o oth these outstning neurosurgeons. When Cushing move to Boston in 1912, tking with him most o his st, Dny ws le ehin, ut ws soon on the st t Johns Hopkins, where he soon estlishe himsel s rillint innovtor n super n, in ontrst to Cushing, rpi opertor. In 1922, he reporte his tehnique o omplete removl o n ousti neurom ( irly ommon tumour o the eighth uitory rnil
nerve). Beore tht time, Cushing h vote n inomplete intrpsulr removl o the growth. He ws the rst to perorm the opertion o lipping the eeing rtery to oliterte Cirle o Willis neurysm on the inerior spet o the rin. He rrie out unmentl reserh on the seretion n irultion irult ion o ererospinl ui n evise proeures to tret hyroephlus. Dny evelope the rst riologil tehnique or visulising intrererl pthology. Tis involve the injetion o ir s ontrst mteril into the ventriulr system o the rin (ventriulogrphy), whih t the time ws n enormous vne in the ignosis o ol lesions within the skull. At rst, this rillint rill int innovtion innovtion ws oppose y Cushing, who elieve tht it woul istrt neurosurgeons rom trying to mke n n urte ignosis y linil exmintion only !
CAESARIAN SECTION Te erly history o Cesrin setion (see Figure 5.9) is 5.9) is shroue in myth n mystery. Te origin o the very nme itsel hs vrious interpretions. Te story tht Julius Cesr ws elivere y this mens is highly improle, sine his mother, Aureli, ws live n well t the time o his invsion o Britin in 55 bc! In 715 bc, Num Pompillius, King o Rome, ente lw in whih uril o e pregnnt womn ws orien until the oetus h een remove, so tht mother n hil oul e urie seprtely. Te lex Regia (Royl Lw) lter eme the lex Caesarea – more likely explntion o the term. Tere re numerous reerenes to this proeure in Anient myths n me y lssil writers. Ovi, the Romn poet, esries how Aesulpius, go o Physi, ws elivere y this mens, the surgeon eing none other thn the gret Apollo himsel (Figure (Figure 8.28). Te 8.28). Te well-known Shkesperin quottion rom Macbeth:
Figure 8.27 Walter Dandy (on the let) with
his rival in surgery and tennis, Harvey Cushing. (From Harvey Cushing, a Biography , John Fulton Oxord, Blackwell Publications, 1946.)
Tell them Macdu was rom his mother’s womb Untimely ripped is probably derived rom Holinshead’s Holinsh ead’s The Chronicles of England, Scotland and Ireland o 1577 15 77 – another myth!
Te term itsel ppers rst to hve een use in print in ook y Frnis Rousset, physiin
120 The birth o modern surgery
Figure 8.28 Aesculapius being delivered rom his mother Coronis by Apollo. Woodcut rom Alessandrio Beneditti’s Beneditt i’s De Re Medicine Medici ne 1549. 1549.
to the Duke o Svoy, pulishe in 1581 n title Enantement Caesareinne, in whih he vises the opertion to e perorme on the living mother n reors seven se reports tht he h ollete, whih purporte survivl o the mother. Other surgeons were more ynil. Amroise Pré (see Figure 9.4) 9.4) in his extbook o Surgery , pulishe t out the sme time, even though he h her o suessul se, strongly ritiise the opertion. Most o the erly ounts were o opertions rrie out er the eth o the mother in n ttempt to sve the hil, ut there were lso reports o women in ostrute lour opert-
with seven metl spikes psse through the eges o the woun n tie together with string. Felkin le 11 ys lter, t whih time oth mother n hil ppere well. Reing this report, one n esily imgine similr opertions tking ple, sometimes with eqully hppy results, over the enturies (Figure (Figure 8.29). It seems tht the rst suessul Cesrin to e perorme in the British Isles ws perorme y skilul ut illiterte miwie, Mry Donlly, in Clremont, Ireln, in 1738. Te ptient, Alie O’Nele, ge 33, ws rmer’s wie who h lrey h severl hilren. She h now een in lour or 12 ys. Te miwie opene the lower
ing on themselves eingreently, elivereshowing thus y tht the esperte husn.orMore suh inee oul hve een true, there hve een eye witness ounts o the opertion eing perorme in primitive ommunities. Roert Felkin, MD, in 1884, pulishe vivi esription in the o Cesrin setion Edinburgh Medical Journal o he h oserve in Ugn, perorme y ntive prtitioner. Te ptient, primipr ge 20, ws rst intoxite with nn wine. Te wine ws then use oth to the the girl’s omen n the surgeon’s hns. A miline mi line inision ws me rom the puis to the umilius. Te ssistnt uterise
omen n the She uterus rzor n elivere e hil. thenwith hel the woun eges together while neighour rn mile to eth tilor’s neele n thre with whih the miwie lose the ut in the ominl wll. Te mother reovere ut, s ws lmost invrile in erly suessul ttempts t ominl surgery, she evelope lrge ventrl herni. Willim Smellie (1697–1763) (Figure (Figure 8.30) 8.30) o Lnrk, Sotln, n then Lonon, regre s the ther o British miwiery n pioneer in the use o the ostetril oreps, pulishe his reatise on the Teory and Practice o Midwiery in 1752.
the with Te uterus wsleeing inise, vessels the y n re-hot then theiron. plent elivere, n the ominl woun rought together
As might e expete rom this soun, experiene n prgmti ostetriin, he took ommonsense pproh to the sujet o Cesrin setion.
Caesarian section 121
Figure 8.29 Drawing by Robert Felkin o a Caesarian section he witnessed in Uganda. Edinburgh Journal of Medicine, Medicine, 1884.
Te opertion might e employe in ostrute lour when it ws impossile to insert the hn vginll vgi nllyy into the pelvis, when the womn ws strong n when no other mens ws ville o sving either mother or hil. Alterntively, it might e employe when the mother h expire,
n there ws hne o sving the innt. His personl experiene ppers to hve een limite to three ses – ll perorme er eth o the mother rom hemorrhge use y plent previ. In ll ses, the hil ws e. Smellie quotes, like other ontemporry writers, the suess o Mry Donlly. O ourse, the stnr prtie in those ys in the mngement o n ostrute lour ws to perorm estrutive opertion, rniotomy, on the oetus n then to eliver the prts pieemel. Apprently the rst Cesrin opertion with mternl survivl to e perorme y meil prtitioner in this lthough it ws not ountry reorews till not 1798.until Tis1793, ws perorme y surgeon nme Hwren in Wign, Lnshire. His ptient, ge 40, h h severl hilren previously ut now h grossly eorme pelvis s result o severe rture. Aer the ptient h een in lour l our or 3 ys, Hwren ws summone. He opene the omen through 5-inh inision to the le o the miline n elivere e oetus. Te mother survive. Tt wise ostetriin ostetr iin Jmes Blunell (1790–1 1790–1877) 877) o Guy’s’ Hospitl (see Figure 9.29), whom we hve lrey met s the ther o linil loo trns-
Figure 8.30 William Smellie. Portrait in the Royal College o Surgeons o Edinburgh. (Reproduced by kind permission.)
usion, speulte in his opulishe 1832 whether the ngers Cesrinletures setion in– hemorrhge n sepsis – might m ight not e onsierly
122 The birth o modern surgery
reue y removl removl o the uterus er elivery el ivery o the hil. Tis speultion ws se on his suessul perormne o vginl hysteretomy on womn with totlly prolpse uterus some months er she h elivere. As we shll see, this ie ws tken t ken up with enthusism our ees lter n ws rst rrie out the yer eore he ie. Te introution o nesthesi n then o ntisepti surgery (see Chpter 7) 7) renere the opertion t lst pinless n ertinly ser. Initil initions were priniplly or the elivery o women with ostrute lour ue to pelvi eormity or ostrution rom n ovrin or other pel vi tumour. Te gret nger nger ws w s still sepsis rom rom the uterus – ontminte s result o prolonge lour, oen with repete pre-opertive vginl exmintions, whih lmost lwys resulte in n inete irth nl. Euro Porro (1842–1902), proessor o ostetris t Pvi, Itly, isstise with the high mortlity o the opertion, evise new proeure in 1876 – rst propose, s we hve note erlier, y Blunell. Immeitely er elivering the hil, ligture o wire or elsti ws ple roun the nek o the uterus. Te oy o the uterus, together with the tues n ovries, ovr ies, ws exise n the ervil stump exteriorise – the opertion o Cesrin setion n hysteretomy, or Porro’s Porro’s opertion. His rst rst ptient ws 25-yerol wr who lso h rikets n who ws in her rst pregnny. Te opertion ws rrie out uner hloroorm, using strit septi preutions. Both mother n hil survive surv ive – the rst mternl survivl rom Cesrin setion in Pvi. Te oper-
Figure 8.31 Max Sanger.
tion resulten in enjoye istintimprovement in mternl mortlity perio o populrity. Lwson it o Birminghm Birmingh m (see Figure 8.20) ws 8.20) ws the rst to suggest this opertion or hemorrhge rom plent previ n rrie this out suessully in 1898 or multipr with severe hemorrhge n rigi lose ervix. erv ix. He ws le to report seven Porro opertions with single mternl eth. A mjor vne ws me y the Germn gyneologist Mx Snger (1851–1903) (Figure 8.31), who introue suturing o the uterine inision inste o leving it s gping woun, with post-opertive leeing rom the inision eing ommon – n oen lethlerly – omplition He se, lso vote intervention(Figure in the 8.32). iult eore the mother eome exhuste n septi.
Figure 8.32 “Classical” Caesarian section. The vertical incision through the body o the uterus is sutured, as rst advocated by Max Sanger.
Caesarian section 123
Figure 8.33 The lower-segment Caesarian section: (a) a transverse incision is made through the thin lower segment o the gravid uterus; (b) the baby’s head is being delivered, here with the aid o obstetrical orceps; (c) the uterine incision is sutured.
Snger’s vie mortlity ws soon roppe. opte s stnr, n gin mternl Te next importnt step ws the introution o the lower-segment Cesrin setion (Figure 8.33). In this proeure, the uterine inision is me trnsversely through the muh thinner lower segment o the uterine wll. Tis is muh less vsulr thn the oy o the uterus, esier to suture, n gretly reues the risk o rupture o the uterus in ny susequent vginl elivery. It ws rst
perorme or oth mother hil y G suessully Toms (1831–1903) t the Collegen o Physiins n Surgeons, New York, in 1878. His ptient ws ripple wr with gross pelvi ontrtion. trt ion. It ws populrise populr ise in the Unite Kingom y John Munro Kerr (1868–1960) o Gsgow n Sir Erley Holln (1879–1967) o the Lonon Hospitl, who oth reporte exellent results in 1921, n the moern opertion o Cesrin setion ws rmly estlishe.
9 The surger surgeryy of warfare warfare Mnkin hs lwys een sujet to injury; the erliest surgeons were no out those men n women who were prtiulrly skille in ining up the ontusions, lertions, rtures, perortions n evisertions o their ellows (Figure 9.1). Sine mn is unoutely the most viious vi ious n g ggre gressive ssive o l lll n nim imls, ls, muh o this trum ws inite in ttle, n wrre hs thereore plye n importnt prt in the evelopment o woun mngement. Inee, it hs een si tht the only thing to enet rom wr is surgery.
Figu re 9.1 Figure 9.1 Achilles bandages the arm o Patroclus during the Trojan Wars 1200 bc .
Until the introution o gunpower into wrre in the 14th entury, wr wouns were inite minly y knives, swors, spers, rrows r rows n vrious lunt wepons suh s the me n ugel. Te shrp wepons woul proue penetrting n lerting injuries, n the lunt instruments woul proue severe ontusions. Te erly surgeons well reognise tht t ht some injuries were going going to prove lmost invrily tl. Tese omprise penetrtion o vitl struture, suh s perorting woun o the skull, hest or omen, or hemorrhge rom mjor loo vessel. However, i the vitim survive sur vive the initil injury, he ws very likely to live. Tis ws euse these lerte n ontuse wouns proue little tissue estrution n thus llowe the nturl powers o the oy’s heling to ure the vitim. So the surgeon eme skille t ressing n nging wouns n splinting rtures. Te vrious ointments employe, lthough proly usully ineetive, t lest i little hrm. Hemorrhge woul e trete y pressure on the woun or the use o the utery. Te tehnique o tying the leeing rtery, evie introue y the Alexnrin surgeons roun 250 bc n esrie y the Romn writer Celsus in the 1st entury An, ppere to hve een orgotten. Te meievl surgil textooks oen rrie n illustrtion o ‘woun mn’ tht showe the vrious injuries the surgeons o the Mile Ages might e lle upon to tret; we n guess quite urtely whih woul prove suessul n whih woul e lmost ertinly lethl
(From a painting on an ancient Greek vase.)
(Figure 9.2) 9.2).. 125
126 6 The surgery o o warare 12
gngrene o type ty pe not previously seen were enounenountere y surgeons treting these wr wouns. Now this, o ourse, ws enturies eore our knowlege o the teril ustion o woun inetion. It ws not unresonle, thereore, or militry surgeons to onlue tht these wul omplitions were ue to the poisonous nture o the gunpower itsel. Te solution ws oviously to estroy est roy the poison, n this ws one y mens o re-hot utery or y the use o oiling oil poure into the woun. Te gret populrity o the ltter metho ws unoutely ue to the writings o the Itlin surgeon Giovnni Vigo (1460–1525), whose surgil tretise title A Compendious Practice o the ws rst pulishe in Rome in 1514 Art o Surgery ws n went through more thn 40 eitions in mny lnguges; it gretly inuene the surgil thinking o his time. O ourse, we now know tht this prtie h the opposite eet to the one esire. Te re-hot utery utery (Figure 9.3 9.3)) n the t he oiling oil in t estroye more tissue thn the missile itsel n ggrvte n lrey serious sitution, s well
Figure 9.2 A ‘wound man’. (From Hans Gersdor: Feldbusch der Wundarztney . Strasb St rasburg, urg, 15 1517 17.. Courtesy o J Kirkup, Fellow o the Royal College o Surgeons [FRCS].)
THE INVENTION OF GUNPOWDER Gunpower ppers to hve een invente in Chin n ws use in the mnuture o reworks n, proly,, lso in nnons. proly n nons. It rst ppere in Europe Eu rope in the 14th entury, n it is well oumente tht nnons were employe in the Bttle o Créy in 1346 when Philip VI o Frne ws eete y Ewr III n his longowmen. Te introution o rerms ompletely hnge the pthology o wr wouns. Te gross tissue estrution estrut ion proue proue y the musket ll n nnon provie wonerul meium or the growth o teri, espeilly neroi miroes, those tht thrive in the sene n grow e tissues. inlue o theoxygen orgnisms tht on proue tetnusTese n gs gngrene. Tus, reul woun inetion n
Figure 9.3 Cauterisation o a wound o the thigh.
The invention o gunpowde gunpowderr 127
s initing untol torture upon the poor solier vitim. We now ome to one o those gret lnmrks tht puntute surgil history; surgeon who, through his exmple n writings, gretly inuene progress in the mngement o wouns. Amroise Pré (1510–1590) ws orn in the little town o Lvl in the t he Provine o Mine (Figure (Figu re 9.4). 9.4). His ther ws proly vlet e hmre n rer to the lol squire, n he my thus hve otine some interest in the work o rersurgeons. Pré’s sister mrrie rer-surgeon who prtise in Pris, n his eler rother ws mster rer-surgeon in Vitré. Pré my hve egun the stuy o surgery with his rother, n it is ertin tht he i work with rer-surgeon in the provines eore oming to Pris t the ge o 22 s n pprentie rer-surgeon. He ws soon ppointe ompgnon-hirurgeon, roughly equivlent to house surgeon toy, t the Hôtel Dieu, tht immense meievl hospitl n the only one in Pris t the time, where he worke or the next
3 or 4 yers n must hve gine gret experiene in tht repository o pthology. Perhps euse he oul not or to py the ees or mission to the rnks o the rersurgeons, Pré strte his reer t the ge o 26 s militry surgeon. In those ys, there ws no orgnise meil re or the humle privte soliers o rmies in the el. Surgeons were tthe to iniviul generls n to other importnt personges, n might, i they wishe, give wht i they oul to the ommon soliers in their spre time. Otherwise, the troops h to rely on the rough n rey help o their ompnions or o motley row o horse otors, rriers, quks, mountenks n mp ollowers. Pré ws ppointe surgeon to the Mreshl e Montejn, who ws olonel-generl o the Frenh inntry. Tis, his rst o mny mpigns, took him to urin, n it ws here in 1537 tht he me his unmentl oservtions on the tretment o gunshot wouns. He soon relise tht the epte metho o treting these injuries with oiling oil i more hrm thn goo n sustitute more humne n less estrutive ressing. Here is his esription o wht toy might well e lle one o the erliest e rliest ontrolle ontrolle surgil experiments. How mny o us hve rrie r rie out some new untrie tretment n hve shre Pré’s experiene o eing unle to sleep n hve ome into the wr to see how ptient is eore nyone else is roun, with pulse ring, to see whether the tretment we hve rrie out hs een rillint suess or isstrous ilure? I was at that time a resh-water surgeon, since I had not yet seen and treated wounds made by rearms. It is true I had ha d read in Jean de Vigo in his rst book o Wounds in General Chapter 8, 8, that wounds made by rearms are poisoned because o the powder. For their cure he advised their cauterisation with oil o elders mixed with a little theriac. To not ail, this oil must be applied boiling even though this would cause the wounded extreme pain. I wished to know rst how
Figure 9.4 Ambroise Paré, aged 45. (From Georey Keynes: Apologie and Tr Treatise eatise of Ambroise Paré. Paré. London, Falcon, 1951.)
to apply how the which other surgeons did their rstit, dressings, was to apply the oil as boiling as possible. So I took
128 8 The surgery o o warare 12
heart to do as they did. Finally, my oil was exhausted and I was orced instead to apply a digestive made o egg yolk, rose oil and turpentine. That night I could not sleep easily, thinking that by ailure o cauterising, I would nd the wounded in whom I had ailed to put the oil dead o poisoning. This made me get up early in the morning to visit them. There, beyond my hopes, I ound those on whom I had used the digestive medication eeling little pain in their wounds, without infammation and swelling, having rested well through the night. The others on whom I had used the oil I ound everish, with great pain, swelling and infammation around their wounds. Then I resolved never again to so cruelly burn the poor wounded by gunshot.
one o my servants, to teach him and to embolden him in such works, and there he readily tied the vessels to stay the bleeding without application o hot irons (Figure 9.5). He was well cured, God be praised, and is returned home to his house with a wooden leg.
So here ws Pré t the ge o 73 pssing own his skill n experiene to his pprenties, pprenties, trition we still see toy s surgeons teh their resients in the operting thetre. Pré went rom me to me n ominte the history o surgery in the 16th entury. He ws vetern o no less thn 17 militry mpigns n surgeon to our suessive kings o Frne. However, his prtie ontinue to emre the
Pré lso went on to show tht leeing er mputtion o lim shoul e rreste not y the terrile metho o the re-hot utery ut y simply tying the ivie loo vessels. Ligtion o loo vessels ws known to the nients, n Pré’s only lim, s he mkes quite ler in his own writings, ws tht he ws the rst to pply this tehnique in perorming mputtions. He rst employe the ligture in mputtion o the leg in 1552 t the siege o Dnvillier ut i not pulish his tehnique until 1564 when he wrote: ‘whereore I must ernestly entret ll surgeons tht leving this ol n too ruel wy o heling they will emre this new, whih I think ws tught me y the speil vour o the sre Deity, or I lerne it not o my msters nor o ny other, neither hve I t ny time oun it use y ny’. A esription y Pré o one suh se is worth repeting here: In the year 1583, the tenth day o December, Toussaint Toussaint Posson, having his leg all ulcered and all the bones carried and rotten, prayed me or the honour o God to cut o his leg by reason o the great pain which he could no [sic] longer
Figure 9.5 A below-knee amputation in the 16th century. Note the patient in the background
endure. was I caused Ater his leghistobody be cut oprepared our ngers below the patella by Daniel Poullet,
who has had his let hand amputated. (From Hans von Gersdor : Feldbuch der Wundartzney . Strasburg, 1517.)
The invention o gunpowde gunpowderr 129
humlest solier s well. He ie t the ge o 80 in Pris s he h lwys live: live : simple, humle mn. In his very rst mpign, he ene his esription o the tretment o gunshot woun o the nkle with perhps his most mous phrse, ‘I resse the woun n Go hele him’. Te most notle English surgeon o the 16th entury ws Toms Gle (1507–1587), whose long lie orrespone losely to tht o Amroise Pré n inee is known s ‘the English Pré’. He omine his militry reer with his ivilin prtie in Lonon n eventully sueee Toms Viry (see Figure 5.2) 5.2) s Mster o the Compny o Brer-Surgeons. He serve in the rmy o Henry VIII n ws present t the siege o Montreuil in 1544. Lter, he ws serjent surgeon to Elizeth I. Gle ws proli uthor who pulishe in English; his most mous pulition ws his Certaine Workes o Chirurgerie (1563) tht ontine setion on ‘wouns me with gunshot’ in whih he enie the tritionl misoneption tht gunpower ws itsel poisonous. He erie the poor qulity o men pretening to e surgeons in the militry; these inlue tinkers, olers n sowgelers, who trete wouns with grese use to lurite horse’s hooves, shoemker’s wx n the rust o ol kettles. Over the next two n hl enturies, until the revolution ws ete y nesthesi n ntisepsis (see Chpter 7), 7), there ws essentilly little hnge in the surgery o wrre. Mny surgeons gine muh prtil experiene on the ttleel, some lter hieving gret me. For
Figure 9.6 Richard Wiseman. Royal College o Surgeons o England.
At the eginning o the Civil Wr in 1645 etween the Cvliers o Chrles I n the Rounhes o Oliver Cromwell, Wisemn ws ppointe surgeon to Roylist ttlion n ws present t the ttles o unton n ruro. With the eet o his troops, Wisemn espe n worke in exile in Frne n the Low Countries s surgeon. Te yer 1649 sw the tril n exeution y epittion o Chrles I. Te ollowing yer, his
exmple, John Hunter serve t Belle Isle n Portugl uring(1728–1793) the Seven Yers’ Wr, n Sir Chrles Chrle s Bell (177 1774–1842) 4–1842) ttene the woune er Wt Wterloo. erloo. A numer o surgeons me their reers in militry or nvl servie n renere importnt ontriutions y their experiene n writings. Among the most olourul o the militry surgeons ws Rihr Wisemn (?1621–1676), whose lie res more like novel thn the iogrphy o istinguishe surgeon (Figure 9.6). We o not even know the ext te or ple o his irth n know nothing o his prentge, whih inites
son,ollowers now Chrles II, le Holln nompnie lne with his in Sotln. He ws y Rihr Wisemn, who te s surgeon t severl looy ttles, inluing the ttle o Dunr, ut the Roylists were nlly eete in 16511 t the ttle 165 tt le o Worester. Worester. Chrles, er er mny ventures, mnge to espe to the ontinent ut mny o his ollowers, inluing Wisemn, were pture n spent mny months in prison t Chester. On his relese, Wisemn prtise s surgeon in Lonon ut ws imprisone gin or some months. In 1654, his prtie in ruins, he le or Spin n serve in the Spnish nvy. On the
tht he ws proly illegitimte. In 1637,n he ws pprentie to Rihr Smith, surgeon, ollowing this, th is, he my hve serve in the Duth Nvy.
restortion Chrles II in ws ppointe sohis surgeon. Five1660, yersWisemn lter, he ws elete mster o the Compny o Brer-surgeons,
o warare 130 The surgery o
n in 1672, he ws ppointe s serjent surgeon to the king. He ws sik mn, proly rom pulmonry tuerulosis, ut in 1676, the yer o his eth, he pulishe his mjor work y whih he is rememere to this y. Te Several Chirurgical reatises rells Wisemn’s wie surgil experiene ot n shore shore in oth militry n ivilin prtie. He quotes no less thn 600 ses rom his personl experiene. experiene. Te work is logilly rrnge n is prtiulrly pr tiulrly etile in the setions evote evote to injuries. He stresse tht the eision to mputte lim shoul e me promptly, when the ptient woul e less sensitive to pin. He wrote: ‘In the het o ght, whether it e t se or ln, the t he hirurgeon ought to onsier t the rst ressing, wht possiility there is o preserving the woune memer; oringly i there woul e no hope o sving it, to mke his mputtion t tht instnt, while the ptient is ree o ever’. ypil o Wisemn’s vivi writings is this se report in his setion on wouns on the rin: At the siege o Melcombe-Regis, Melcombe- Regis, a ootsoldier o Lieutenant-Colonel Ballard’s by the grazing o a cannon-shot, had a great part o his orehead carried o, and the skull ractured rac tured into many pieces and some o it driven with the hairy scalp into the brain. The man ell down as dead, but ater a while moved and an hour or two ater a ter,, his ellow soldiers seeing him endeavour to rise, etched me to him. I pulled out the pieces o bone and lacerated fesh rom amongst the brain in which they were entangled, and dressed him up with sot olded linen dipped in a Cephalick Balsam, and with plaster [sic] and bandage, bound him up supposing I should never dress him anymore [sic]. Yet he lived 17 days and the 15th day walked rom that great corner ort over against Portland by the bridge which separates Weymouth rom Melcombe-Regis only led by the hand o someone o his ellow soldiers. The second day ater he ell into a spasmus, and died, howling like a dog as most o those do who have been so wounded.
Presumly he ie o tetnus.
THE NAPOLEONIC WARS Te Npoleoni Wrs proue two outstning Frenh surgeons, Pery n Lrrey. Pierre Frnçois Pery (1754–1825) serve s surgeon in hie with the Frenh rmy in Spin. He ws the rst to introue into ny rmy trine orps o el strether erers or the skille trnsporttion o woune to surgil i. His system ws universlly opte y the Frenh rmy in 1813. Although vst numers o surgeons, rom every Europen ountry, were engge in eling with the rnge o the Npoleoni Wrs (1792–1815), one stoo out s the gretest militry surgeon sine Amroise Pré; he ws nother Frenhmn, Dominique Jen Lrrey (1766–1842) (Figure 9.7). At the tener ge o 13, he eme e me pprentie to his rother, surgeon in oulouse. On qulition, he joine the Frenh nvy in 1787 n serve s ship’s surgeon long the ost o Newounln. He returne to Frne ew months eore the revolution o 1789. In 1792, Lrrey ws poste to the
Figure 9.7 Dominique Jean Larrey, portrait attributed to Mme. Benoit. (From Dible JH: Napoleon’s Surgeon. Surgeon. London, Lond on, Heinemann, 197 1970.) 0.)
The Napoleonic Wars 13 131 1
Army o the Rhine, n rom then on ws engge in lmost ontinuous tive militry uties until Wterloo W terloo in 1815, where he ws seriously ser iously woune. He serve ll over Europe, in Egypt, Syri n Russi, in totl o 25 mpigns n 60 ttles. He ws hie surgeon to the Imperil Gur, surgeon in hie to the Imperil Army n proessor o surgery t the rmy meil shool t Vl-eGre in Pris. Aer the Npoleoni Wr, Lrrey eme surgeon inspetor inspe tor to the rmy n hie surgeon t the Invlies, ontinuing to serve militry meiine in his re o the rmy r my veterns veterns until his retirement t the ge o 72. Lrrey’s ontriutions to militry surgery were primrily his orgnistionl skills. He insiste on getting his speil surgil tems ner the ront line to ensure erly surgery or the woune n stresse the rpi evution o woune men y mens o his speilly esigne light horse-rwn horse-rwn vehiles, whih he nme his ‘ying mul mulnes’ nes’ (Figure 9.8). He li emphsis on the esirility o immeite mputtion or seriously mge lims. His work onstitute the ountion o the present onepts o militry surgery. It shoul e note tht the wor ‘mulne’ in Frenh hs ierent onnottion n mens el hospitl tthe to the rmy, n moving with it, not the onveyne use or trnsporttion o the woune. In the mist o Lrrey’s wrtime uties, he pulishe his mssive Memoirs o Military Surgery , whih ws promptly trnslte into English! In it, he writes
The rst 24 hours is the only period peri od during which the system remains tranquil, and we should hasten during this time, as in all dangerous diseases, to adopt the necessary necessar y remedy. In the army many circumstances orce the necessity o primitive amputation: rst the inconvenience which attends the transportation o the wounded rom the eld o battle to the military hospitals on badly constructed carriages; the jarring o these wagons produces such disorder in the wounds, and in all the nerves, that the greater part o the wounded perish on the way, especially i it be long, and the heat or cold o the weather be extreme. Secondly, the danger o remaining long in the hospital. This risk is much diminished by amputation. It converts a gunshot wound into one which is capable o being speedily healed, and obviates the causes that produce the hospital ever and gangrene. Thirdly, in case the wounded are o necessity abandoned on the eld o battle, it is then important that amputation be perormed, because when it is completed, they may remain several days without being dressed and the subsequent dressings are more easily accomplished. Moreover, it oten happens, that these unortunate persons do not nd surgeons suciently skilul to operate, as we have seen
When a limb is so much injured by a gunshot wound that it cannot be saved, it should be amputated immediately .
among nations whose hospitalssome were not organised likemilitary ours.
Not only i Lrrey hve gret orgnistionl n tehing skills he ws lso rve solier n skillul n rpi surgeon. At the ttle o Alexnri in 1801, he operte on Generl Sylly in the el, then hoiste him onto his k n rn with him to espe the vning enemy. In relling this inient 40 yers lter, Lrrey wrote General Sylly had his let leg almost completely shot away at the knee joint, the limb being attached only by a ew
Figure 9.8 Larrey’s light ambulance. (From Dible JH: Napoleon’s Surgeon. Surgeon. London, Heinemann, 1970.)
strands o ligaments was carried behind theand linetendons. o battleHe to the ambulance o the centre but bu t did not
132 2 The surgery o o warare 13
realise the seriousness o his wound on account o his state o extreme collapse rom loss o blood… I perormed the amputation in three minutes amidst the ghting, had just nished when we were charged by a body o English cavalry. I had barely time to hoist the patient onto my shoulders and carry him as quickly as I could towards our army, which had begun to retreat. I crossed a series o holes or ditches used or cultivation o capers, which saved us, since the cavalry could not ollow over broken ground and I was ortunate enough to gain our rearguard ahead o the English dragoons. I ultimately reached Alexandria with my patient on my shoulders and eected his cure there. The General has been living in France in retirement or many years.
Lrrey ws woune n le or e t the ttle o Wterloo, pture y the Prussins n sentene to e shot. Just eore the time o his exeution, he ws ortuntely reognise y Germn surgeon who h ttene his letures n who interee or him. He ws rought eore the Prussin Commner, Mrshll Blüher, whose son h een woune, pture y the Frenh n trete suessully y Lrrey. Not surprisingly, Blüher nelle the eth sentene. At the ttle o Boroino in the Russin mpign o 1812, Lrrey perorme no less thn 200 mputtions in 24-hour perio. He esrie his own tehnique or the rpi isrtiultion o the rm t the shouler joint (Figure 9.9). Here is typil ty pil se report o Lrrey rom his memoirs:
Figure 9.9 Larrey’s method o amputation at the shoulder. (From Dible JH: Napoleon’s Surgeon. Surgeon. London, Heinemann, 1970.)
and driven into the axilla. One o them was wedged into the brachial plexus, and several o its nerves broken. The axillary artery was much distended and ready to break. His pulse was scarcely
At the latter engagement [the battle o Wagram 1809] the rst who was brought to my ambulance was General Daboville, Dabovill e, then Colonel o light artillery. A large ball had carried away part o his right shoulder and ractured the scapulohumeral articulation. A large portion o the pectoralis major, the deltoid and latissimus dorsi muscles were torn away
perceptible and Indeed, he appeared be in articulo mortis. death to seemed to approach so rapidly that I hesitated under the supposition that he could not live under the operation. But I resolved to go through with it, more with an expectation o relieving his pain than o seeing him survive. The operation was perormed in a ew minutes and to my great surprise succeeded completely. Had it been delayed in this case a ew minutes longer, he never would have gathered the laurels which he deserved. deser ved.
and thewere acromion and extremity clavicle ractured. The head o o the the humerus was broken into three pieces
He waswhere placed miserable bed he o straw, he on lay avery quietly until was sent to Vienna. During this period,
The Crimean War War 133
he several times ell into syncope, and I was apprehensive he could not support the atigue o this short journey and he was thereore removed among the last…. His wound was very large but he continued calm and an d spoke with a more audible voice. The dressings were simple, and were perormed under my own inspection. The Colonel’s strength gradually returned and in a short time he could use light ood and was cured perectly in three months.
o the wr, Guthrie pulishe his Gunshot Wounds, in whih, like Lrrey, he vise erly mputtion, where this ws inite, ertinly within the rst 24 hours o wouning. He serve on the st o Westminster Hospitl, oune the Royl Westminster Ophthlmi Hospitl n wrote Te Operative Surgery o the Eye (1823), where he vise extrtion o the lens in trt surgery rther thn ‘ouhing’ (i.e. ispling) it. Tis quottion rom Guthrie’s reatise on Gunshot Wounds gives n exmple o his pithy writing, se on his onsierle experiene:
On the British sie, one surgeon istinguishe himsel suiently to ern the title o ‘the British Lrrey’. Tis ws George Jmes Guthrie (1785–1856) (Figure 9.10). At the ge o 16, he entere the rmy s hospitl mte, ut soon er this,, it eme ompulsory this ompulsor y or suh men to eome meilly qulie, so Guthrie st n psse the Memership o the Royl College o Surgeons
A wound rom a cannon-shot injuring the bones o the elbow joint demands immediate amputation, as the neighbouring parts are also generally injured. The operation being necessary, the patient should be placed upon a chair c hair… … i the surgeon has the slightest condence in himsel, and the assistants are
(MRCS) exm. ex m. Tis T is ws w s ollowe y 5 yers o militry surgery in Cn n n then 6 yers s surgeon in the peninsulr mpign. Guthrie returne rom ivilin lie to help el with the woune t Wterloo. He ws present t numerous ttles, or exmple, he re or 3,000 woune er the Bttle o lver in Spin n even pture Frenh nnon single-hne. At the en
good, no tourniquet should be applied, but the artery be compressed against the bone by two ore-ngers. For my own part, I never apply a tourniquet; and I believe i by any accident this assistant should ail, the operator can without diculty compress the artery himsel, so as to prevent any evil consequence, and not interrupt the operation; and in the rst case in which I tried the operation on the arm, I had to compress the artery against the head o the humerus with the let hand, whilst I sawed the bone with the right.
THE CRIMEAN WAR Te Crimen Wr (1854–1855) ws the rst mjor mpign in whih nesthesi ws employe. Aprt rom this, the wr ws story o n illplnne tstrophe on the prt o the British Meil Servies. Te Frenh, ue no out to the lessons o Lrrey, h the vntges o light mulnes to trnsport their woune. Te miserle suerings o the British sik n woune Figure 9.10 George James Guthrie. Royal College o Surgeons o England.
use n outry t 9.11), home. Florene (1820–1910) (Figure (Figure 9.11), ly o Nightingle goo irth n eution, who h trine in Germny n
o warare 134 The surgery o
h set up nursing home in Lonon, orgnise st o women nurses or servie t the militry hospitl t Sutri. Te rst things she requisitione on her rrivl were 300 sruing rushes.
Figure 9.11 Florence Nightingale. Signed and dated photograph, photogra ph, 18 July 186 1861. 1. (Reproduced by courtesy o the Florence Nightingale Museum Trust, London.)
Returning to Engln er the wr, she estlishe the Nightingle Shool t St Toms’ Hospitl n remine superintenent o the shool or the ollowing 27 yers. She is rightly rig htly regre toy s one o the ouners o the nursing proession (Figures 9.12 n 9.13). Te gretest Russin militry surgeon o the time ws Nikoli Pirogo (1810–1881), who ws trine in Mosow n eme proessor o surgery in St Petersurg. He serve in mny mpigns n, in prtiulr, ws surgeon in hie in Crime. Here, he i equivlent work to Florene Nightingle, introuing skille emle nurses into his hospitls n emphsising the nee or proper meil equipment or the woune. He ws erly to opt nesthesi n evise onservtive mputtion o the oot, whih still ers his nme. He insiste tht surgeons require high stnr o ntomil knowlege n pulishe remrkle tls o ntomy in ve volumes etween 1852 n 1859. Tis ontine series o 200 pltes epiting trnsverse setions through the oy, otine rom vers, whih he roze in the snow ! A ew yers er the Crimen Wr, young Swiss nker, JH Dunnt, witnesse the looy ttle o Solerino etween the Frenh n the Austrins in 1859. His esription o the ttle n the horrors o the neglete woune, pulishe in 1862, inspire the ormtion o the Re Cross.
Figure Figu re 9.12 9.12 Watercolour by captain Hedley Vicars o a scene rom the Crimean War; wounded being
transported ater the Battle o Inkerman. Vicars served in the 97th regiment o inantry; he was killed during an assault on the Russian trenches near Sebastopol on 22 March 1855. (Reproduced by courtesy o the Florence Nightingale Museum Trust, London.)
The American Civil War 135
Figu re 9.13 Figure 9.13 Watercolour by General Edward Wray o the burial ground at the General Hospital, Scutari, in April 1855. There were two British Army Hospitals at Scutari during the Crimean War, the Barrack Hospital and the smaller General Hospital. Scutari (the anglicised version o Uskudar) was a suburb on the Asian side o Constantinople. Major (later Lieutenant General) Edward Wray (1823–1892), a British artillery ocer, was attached to the Turkish Army during the Crimean War. (Reproduced by courtesy o the Florence Nightingale Museum Trust, London.)
THE AMERICAN CIVIL WAR Te Amerin Civil Wr (1861–1865) sw the wiespre use o nesthesi; this ws usully hloroorm (euse o the onveniene o the smll mount tht neee to e employe), less oen ether or mixture o the two. Willim Morton himsel, the entist who introue the use o ether (see Chpter 7), serve 7), serve s ivilin nesthetist in the Union Army. He wrote in letter to rien r ien in 1864:
those who can bear the journey jour ney are sent at once to Fredericksburg. The nature o the operations to be perormed on the others is then decided upon and noted upon a bit o paper pinned to the pillow or roll o blanket under each patient’s head. When this has been done I prepare the patient or the knie, producing perect anaesthesia in the average time o three minutes, and the operators ollow, perorming their operations with dexterous skill, while the dressers in their turn bound up the stumps.
When there is any heavy ring heard the ambulance corps, with its attendants, stationed close to the scene o the action, starts or the wounded. The ambulances are halted nearby, and the attendants go with stretchers and bring out the wounded. The rebels do not generally re upon those wearing
Although the gonies o the surgeon’s knie were relieve, mortlity remine high, priniplly euse o post-opertive woun inetion, with pyemi, urrowing sesses n seonry hemorrhge s inete ligtures roun loo
ambulance badges. Upon the arrival o a train o ambulances at a eld hospital, the wounds are hastily examined and
vessels loosene. Te33.2%; mortlity mortl orthigh, mputtion o the lower lims ws titythe it rose to 54.2% n t the hip rehe erul 83.3%.
136 The surgery o warare
It shoul e rememere tht the eths rom ttle were mthe, inee exeee, in this wr, s in ll others up to well into the 20th entury, y eths rom the meil iseses o rowing n o poor snittion. Tus, the Union ores in the Amerin Civil Wr lost 96,000 in ttle ut 183,000 rom iseses, o whih ysentery eture highest on the list.
THE FRANCO-PRUSSIAN WAR Te Frno-Prussin Wr (1870–1871) ws the rst mjor onit er the pulition o Lister’s ppers on the ntisepti tretment o wouns in 1867 (see Chpter 7). 7). Although this ws reognise y the Germn surgeons to e n importnt vne – more so thn y their Frenh n, inee, their British ounterprts t this time – Lister’s tehnique or the most prt ws put into eet rther sully, wouns tening to e pke with whtever ressing ws ville. Lister himsel pulishe short pper in the British Medical Journal in 1870, whih gve exellent vie on the mngement o wr wouns. Tis omprise metiulous lensing o the woun y irrigtion with roli i, extrtion o oreign mteril, spiules o one, et., ligtion o loo vessels with sterilise tgut n then leving the woun open, metiulously protete with lrge ntisepti ressing. owrs the en o the wr, the British supplie oth sies with the neessry mteril or Lister’s metho to e use. Although the experiene o numer o hospitls tht i use the ntiseptiometho helpe onvine o n the vlue t his tehnique, this tehn ique,tomostly it ws wsurgeons s ignore, the eth rte or penetrting wouns remine high, even worse in t in mny series, thn those pulishe rom the Amerin Civil Wr. For exmple, t the ttle o Metz, the Germn mortlity or upper extremity wouns ws 41% n or lower extremity wouns ws 50%, while penetrting injuries o the knee joint rrie 77% mortlity. In most ses, it ws the ol story o sepsis.
THE BOER WAR Te Boeruren Wr (1899–1902), (1on 899–1902), one gin, r greter the physiins thn ple on the surgeons. Enteri ever lone ounte or twie s
mny eths mong the British (over 8,000) thn ourre rom Boer shot n shell. Sir Almroth Wright (1861–1947) proue vine ginst the enteri ever orgnisms – typhoi, prtyphoi A n prtyphoi B – whih ws shown to e highly eetive. For exmple, uring the siege o Lysmith, the iniene o typhoi ever mong 1,705 inoulte soliers ws 2%, wheres mong 10,529 uninoulte men, the iniene ws 14%. (In the First Worl Wr, 90% o the troops were inoulte; the iniene o typhoi ever per 1,000 strength ws 2.35 ses ompre with 105 ses in the Boer Wr.) o the surgeon, the results o tretment o the woune seeme highly stistory. Most wouns were use y Muser rie ullets re t onsierle rnge, whih proue reltively ‘len’ wouns. Furthermore, the mpign took ple over terrin o sunke rok n sn, sn , on whih the risk o inetion rom ngerous soil n el orgnisms ws miniml. Suh injuries respone extremely well to si Listerin ntisepti tretment. Willim Will im MCormk MCor mk (1836–1901 (1836–1901), ), surgeon t St Toms’, who h prtil ttle experiene in the Frno-Prussin n the Russo-urkish wrs, ws ppointe onsultnt surgeon to the South Arin Fiel Fore. As result o his oser vtions, he vise strit stritly ly onservtive onser vtive tretment tre tment or gunshot wouns o the omen, vie tht, s we shll see, h isstrous onsequenes in the erly ys o the Gret Wr ew yers lter. His vie ws no out se on the result o seeing ptients t the se hospitls who h survived the immeite injury to the omen quent severl ys o evution to the n rer.suseSuh ptients, i still live, h oviously sele o their injury y this time n ertinly woul not hve enete rom melesome surgil intererene t this stge.
THE RUSSO-JAPANESE WAR During the Russo-Jpnese wr o 1904, exellent results were otine y pioneer womn surgeon, results tht were to e lrgely ignore y the outsie worl. Priness Ver Geroitz ws Russin surgeon who h stuie meiine in Germny. She rought well-equippe mulne trin lose to the ront line n ws le to operte on
The First World War 137
ttle sulties within short time o wouning. Her poliy o erly surgery or penetrting wouns o the omen proue sttistis r etter thn h previously een otine. Although priness, Geroitz survive the Revolution n eme proessor o surgery in Kiev in the 1920s.
THE FIRST WORLD WAR
In the erly ys o ‘Te Gret Wr’ (1914–1918), s it ws lle until the next worl tstrophe, surgeons in the Royl Army Meil Corps (RAMC) in Flners were mze n horrie t the wouns they were lle upon to tret. Tese surgeons were experiene men: the regulr soliers were oen veterns o South South Ari, Ar i, the erritoril erritorilss h extensive experiene o mjor inustril ients t home, n they were thereore milir with the goo results to e expete rom routine ntisepti tretment o suh wouns. Now they were seeing ierent pthology, the eets o high explosive, high veloity missiles – mhine-gun ullets, shell rgments, shrpnel – t lose rnge on humn tissues. Moreover, these wouns were hevily ontminte ontminte with the t he ertile n ertilise soil o Belgium n Northern Frne (Figure 9.14) n teeme with the neroi lostriil orgnisms o gs gngrene n tetnus, whih oun n iel ulture meium in evsulrise so tissues. Gs gngrene ws more ommon thn in ny wr previously oumente (Figure 9.15), n tetnus omplite 8.8 per 1,000 wouns. Pyemi n erysipels were ommon, n seonry
hemorrhge ws ere omplition s ligtures sloughe o loo vessels in septi wouns. A ompoun rture o the emur rrie with it n 80% mortlity. Strenuous ttempts were me to improve the sitution; ntisepti inusions were not oun to e the nswer, ut over the next yer or so, it eme ovious tht est results were otine y erly surgery t whih exision o ll e n evitlise tissues rom the woun oul e rrie out, together with removl o ny oreign mtter suh s
Figu re 9. Figure 9.15 15 Multiple shell wounds o the leg, leading to gas gangrene. Illustrations o war surgery. (From British Journal of Surgery 1916; 1916; 4, 55.)
Figu re 9.14 Figure 9.14 The primitive conditions at the Western Front. (a) A regimental aid post; rst aid is given by the regimental medical ocer. (b) A horse-drawn ambulance o the RAMC. (Permission o trustees, Imperial War Museum, London.)
o warare 138 The surgery o
Figu re 9.16 Figure 9.16 Stages o delayed primary suture. (a) Explosive exit wound in arm caused by rife bullet 13 hours ater infiction. Comminuted racture o the humerus. (b) Wound ater excision o damaged muscle and cleansing o the racture. Deep sutures o silk in position. (c) Closure o the wound 7 days later. The wound healed by rst intention. (Pictures and text rom Fraser F: F: Primary and Delayed Primary Suture of Gunshot Wounds. A Report of Research Work at a CCS, 27 December 1917–1 March 1918 .) .)
piees o uniorm. Te woun ws not lose, ut the skin pproximte y ew loose stithes over sterile ressing. Four or ve ys lter, with the ptient y now t se hospitl, the woun ws inspete n, i helthy helt hy,, the skin oul e suture. Tis tehnique, lle elye primry suture, ws perhps the gretest vne me in militry surgery uring the wr n ws lesson tht h to e re-lerne in susequent onits (Figure 9.16). Te nee or erly surgery ws met y estlishing vne surgil units, mnne y surgeons n nesthetists n nursing sisters (the nerest women were to get to the ront line uring the wr), terme Csulty Clering Sttions (CCS) (Figure 9.17). Tese were situte six to nine miles
rom the ront line n were esigne to mit etween 150 n 300 sulties t time. Te prolem o the high eth rte rom ompoun rtures o the emur ws resse y Sir Roert Jones (1857–1933), n orthopei surgeon rom Liverpool who h h onsierle experiene orgnising the sulty servies serv ies in the onstrution o the Mnhester Ship Cnl. As iretor generl generl o militry orthopeis, he introue introue the use o the Toms Splint, invente y his unle, Hugh Owen Toms (1834–1891) to the Western Front (see Figures 9.18 n 10.2). 10.2). Strether Strether erers were tught how to pply the splint linole, so tht they oul immoilise the leg o woune solier on the ttleel in the rk. (I hve ttempte to o this mysel, n I n onrm tht it is very ii ult!) Speil wrs were estlishe to el with
Figu re 9. Figure 9.17 17 Operating theatre in a CCS, behind the line at the Battle o the Somme 1916. Note the ‘QA’, the Queen Alexandra’s Nursing Service,
Figu re 9. Figure 9.18 18 The Thomas splint used to treat a compound racture o the emur. (From Max
sister; this is the closest to the ront line that women reached in the Great War. (Permission o Trustees, Imperial War Museum, London.)
Page C, Le Mesurier AB: The early treatment o gunshot ractures o the thigh. British Journal of Surgery 1918; 1918; 5, 66.)
The First World War 139
Figu re 9.19 Figure 9.19 A ward dedicated to ractures o the emur. (From Hurley V, Weedon SH: Treatment o cases o ractured emur at a base hospital in France. British Journal of Surgery 1919; 1919; 6, 351.)
this injury (Figure 9.19), n there ws stistory rop in mortlity y the en o 1915. Woun exision omine with tetnus prophylxis given t the el mulne reue the iniene o tetnus to the region o 0.2 per 1,000. Gs gngrene, gng rene, however, however, ws still stil l enountere when there ws ely in the woune solier reeiving enitive surgery. In the erly ys o the wr, surgeons were irete to tret penetrting ominl injuries onservtively, in line with the South Arin experienes. It soon eme evient to the rontline surgeons tht the results o suh mngement were isstrous. At the se hospitls, the mortlity or ominl injuries ws in the region o 80% n, o ourse, mny more eths h lrey ourre in the lines o evution. Tis is hrly surprising euse o the evstting eets o high explosive missiles on the omen (Figures 9.20 n 9.21). Impresse y these wul results, group o young British surgeons, operting t
Figure 9.20 Lacerated bullet wound o spleen.
Figure 9.21 Multiple wounds o the small intestine as the result o a rife bullet. The bowel was
(From Cuthbert Wallace: A study o 1200 cases o gunshot wounds o the abdomen. British Journal of Surgery 1917; 1917; 4, 679.)
resected, but the patient died a ew hours later at the CCS. (From Illustrations o war surgery. British Journal of Surgery 1916; 1916; 4, 63.)
o warare 140 The surgery o
wouns o the ler, whih were lose with theter or suprpui ringe. One o the young British surgeons working t the CCSs ws Mjor Goron ylor (1878–1960) (Figure 9.23) o the Milesex Hospitl, Lonon. His spee n skill, prtiulrly pr tiulrly with the surgery o ominl injuries, eme legen. He ene the wr s onsultnt surgeon to the Fourth Army n in the Seon Worl Wr Wr joine the Nvl Meil Me il Servie s rer mirl. At the outrek o the Seon Worl Wr, he pulishe smll ook on ominl wouns se on his wr experiene; this extrt gives striking striki ng exmple o o the wrtime surgery o penetrting wouns o the omen:
Figure 9.22 Portion o the small intestine show-
ing wounds produced o shell. The20 piece o bowel, whichby is a6 ragment eet in length, was successully excised by Owen Richards on 18 March 191 1915. 5. This was the rst r st successul success ul case o bowel injury treated on the British ront. The patient walked back with his intestines outside his abdomen because ‘he wanted to die in his own lines’. (Text (Text and illustration illu stration rom rom Gordon Taylor G: Abdominal Injuries in Warfare. Warfare. Bristol, John Wright, 1939.)
Private T. was admitted into a Casualty Clearing Station on September 18th 1918, 19 18, with a severe wound o the th e abdomen. He came to operation eight and a hal hours ater being hit, and was ound to have a hernia o shattered, strangled small intestine through a wound in the right hypochondrium; about 18 inches o bowel was thus prolapsed. The missile had then passed down between the internal oblique and transversalis
the CCSs lose ehin the ront line, were le to show tht erly intervention gve the ptients with wouns o the elly their only resonle hne o survivl. Te rst notle o suess wswho thth o Owen Rihrs, proessor surgery een me temporry ptin in the British Expeitionry Fore. Erly in 1915, he perorme two suessul resetions or gunshot wouns o the smll intestine (Figure 9.22). It ws soon evient tht erly surgery ws the only hope or suh ses, n even then, o ourse, in the sene o ntiiotis n eetive eet ive ui replement n pupuity o loo trnsusions, the mortlity remine high: or the smll intestine in the region o 65% n or the olon in the t he region o 59%. Perortions o the smll owel were suture with ringe or resete ex tensive. extensive. Perortions olythe olon were suture ii smll ut otherwise usul usully exteriorise. Wouns o the stomh were suture, s were
Figure 9.23 Sir Gordon Gordon Taylor as a major in the RAMC in i n the First World War. War. Royal College o Surgeons o England.
The First World War 14 141 1
muscles o the abdominal wall on the right side, and had struck against and shattered the anterior part o the crest o the ilium. Thence its course was defected again into the peritoneal cavity, and it had become impacted in the posterior surace o the right pubic bone, transxing the bladder and impaling a coil o ileum against that bone. With such orce had the projective been driven into the os pubis, that a considerable pull was required to dislodge it. The patient, when placed on the operating table, had a surprisingly good pulse o 96; but immediately the wound o entry was enlarged and the constriction o the neck o the prolapsed bowel thereby released, the pulse-rate rose to 130. The wound was lthy, and parietes and bowel alike were covered with grease and dirt. Four eet o badly damaged and perorated jejunum were resected, and other coils o jejunum and upper ileum were assiduously cleansed o grease and clothing. The coil o lower ileum impaled against the pubic bone was gangrenous and stinking, and a second resection o 2½ t was perormed. The posterior wall o the bladder was sutured and a glove drain was passed down into the cave o Retzius towards the wound on the anterior vesical surace. Very wide excision o the
the ourteenth day, and subsequently to England, February 7th 1919. Nearly 21 years later he is in good goo d health.
Compoun skull injuries were ommon, s men peere over the prpet o the trenhes (Figure 9.24). Mny lives were unoutely sve y the introution o steel helmets to the rmies onronting eh other on the Western Front (Figure 9.25). Importnt work ws rrie out y Hrvey Hr vey Cushing (1 (1869–1939 869–1939)) on the mngement o penetrting injuries o the rin. Cushing ws one o the ouning thers o Amerin neurosurgery, rst in Bltimore B ltimore n then in Boston (Figure (Figure 8.27). 8.27). He tught the importne o metiulous exision
Figure 9.24 Severe orbito-rontal perorating wound rom a rife bullet. Patient died rom gas encephalitis. (From Harvey Cushing: A study o a series o wounds involving the brain and its enveloping structures. British Journal of Surgery 1918; 5, 558.)
damaged abdominal muscles had wasbeen perormed, ater the peritoneum closed; a deect in the latter was lled in by a grat o ascia obtained rom the anterior layer o the sheath o the rectus. The anterior end o the crest o the ilium was widely exsected, the wound was packed with gauze soaked in favine, and requent instillations with favine through Carrel’s tubes were enjoined. A transusion transu sion o 900 cc o blood was given and the patient was treated by the usual resuscitatory measures. The gauze and
Figure 9.25 A British ‘Tommy’s’ helmet. The subtitle reads: ‘Showing seriously damaged helmet o patient with but lightly scored cranium’. (From
Carrel’s were removed on The the th day tubes and skin was resutured. patient was evacuated to the Base on
Harvey Cushing: A study o a series o wounds involving the brain and its enveloping structures. British Journal of Surgery 1918; 1918; 5, 558.)
142 2 The surgery o warare 14
Figure 9.26 Cushing’s technique o suction debridement o a cerebral wound track.
o the woun n showe how glss suker oul e use to erie pulpe rin (Figure 9.26). Removl o the missile rom the woun trk ws importnt, n this ws helpe y the vilility o X-rys t the CCSs. Cushing lso pioneere the use o the eletromgnet to remove metlli oreign oies rom the rin. Beuse o its exellent loo supply, the slp woun oul e lose y primry suture, ut i there ws extensive skin loss, Cushing introue his rottion p or losure o the slp eet. Most o Cushing’s experiene me rom his perios o intensive militry surgery, rst in the spring o 1915 with n Amerin unit eling minly with Frenh sulties. On his return to the Unite Sttes, perhps relising tht Amerin intervention in the wr ws w s inevitle, he set out orgnising Bse Hospitl in Boston. He ws sent to Frne gin in i n My 1917 1917 tthe to the British Br itish Expeitionryy Fore (Figure 9.27). Expeitionr 9.27). Troughout this perio o militry servie, Cushing kept metiulous, lmost ily iry, whih he eite into single volume (now long out o print). oy, his se reports re with gret poignny n illustrte, perhps s well s ny written wr itten ount y ny other surgil uthor, the horrors n utility o wr: Wednesday 15 August 1917
We nearly onyesterday’s six cases innote. the twenty our‘busted’ hours since We began at 8 p.m. on ‘L/Cpl. Wiseman Wis eman
Figure 9.27 Harvey Cushing and his team at a CCS in 1917. Cushing sits in the ront row on the let. (From Cushing H: From a Surgeon’s Journal 1915–1918 . London, Constable, Cons table, 1936.)
392332; 1/9 Londons S.W. Frac. Skull’, which interpreted means that a lance corporal o the 9th Londons had a shell wound. It went through his helmet in the parietal region, with indriven ragments to the ventricle. These cases take t ake a long time i done careully enough to orestall inection, and it was eleven o’clock beore we got to ‘Sgt. Chave, C.25912, M.G.C. 167-S.W. head and backpenet’ according to his eldambulance card. This sergeant o the Machine Gunners had almost the whole o his right rontal lobe blown out, with a lodged piece o shell almost an inch square, and extensive radiating ractures, which meanincluding taking o o his rontal bone, themost rontal sinuses – an enormous operation done under local anaesthesia. We crawled home or some eggs in the mess and to bed at 2.30 a.m. – six hours or these two cases. Friday 17 August 1917
We beat our record today with eight cases – all serious ones. A prompt start at 9 a.m. with two cases always in waiting – notesIt’s made, X-rays and heads shaved. amusing totaken, think that at home I used to regard a single major
The First World War 143
waiting was a little 18-year-old Tommy rom East London – scared, peaked, undered, underdeveloped. He had been in training or 6 months and was in in the trenches or the rst time during duri ng the present show – just 10 minutes when he was hit.
cranial operation as a day’s work. These eight averaged two hours apiece – one or two very interesting ones. One in particular – a sergeant, unconscious, with a small wound o entrance in the vertex and a oreign body just beside the sella turcica. turcic a. We have learned a new way o doing these things t hings – viz., to encircle the penetrating wound in the skull with Montenovesi orceps, and to take the ractured area with the depressed bone ragments out in one piece – then to catheterize the tract and to wash it out with a Carrel syringe through the tube. In doing so the suction o the bulb is enough occasionally to bring out a small bone ragment clinging to the eye o the catheter. Indeed, one can usually detect ragments by the eel o the catheter; they are oten driven in two or three inches. In this particular man, however, ater the tract was washed washe d clear o blood and disorganized brain, the nail was inserted its ull 6 inches, and I tried twice unsuccessully to draw out the ragment with the magnet. On the third attempt, I ound to my disgust that the current was switched o. There was nothing to do but make the best o it, and a small stomach tube was procured, cut o, boiled, inserted in the 6-inch tract, suction put on, and a deormed shrap-
Cushing’s slow n metiulous neurosurgil tehnique me in or onsierle ritiism oth rom his British n Amerin ollegues. It is true tht uring mjor ttles mny ses o he wouns ie eore they oul e operte on. However, Cushing insiste tht unless equte surgery ws rrie out, the ptient ws proly etter le untouhe. In spite o the pioneer work o Crrel Cr rel (see Figure Figure 15.4), who 15.4), who h shown how to suture loo vessels in the experimentl lortory, lortory, rteril reonstru reonstru-tion surgery ws virtully unknown. Mjor rteries, i torn, were ligte, n this le, espeilly in the presene o n ssoite rture, to mputtion in most ses – ning me gin in the Seon Worl Wr. It ws not, inee, until the Koren Wr tht rteril reonstrution eme possiility possi ility in militry surgery surgery.. A prtiulrly serious prolem ws woun inetion. Aer muh experimenttion, irrigtion o the woun with hypohlorie solution through multiple tues (the Crrel–Dkin tehnique) ws in ommon use. Its vlue proly ly more in the t tht reul ringe o the woun ws perorme rther thn ny ny eet o the irrigting solu-
nel ball (not the expected o steel shell) was removed on thepiece rst trial – o course, a non-magnetisable object. Tonight while operating on a Boche prisoner with a ‘G.S.W. head’ about 11 p.m. – our seventh case – some Fritz planes came over on a bombing raid, as they do almost every night nowadays – nowanights (which is it?). O course all our lights were switched o, and we had to nish with candles. I we didn’t do a very good job, it was Fritz’s ault, not entirely ours.
tionMny itsel tlities (Figure 9.28). (Figure o wr were ue to, or ompoune y, severe loo loss. Sir Christopher Wren (1632–1723), the elerte English rhitet, experimente with intrvenous injetions o vrious uis in nimls. Rihr Lower (163 1631– 1–169 16911) rst trns trnsuse use loo rom one niml niml into the vein o nother n lter trnsuse loo rom sheep into mn, hving een preee in this experiment y ew months in 1667 y Jen Bptiste Denys (1625–1704). Te rst suessul humn loo trnsusions or spei therpeuti purposes were rrie out y Jmes Blunell
Theellow Bochewith prisoner, I may add,badly was a big a square head, punctured though it was. The case in
(1790–1877) (Guy’s’ Figure 9.29) 9.29). HeToms’s trine tn the ontinUnite Hospitls o (Figure n .St ue his meil eution in Einurgh, where
o warare 144 The surgery o
Figure 9.28 Diagram o the Carrel–Dakin method or irrigation o a massive penetrating wound o the thigh.
Figure 9.29 James Blundell, pioneer o human blood transusion. Gordon Museum, Guy’s Hospital.
he grute with n MD in 1813. He returne to Guy’s to teh miwiery n eme proessor o physiology n ostetris in 1823. He prtise n tught the importne o rtiil respirti respirtion on in the pprently stillorn y n esrie trhel pipe, whih he inserte y sliing the tue long his orenger psse over the y’s tongue n own to the entry entry o the lrynx. lryn x. Blunell rst rrie rrie out numerous experiments in loo trnsusion in ogs. His rst humn experiment ws in 1818. Tis ws in mn ‘ying rom innition inue y mlignnt isese o the pylorus’. He improve er the trnsusion, ut ‘ie o exhustion’ 56 hours lter. O the remining nine ses oumente, ve were suessul. Te rst o these ws womn ying o post-prtum post- prtum hemorrhge, who reovere er reeiving trnsusion rom her husn. His other suesses were three urther ses o post-prtum leeing n oy in shok er mputtion o the leg. Te mounts trnsuse rnge rom 4 to 14 ounes, n the onors were either the ptient’s husn or the ttening otor. Blunell’s equipment vrie s the stuies ontinue. One exmple, the ‘grvittor’, is shown shown in Figure 9.30. Te prolem o lotting o the onor loo ws solve in 1914, when it ws oun tht soium itrte ws n eetive nti-ogulnt. A mjor omplition o trnsusion ws enountere requently when the trnsuse loo ws rpily estroye in the reipient’s irultion, oen ompnie y shok n even eth. Tis ws shown y Krl Lnsteiner (1868–1943) in 1900
Figure 9.30 John Blundell’s method o blood transusion, transusi on, 1829. 1829.
The First World War 145
to e ue to the presene o two omplex gglutinting sustnes, A n B. Tis enle him to ivie sujets into our min groups (A, B, AB n O) n enle the trnsusion o mthe loo to e me. Lnsteiner ws wre the Noel Prize in 1930. By 1914, trnsusion o loo ws well reognise, ut it ws teious proeure n iult to rry out uner the wrtime onitions o the CCSs, lthough trnsusion with sline n with solution o gum i in norml sline ws oen use. Sir Georey Keynes (1887–1982), surgeon t St Brtholomew’s Hospitl n CCS surgeon in Flners, ws n enthusist in the use o loo trnsusion. Donors were hosen y preliminry loo grouping o oth ptient n prospetive onor, n onors were hosen rom mong the lightly woune men. Te inuement ws n extr ortnight’s leve. Keynes writes in his utoiogrphy Te Gates o Memory : Transusion naturally provided an incomparable extension o the possibilities o lie-saving surgery. Trained anaesthetists were scarce, and oten I dispensed with their services. A preliminary transusion ollowed by a spinal analgesic enabled me to do a major amputation single-handed. A second transusion then established the patient so rmly on the road to recovery that he could be dismissed to the ward
transuse him and carry out the necessary operation. Most o them were suering primarily rom shock and loss o blood, and in this way I had the satisaction o pulling many men back rom the jaws o death.
Te speilty o plsti surgery ws rete uring the First Worl Wr. At rst, little oul e one or the reul eormities o e n jw tht resulte rom high-veloity missiles (Figure 9.31). A young New Zelner in the RAMC, Hrol Del Gillies (1882–1960), n EN surgeon, set up speil unit t the Cmrige Hospitl, Alershot, n lter estlishe mjor hospitl or this work t Queen Mry’s Hospitl, Siup. Here, he evelope tem o surgeons n entl surgeons rom ll over the Dominions n, strting rom srth, invente tehniques suh s the tue peile p, usully tken rom the hest or the nek, to reple missing il tissue. Bone grs, usully rom the ili rest, were use to reonstrut shttere jws.
without urther anxiety. by At the other times I was greatly distressed state o aairs in one large tent known as ‘the moribund ward’. This contained all the patients regarded by a responsible ocer as being probably past surgical aid, since it was our duty to operate where there was reasonable hope o recovery, rather than to waste eort where there seemed to be none. The possibility o blood transusion now raised hopes where ormerly there had not been any, and I made it my business during any lull
Figure 9.31 High-velocity compound racture o the jaw. (From Kazanjian VH, Burrows H: The
in the work to asteal into the ward, choose patient whomoribund was still breathing and had a perceptible pulse,
treatment o haemorrhage caused by gunshot wounds o the ace and jaws. British Journal of Surgery 1918; 1918; 5, 126.)
146 The surgery o warare
Te nesthetists enountere two prolems; how to nesthetise ptient with smshe e n how to keep the equipment wy rom the surgeon. wo young otors, Stnley Rowothm (1890–1979) n Ivn Mgill (1888–1986), who were to eome leers in the el, evelope the tehnique o using tue psse long the nose into the trhe (nso-trhel intution), through whih the nestheti oul e ministere, metho whih is now stnr prtie. It is thereore esy, though mzing, to ppreite tht, in our terrile yers, enormous vnes were me in orthopei, trumti, ominl, neurologil n plsti surgery, n in resusittion n nesthesi.
Figure 9.32 Joseph Trueta. (Photograph pro-
omrment, oretste o the horrors o the Seon Worl Wr. Joseph ruet (1897–1977), proessor o surgery in Brelon (Figure 9.32), prehe the importne o thorough woun exision, then ressing the woun with guze n immoilising the lim in plster o Pris. Tis ovite the nee or requent ressings, gret vntge in the rowe hospitls with lk o skille surgeons. Although the plster sts smelle to high heven, the ptients remine well n omortle, n there were very ew ses o gs gngrene or tetnus, sine the wouns h n exellent loo supply n evitlise tissue h een remove. Te isvntge o this metho ws the slow heling o the woun, lthough this oul e speee up y skin gring (Figure 9.33). Te woun ws le untouhe etween 4 n 6 weeks, n the plsters were hnge every ouple o months until the woun hele. In his own hns, ruet’s metho gve exellent results. By the en o the wr, he n his tem h trete nerly 20,000 sulties with only our mputtions n ewer thn 100 eths, lthough other, less experiene, surgeons h muh less stistory results. owrs the en o the wr, when it ws ovious tht Frno’s Ntionlists were winning n tht the uture o people on the Government sie, even eminent surgeons, woul e in jeopry, ruet le Spin. He ws put on the st o the Wingel–Morris Orthopei Hospitl in Oxor, me gret ontriutions to the trining o llie surgeons in the Seon Worl Wr
vided by Mr John Goodellow, FRCS.)
n eme proessor o orthopei surgery in
THE SPANISH CIVIL WAR Te Spnish Civil Wr (1936–1939) ws the rst time in the Western worl tht mssive ivilin sulties were to e sustine rom eril
Figure 9.33 The Trueta technique, Spain 1936. (a) Photograph at 6 days. Wounds o shoulder should er and emur
produced in an air raid. Note that the plaster is bloodstained. The patient is comortable. (b) Photograph taken ater removal o the plaster on the 70th day.
The Second World (1939–1945) 45) 14 147 7 Worl d War (1939–19
Oxor. In 1955, he ws the exminer or my mster o surgery thesis – n psse me !
THE SECOND WORLD WAR (1939–1945) Wheres surgery in the First Worl Wr proue importnt innovtions, surgery in the Seon Worl Wr onsiste o onsolition n onrmtion o the lessons o 1914–1918: the vlue o rpi evution, surgil units s ner to the ttle ront s possile, erly exision o wouns, elye primry suture, eetive immoilistion o injure lims, erly surgery o ominl n hest wouns, metiulous re o he injuries n speilise units or plsti surgery. A surgeon rom CCS t Somme in 1916 woul hve elt very muh t home in Fiel Surgil Unit in Normny in 1944. It ws in the nillry nillr y spets o the re o the
Figure 9.34 The army blood bank at Bristol shortly ater the D-Day landings in France, June 1944. (From Cope Z, ed.: History of the Second World War Medical Series – Surgery , 1953. 19 53. Crown copyright; reproduced with permission o the Controller o Her Majesty’s Stationery Oce.)
woune enormous vnes me, in prtiulr,tht in loo trnsusion nwere in the introution o sulphonmies n, espeilly, o peniillin in omting woun inetion. By the en o the First Worl Wr, itrte loo ws store eore mjor ttles. By 1939, the Re Cross h orgnise register o loo onors, n it ws well reognise tht rerigerte itrte loo oul e store sely or up to ouple o weeks. Tnks to the orgnising genius Brigier Sir Lionel Whity (1895–1956), n the RAMC entere the wr with ully opertionl pln. Tis enle lrge quntities o loo n plsm to e ville to store oth militry nrie ivilin sulties (Figures 9.34 n 9.35). Whity himsel h serve s n oer, h een seriously woune in 1918 n h reeive loo trnsusion eore hving leg mputte through the thigh y Goron ylor (see Figure 9.23), 9.23), who then ie his ptient’s mission to his meil shool, the Milesex, s stuent. Sine the work o Louis Psteur on the teril sis o woun inetion inet ion n o Joseph Lister on the ntisepti tretment o wouns, in whih hemil gents were use to kill the ontminting te-
Figure 9.35 A blood transusion taking place in a tented CCS, Normandy 19 1944. 44. (From Cope Z, ed.: ed .: History of the Second World War Medical Series – Surgery , 1953. Crown copyright; reproduced with permission o the Controller o Her Majesty’s Stationery Oce.)
ri, sientists o the possiility o nmeil gent tht woul reme estroy inving miroes
men hemil ullet tht woul ws kill the orgnism ut not the ptient. Slvrsn hrly the
without mge to the ptient’s helthy tissues. Pul Ehrlih (1854–1915) o Frnkurt-on-Mine, Frnkurt-on-Mine, Germny, synthesise the rsenil ompoun Slvrsn, whih ws use linilly in 1911 s the rst relly eetive rug ginst syphilis. It ws Ehrlih who oine the term ‘mgi ullet’ to
o warare 148 The surgery o
peret ullet sine it is toxi rug with unplesnt sie eets. Te next mjor lnmrk in hemotherpy gin me rom Germny. Gerhrt Domgk (1895–1964) (1 895–1964) showe showe tht the t he niline ni line ye Prontosil P rontosil Rur ws highly eetive ginst the muhree spreing inetions proue y streptooi, in spite o the isvntge tht the rug stine the ptient, ortuntely temporrily, right re olour. Tese importnt nings were pulishe in 1935. Within weeks o this pper ppering, workers t the Psteur Institute in Pris showe tht it ws the sulphnilmie moiety o the Prontosil moleule tht ws the tive gent. Te next ew yers sw urry o tivity, oth y the syntheti hemists n liniins, in the evelopment o new sulphonmie rugs. Te eetiveness o these gents ginst mny inetions, suh s pneumoni n puerperl ever (sepsis ollowing hilirth), seeme lmost mirulous. Sulphonmies were use uring the Spnish Civil Wr n lso in the Seon Worl Wo rl Wr in the t he tretment o mjor wouns n ertinly reue the risk o woun inetions. However, they h the serious isvntge o eing ineetive in the presene o pus, i.e. one woun inetion ws estlishe, n were lso vlueless vlu eless in the tret tretment ment o gs gng gngrene rene n tetnus. But wht o the ntimiroil gents erive rom ungi n teri, the ntiiotis? Most people elieve tht the story egins with the esription o peniillin y Alexner Fleming
Lister ientie the ungus s Penicillium glaucum. In 1884, Lister trete nurse nme Ellen Jones t King’s College Hospitl, Lonon, who h eep uttok sess tht ws heling very slowly with n extrt o ulture o this ungus. Unortuntely,, Lister i Unortuntely i not pulish his methos or the results o using wht ws presumly rue peniillin. Numerous other reports ppere over the yers, inluing one rom Louis Psteur himsel in 1877, in whih he reporte tht nthrx illi were inhiite in ulture y unspeie teri n postulte tht this t his might prove to e o linil vlue. Now to Alexner Fleming (1881–1955) n his ple in the history o ntiiosis. While working s teriologist t St Mry’s Hospitl, Lonon, in 1928, he me the oservtion tht ulture plte o Staphylococcus aureus, ommon use o oils, sesses n mny other serious inetions, ontminte y spores o Penicillium moul showe lysis roun the ontminting ungi. He me etile stuy o this phenomenon, nme the gent proue y the moul ‘peniillin’ ‘peniilli n’,, showe tht rue extrt rom the moul ws remrkly tive ginst whole rnge o teri n pulishe report on this phenomeno phenomenon n in 1929. However, However, eorts y Fleming n his ollegues ile to onentrte n puriy peniillin. en yers psse eore Howr Florey (1898–1968), proessor o pthology t the University Unive rsity o Oxor, n n young Germn Germ n Jewish reugee iohemist, Ernst Chin (1906–1979),
in 1928. t,Inthe story goes k muh urther thnInthis. 1870, John Buron Snerson (1828–1905), while working s meil oer o helth in Pington (he susequently eme the proessor o meiine in Oxor), in numerous experiments showe tht teri i not grow in ulture ui tht ontine visile moul. Te pulition o Snerson’s report stimulte Joseph Lister himsel to egin series o experiments in whih he show showe e tht urine u rine tht h hevy growth o moul showe norml egenerte teri or the omplete sene o miro-orgnisms n tht the urine uner these
etermine to rry ourring out systemti stuysuo the known nturlly ntiteril stnes. A review o previous pulitions in this el nturlly inlue Fleming’s pper o 1929 n, with the ssistne o tem o eite young sientists, the iult tsk o extrting peniillin rom the moul o Penicillium notatum ws rrie out. In My 1940, enough peniillin ws ville or ruil niml experiment, whih showe tht the ry, stle rown power prepre y proess o reeze-rying ws highly eetive in proteting mie given lethl injetion o Staphyloc Staphylococcus occus aureus. By the eginning o
irumstnes usully sweet smelling. Aie y his rother Artremine Arthur, hur, n expert myologist,
1941 1941, Florey h eings, enough n, mteril to egin his rst tril ,on humn gin, the results in
The Second World War (1939–1945) (1939–1945) 149
ptients with overwhelming teril inetions were most enourging. It ws ovious tht peniillin ws potentilly powerul wepon in oth the tretment n prevention o inetion in wr wouns. Superhumn eorts were me to inrese the yiel o peniillin in the ‘tory’ set up in the Pthology Deprtment t Oxor. In 1941, with the Unite Sttes in the wr, proution o peniillin ws unertken y numer o mjor Amerin phrmeutil ompnies. By the Siily lnings in 1943 (Figure 9.36), enough enough peniillin ws ville or extensive extensive linil trils, tri ls, oth s lol tretment in the woun n y intrmusulr injetion; the results were exellent. It ws soon shown tht the lostrii group o teri (those responsile or gs gngrene n tetnus) ws highly sensitive to the rug. By the D-Dy lnings in Normny in 1944, there ws enough peniillin to llow its use or ll sulties. Te ntiioti er h well n truly ommene. Susequent wrs hve reinore the lessons o the two Gret Wrs, lessons lerne rom the suerings o ountless millions o injure men n women. Signint vnes ontinue to e me; or exmple, the evelopment o sophistite vsulr surgery in the 1950s, using vein
n syntheti grs, enle mny extremities to e sve in the Koren n susequent wrs tht woul previously hve require mputtion. Tese priniples o tretment, o ourse, hve een pplie to the surgery o ivilin trum. Te reul vsulr injuries proue y ‘kneepping’ rrie out y terrorists in Northern Ireln, were trete long wrtime priniples, prinipl es, the mge mge vessels repire y grs gr s n lims rrely lost. I ws involve in treting sulties rom our mjor terrorist ‘inients’ t Westminster Hospitl, Lonon. Woun exision, immoilistion, ntiiotis n elye primry suture were rrie out in every se n without single exmple o woun inetion (Figure 9.37). Te only thing to enet rom wr is surgery.
Figure 9.36 A tented CCS and eld surgical unit at the Sicily Sicil y landings (1943). (1943). Penicillin was now available or local but not systemic treatment o wounds in the Services. (From Cope Z, ed.: History of the Second World War Medical Series – Surgery , 1953. Crown copyright; reproduced with permission o
Figure 9.37 A victim o the Harrods bombing by the Irish Republic Army (IRA) 1984; multiple injuries including traumatic amputation o the right leg at mid-thigh. mid -thigh. Treated by wound exci-
the Controller o Her Majesty’s Stationery Oce.)
sion and delayed primary closure. (Photographic Department, Westminster Hospital, London.)
10 Orthopa Or thopaedic edic surgery surgery Te wor ‘orthopei’ originte in 1741 when Nihols Anré (1658–1742), proessor o meiine in the University o Pris, pulishe his ook on the prevention n orretion o musuloskeletl eormities in hilren title L’Orthopédie. Tis wor ws rete rom the Greek orthos, stright, n paideia , the rering o hilren. Te ook’s emlem, stright pole supporting suppo rting ent tree trunk, trun k, is still use s logo y numer o orthopei surgil soieties (Figure 10.1). O ourse, lrge prt o the prtie o orthopeis toy oes onern hilren: rtures n islotions, inluing irth injuries, ongenitl eormities suh s spinl urvture (soliosis), ongenitl islotion o the hip n lu oot, inetious iseses suh s poliomyelitis n tuerulosis, s well s rre one tumours o hilhoo. Te speilty o orthopei surgery is onveniently ivie into the mngement o trum to ones n joints, n the eletive tretment o iseses o these strutures.
FRACTURES AND DISLOCATIONS Te tretment o injuries o ones n joints goes k to the erliest ys o surgery, sine the most primitive o prtitioners woul hve een lle upon to in up injuries n to splint rtures. Te Austrlin Aorigines, until quite reently, took the ge ‘splint the ptient where he lies’ quite literlly: the reltives woul tke it in turn to hol the mge still t the site shelter o the ient until union lim ourre, rue eing erete over oth ptient n humn splint.
Figure 10.1 The bent tree trunk supported by a
pole, rom Nicholas André’s L’Orthopedie, 1741. This emblem is oten used to this day as a logo or orthopaedic associations. 151 1 15
152 Orthopaedic surgery
Sir Gron Elliot-Smith’s Egyptin exvtions hve revele rtures rtu res o 5,000 yers go oun up in splints o rk, wrppe in linen n hel y nges (see Figure 1.4) 1.4).. Te Hipporti writings ierentite simple rom ompoun rtures n esrie the tretment o islotions o the hip n o the shouler (see Figure 3.2), 3.2), while Celsus, the Romn enylopeist o the 1st entury ad, gives instrutions or setting rtures, their immoilistion y splints n the susequent nee or exerises ollowing ony union. Te erliest Anglo-Sxon meil writings reer to the tretment o rtures thus: ‘I the shnks e roken, tke onewort, poun it, pour the white o n egg out, mingle these together… ly this slve on the roken lim n overly with elm-rin pply splint; gin, lwys renew these until the lim e hele’. All sorts o mterils were use to immoilise the rture. Splints o woo, ror n tinplte were employe. Hipportes use mixture o our n gum; nges were hrene with wx, strh, resin n egg white. For the most prt, these evies were lumsy, pinul, ineient n ngerous; gngrene, pressure sores n mlunion pper to hve ourre ommonly even er reltively minor rtures. An rtile in Te Lancet in in 1835 onemne the lrge numer o poor piees o pprtus on the mrket:
o mphor hel roun the injure lim with mny-tile nge. For urther reinorement, he pplie strw gutters, then overe the whole one more with his solution. Tis very soli ressing enle esier trnsport n evution o the injure solier. Plster o Pris ws use y the Ar surgeon Rhzes n y the Hinus, ut it ws the Duth rmy surgeon Antonius Mthijsen (1805– 1878) who introue nges impregnte with plster o Pris in 185 1852. 2. A prtil wr surgeon, he mentione tht i wter ws not ville on the ttleel, urine ws eqully eetive or moistening the plster nges. By the time o the Crimen n Frno-Prussin wrs, plster splints more or less in their moern orm were in reltively ommon use. One splint, in prtiulr, eserves our ttention, the Toms splint. Te story o Hugh Owen Toms (1834–1891) (Figure 10.2) is one o the most interesting in the history o meiine. Te son o onesetter, the whole o his proessionl lie ws spent in generl prtie in the slums o Liverpool, n n he i more thn nyone eore him to vne the tretment o injuries n iseses o ones n joints. Toms me rom mily o unqulie onesetters o Anglesey, whose
Venerable athers o surgery who have departed just look over your shoulders and see what a motley crew you have travelling behind you; carpenters with their boards and glue; tea-trade makers with Japanned splints; ironmongers with tin splints; blacksmiths with iron splints; Hindoos with cane splints (better to be applied to some backs than broken legs); sailors rom the Arctic seas with whale-bone splints, milliners with pasteboard and breaches makers in the rear with straps and buckles to bind the broken ends o bones together.
Dominique Jen Lrrey (1766–1842) (see Figure 9.7), 9.7), tht gret militry surgeon o the Npoleoni invente the ‘nge inmovile’, whih wrs, onsiste o ompresses soke in mixture o egg white, le suette n spirits
Figure 10.2 Hugh Owen Thomas. (Royal College o Surgeons o England.)
Fractures and dislocations 153
serets h een hne own rom ther to son or mny genertions. His ther, Evn Toms, ws etermine tht his son shoul reeive the enets o regulr meil eution, n Hugh stuie t Einurgh n t University College, Lonon, quliying Memer o the Royl College o Surgeons (MRCS) in 1857. He returne to Liverpool n soon gine gret reputtion, with vst prtie mong the poor o Liverpool n mong the numerous serers returning to tht ity, mny with severe injuries sustine weeks or even months eore while t se, where their only re h een rom their shipmtes n ptin (Figure 10.3) 10.3).. We shll onsier lter in this hpter Toms’ ontriutions to the mngement o hroni iseses o joints, ut his splint ws evise to solve the prolem o eient immoilistion o the lower lim, oth in the tretment o rtures n o hroni one isese. Te splint use the ishil tuerosity o the pelvi girle s xe point, n trtion ws pplie y mens o hesive strpping long the leg, whih ws then tie to the lower en o the splint. Te work o Toms might never hve ttine reognition h it not een or his nephew n pupil Sir Roert Jones (1858–1933 (1 858–1933)) who introue i ntroue the t he use o the Toms splint or the mngement o emorl sh rtures in the t he First Worl Worl Wr. Te splint ws t lest prtly responsile or or the rop rop in the mortlity mort lity o
ompoun rtures rt ures o the emur rom 80% 8 0% in 1916 1916 to 7.3% in 1918 (see Figure 9.18). Toms ws thin, rk, rgile little mn. He h n ient while stuent, whih resulte in eorme eyeli n rther spoilt the expression o his e. He h inomitle energy, energ y, n worke rom six in the morning until minight, never tking holiy. He ws lwys resse in lk ot, uttone up t the nek, with peke nvl p tilte over his eetive eyeli. He ws selom seen without igrette in his mouth. Although not reognise in his lietime, Toms is toy knowlege s gret pioneer o orthopei surgery. An importnt ontriution to rture tretment ws me y Perivll Pott (1714–1788) (see Figure 6.12), 6.12), who showe tht isplement o the one rgments in rture is minly ue to tension o the surrouning musles. Tese ores oul e eliminte y pling the injure lim in position tht relxes these musles, thus enling esier reution n more ertin immoilistion o the rture. He gve n exellent esription o rtures o the nkle, oen still reerre to s ‘Pott’s rture’ (see Figure 6.14). Surgeons over the enturies were, o ourse, well milir with the t tht ompoun rture ws very likely to eome in inme me n to suppurte, oen with the emise o the ptient. Amputtion ws ommonly vise in ll ut the most minor o ompoun injuries. Joseph Lister’s work (see Chpter 7) 7) provie the si unerstning o the teril nture o suh woun inetion n
Figure 10.3 Hugh Owen Thomas reducing a dislocated shoulder; no anaesthetic is being used. The assistant on his right is Thomas’ nephew,
provie the prtil to overome this. Surgeons eore Lister methos voie the ie o opertive reution o rtures, euse it ws relise tht operting on lose rture oul, in t, onvert it into ‘ompoun’ injury. Inee, most woul hve regre suh suggestion s eing tntmount to mlprtie. It ws Lister himsel who showe tht, using ntisepti surgil tehniques, it ws se to rry out opertive reution n xtion o rture. He himsel reporte suessul wiring together o rtures o the ptell n o the olernon proess o the elow, where previously lose reution n splinting
Robert Jones, later to become a distinguished Liverpool orthopaedic surgeon and to be knighted.
o suh rtures only proue mlligne joint sures withoul the inevitle evelopment o lte rthriti hnge (Figure (Figure 10.4). Lister gve
154 Orthopaedic surgery
Figure 10.4 An old specimen o a transverse racture o the patella. The widely separated bone ragments are joined by brous tissue. (Gordon Museum, Guy’s Hospital.)
etile ount o his tehnique n results in leture t the Meil Soiety o Lonon, whih ws reporte in the British Medical Journal o o 1883 (Figure 10.5). He wrote In March 1873, my riend Dr Hector Cameron o Glasgow, recommended to my care at the Edinburgh Inrmary a case o ununited racture o the olecranon. He reminds me that I had oten expressed to him the opinion that the use o a metallic suture, antiseptically applied,… ought, in suitable cases, to be extended to the olecranon and patella. The patient was a man 34 years o age, who, ve months previously,
had received a blow rom a policeman’s baton on the let elbow. This occasioned great swelling which seems to have concealed the true nature o the case rom a medical man who he rst consulted. On admission, there was a considerable interval between the olecranon and the shat o the bone; and although the limb was muscular, it was comparatively helpless, as he could not extend the orearm at all without the aid o the other hand. On the 28th o the month, I made a longitudinal incision, exposing the site o the racture, and, at the same time, bringing into view the articular surace o the humerus, and, having pared away the brous material between the ractured suraces, I proceeded to drill the ragments, with a view to the application o the suture. The racture was oblique rom beore backwards, as indicated by this diagram. I ound no diculty with the proximal ragment, in making the drill appear upon the ractured surace at a little distance rom the cartilage (see b), but with the other ragment the obliquity o the position in which the drill had to be placed was so great that, instead o the end o the drill emerging at the ractured surace, as I had intended, I ound it had entered into the substance o the humerus (d). I thereore withdrew
Figure 10.5 Joseph Lister’s operation o wiring o
the and the substituted (cd),,drill (cd) passing eyed endor in itrst. rsat.needle Then, with a gouge, I excavated an opening (e) upon the ractured surace, opposite to the drill hole (b) on the other surace, until the needle was exposed. Withdrawing the needle, I introduced a silver wire in its place and I had no diculty, by means o orceps passed into the excavation made by the gouge in drawing out the wire. I was then able to pass it through the other drilled opening and thus the two ragments were
a ractured olecranon. (From Lister J: An address on treatment o ractures o the patella. British Medical Journal 1883; 1883; 2, 855.)
brought into apposition. The ends o the wire were twisted together and let projecting at the wound. Healing took
Fractures and dislocations 155 5 dislocations 15
place without suppuration or ever, and the wire was removed on the 19th o May, seven weeks ater the operation. The wound made or its extraction soon healed, and the patient returned to Glasgow; and I aterwards had the satisaction o learning that he was wielding the hammer in an iron ship building yard with his ormer energy.
In the sme pper, Lister esries esrie s seon se o ununite rture o the olernon in whih the ptient h onsulte no less thn 18 other surgeons, ll o whom vise ginst opertion. Lister rrie out n opertion similr to the one esrie erlier with peret suess n goes on to sy: I have reerred to a case o ununited racture o the olecranon where 18 surgeons have been previously consulted. I trust no one here will suppose that I mention this circumstance or the purpose o gloriying mysel. I mentioned it in order to emphasise what I believe, that by antiseptic means we can do, and are bound to do, operations o the greatest importance or our patients’ advantage, which, without strict antiseptic means, the best surgeon would not be justied in recommending. How wise those 18 gentlemen were in counselling against operative intererence, provided they were not prepared to
physis t the University o Würzurg in Germny, G ermny, ws lmost immeitely pplie to the urte ignosis o rtures n provie urther impetus to the pioneers o open reution, sine it emonstrte tht oen ntomil reution ws not otine y lose mnipultion. Erly innovtors were Alin Lmotte (1866–1955) o Brussels, who evise vriety o srews, pltes n metl ns, whih he initilly me himsel, n lso tehnique or externl xtion, n Willim Aruthnot Lne L ne (1856–1943) (1856–1943) (Figure (Figure 10.7) o 10.7) o Guy’s Hospitl, Lonon. Lne pioneere the use o srew xtion o rtures, rt ures, whih he ommene in 1893, n y 1905, he h introue his speil perorte stinless stin less steel strips or plting rtures r tures o the long ones (Figure (Figure 10.8). O 10.8). O ourse, ny inetion in suh instnes woul prove isstrous n, in other hns, there were mny ilures. Lne, however, insiste on the stritest sepsis in his thetres, the ‘no touh tehnique’. For this, he evise long rtery n isseting oreps so tht, even in the eepest woun, the ngers tht hel them woul not touh the woun eges. Te sutures were never touhe ut were three using two pirs o isseting oreps. Tis sepsis ws omine with metiulous hemostsis n gentlest hnling o
operate strictly antiseptically, think we must be all agreed. As regardsIthe operative procedure in that case, it was o the most simple character; any rst year student could have done the operation exactly as well as mysel; mysel ; and, thereore, I trust I shall not be misunderstood by its being supposed that I came here to extol my own skill. That which justied me in operating in that case was simply the knowledge that strict antiseptic treatment would convert serious risk into complete saety.
Te isovery o X-rys in 1895 y Wilhelm Roentgen (1845–1923) (Figure 10.6), proessor o
Figure 10.6 Wilhelm Konrad Roentgen. (Royal College o Surgeons o England.)
156 Orthopaedic surgery
nothing o it le’. He spent the whole o his proessionl lie t Guy’s n t Gret Ormon Street, the hospitl or sik hilren. He me importnt tehnil vnes in mny rnhes o surgery. He introue explortion o the mstoi ntrum in the tretment o hroni purulent otitis mei (mile er inetion), evise n ingenious p opertion or the repir o le plte, ws the rst to tret septi thromosis o the lterl sinus ompliting mstoi inetion y ligture o the internl jugulr vein n removl o the septi thromus, ws n erly vote o the use o sline or trnsusion in hemorrhge, pioneere ri resetion or hroni empyem in hilren n ws the rst to perorm suessul ri mssge, whih ws reporte in 1902. Te ptient ws mn o 65 unergoing ppenietomy: Figure 10.7 Sir William Arbuthnot Lane. (This painting hangs in the medical school at Guy’s.)
During the trimming o the stump both pulse and respirations stopped stoppe d together. together. Articial respiration and traction on the tongue were perormed without result. Then the surgeon introduced his hand through the abdominal incision and elt the motionless heart through the diaphragm. He gave it a squeeze or two and elt it restart beating.
the tissue. Muh o his suess ws ue to the t tht he ws rillint ril lint tehnil surgeon. Lne ws suh n interesting hrter tht I must evite rom the sujet o rtures to sy more out him. He ws the son o n rmy r my surgeon n entere Guy’s Hospitl t n erly ge ge o 16. He love ntomy n ws ppointe emonstrtor while still stuent. Aer quliying, he spent urther 5 yers in the t he eprtment o ntomy n like nothing etter thn to emonstrte his prowess s issetor. Inee, the stuents woul sy
Te opertion ws omplete n the ptient reovere ully. Lne lso evise the simple metho o resusittion in smll innts y squeezing iretly on the elsti hest wll. Erly in the 20th entury, Lne strte to eome osesse with the ie tht hroni on-
‘on’t let Lne touh your prt or you will hve
stiption proue toxemi n ws the use
Figure 10.8 Lane’s stainless steel plates or racture xation.
Fractures and dislocations 157 7 dislocations 15
o mny o the ills o ivilistion, rnging rom migrine migr ine to rheumtism. He rr rrie ie out totl oletomies in ptients suering rom suh onitions. Fortuntely, t lter te, Lne prehe tht one might keep the olon s long s it ws mintine empty, n introue the use o liqui prn, given in lrge oses y mouth. At lest this ws ser to the ptient thn hving the whole o his olon remove! Nturlly, his views were met with onsierle opposition. Eventully, Lne took his nme o the meil register to e le to ress the puli y letures n through the press on his ies or helth. He ws inee pioneer in wht we now ll soil meiine. He oune the New Helth Soiety, whose prinipl ims were to teh the puli the simple lws o helth, to ttempt to mke ruit n vegetles unnt n hep or the generl puli n to enourge people to go k to the ln, s well s, o ourse, keeping their owels empty ! Te risks o osteosynthesis, the open xtion o rtures, whih inlue inetion, elye union n tissue retion to the metl employe, rete longstning ete etween the onservtive shool, who woul try where possile to use lose methos, n those surgeons voting open surgery. A leer o onservtism ws Lorenz Böhler (1885–1973) (1 885–1973) o Vienn, Vienn, who prehe re reul ul reution o the rture n n strit immoilistion o the lim, omine with simultneous exerises o ll non-involve joints. His orgnistion methos t the Vienn Aient Hospitl set n exmple or the evelopment o speilist ient units worlwie.
Figure 10.9 X-ray o a Küntscher intramedintramed ullary nail xation o a racture o the tibia. (Westminster Hospital.)
Further vnes inlue the evelopment o non-retive lloys suh s vitllium to onstrut srews n pltes, n the evelopment o ompression srews tht llowe lose pposition o the rture sures. During the Seon Worl Wr, Gerhr Küntsher (1900–1972) in Kiel, Germny, evelope the intrmeullry nil or rture xtion (Figure 10.9). Te iulties o wrtime ommunition ment tht llie surgeons were unwre o this vne until they enountere returning prisoners o wr who h h their rtures trete in this wy. In reent yers, externl xtors hve ome into inresing use, prtiulrly in themultiple tretment o severely omminute n rtures – tehnique rstompoun suggeste y Lmotte nerly entury go (Figure 10.10). 10.10).
Figure 10.10 External xators applied to a severe compound racture o the tibia. An IRA bomb victim treated at Westminster hospital, 1983.
158 Orthopaedic surgery
Frtures o the nek o the emur hve lwys een prtiulr tretment prolem euse o the virtul impossiility o holing the one ens in ontinuity in ll ut impte pertrohnteri rtures. Astley Cooper (1768–1841), in his reatise on Dislocations and Fractures, ws onvine tht non-union ws inevitle in this injury n vise isregring the rture n returning the ptient to his norml lie s r s the t he pinul hip woul llow. It remine or Mrius Smith-Petersen (1886–1953) o Boston to evise nge nil to x the rture in 1925. Tis t rst ws perorme y n open opertion until Sven Johnsson (1880–1959) o Gothenurg, Sween, introue introu e his rilling ri lling metho or pinning the hip tht voie exposing the hip joint, whih eme stnr tehnique (Figure 10.11). Su-pitl rtures o the emorl nek, where it is lmost
Figure 10.12 Prosthetic replacements o ractured emoral heads. Let: A Judet prosthesis; the patient was a male aged 80, who sustained a racture ract ure o the emoral neck, neck , in 1951. 1951. He died at
home o steel a chest i nection inection 4 months later. Right: because A stainless Austin Moore prosthesis used to replace the emoral head in a pathological racture secondary to a carcinoma o the thyroid in a male aged 83. He walked well postoperatively but bu t died 8 months later. (Specimens in the Gordon Museum, Guy’s hospital.) hospit al.)
ertin tht vsulr nerosis o the ethe he will tke ple, n now e trete y immeite replement o the emorl he y mens o prosthesis (Figure 10.12). 10.12).
ELECTIVE ORTHOPAEDICS
Figu re 10.11 Figure 10.11 Autopsy specimen o a pinned hip racture. The label reads: ‘Female aged 53 had sustained a racture o the neck o the right emur in a all 3 weeks prior to her death. d eath. A Smith-Petersen pin was inserted to stabilise the
Until the 19th entury, little oul e one or the hlt, the lme n the t he ripple; ripple; the poor woul rg themselves roun the streets s eggrs, the more ortunte woul e onne to their e or hir. Mnipultions, irons n splints might e trie to orret the eormity eormit y ut with only osionl suess. Unqulie onesetters, onese tters, who were oen quite skille t eling with rtures n islotions, woul lso hve ourishing tre in mssging n mnipulting ptients with isese ones n joints. Tey lerne, rom itter experiene,
rac ture, but the patient racture, pati ent died 13 days later rom rom a pulmonary embolism’. (Gordon Museum, Guy’s Hospital.)
not towhere mnipulte ‘hot’ (n thereore inme) joint, suh intererene woul ert ertinly inly e hrmul.
Elective orthopaedics 159
Te opertive tretment o orthopei iseses ws, o ourse, limite y the pre-Listerin risk o inetion. Avne tuerulous isese o ones n joints requently require mputtion o the lim; inee, the very rst mjor opertion uner ether nesthesi nest hesi ws, in t, mputtion o the leg or tuerulosis o the knee (see Chpter 7). Jmes 7). Jmes Syme (1799–1870) (see Figure 6.31 6.31)) vote exision o the joint rther thn mputtion wherever possile n pulishe, in 1831, pmphlet on the sujet title reatise on the Excision o Diseased Joints. In it he wrote
O ourse, Syme ws orret, lthough his ses were ogge y post-opertive woun inetion. Inee, it is interesting tht Syme’s son-in-lw, Joseph Lister (see Chpter 7), rrie 7), rrie out suessul series o exisions o the wrist joint or tuerulosis using the ntisepti tehnique. One o the erly pioneers to ttempt the orretion o eormities y surgery ws Jques-
o one n joint isese. In 1830, he trete oy o 14 with lu oot y mnipultions or over yer without suess. He then rrie out the opertion o ivision o the Ahilles tenon, ut not y open surgery: he introue nrrow slpel through smll st woun ehin the heel n psse it eep to the tenon, whih ws then ivie – the opertion o suutneous tenotomy. Division o the tenon llowe Stromeyer to mnipulte the exe nkle into its orret position n the tiny skin inision gretly erese the hnes o woun inetion. Te suess o this se enle Stromeyer to preit tht other eormities oul e menle to this type o surgery, s inee they were. In 1836, young English otor, Willim John Little (1810–1894), who h qulie t the Lonon Hospitl 4 yers previously previously,, visite Stromeyer’ Stromeyer’ss lini. Little Litt le h lu oot s result o poliomyelitis t the ge o two; he h een trete in the usul wy with mnipultions n splintge without wit hout susuess. He ws nturlly losely intereste in this eormity n inee ws mking it the sujet or his MD thesis. He h ome to the onlusion tht luing o the eet ws not use y eorme one growth, s h previously een thought, ut resulte rom isorere tion o the musles. Aer wthing Stromeyer t work, Little unerwent his opertion o suutneous tenotomy with onsierle suess. He stye on t Stromeyer’s lini, lerne his tehnique, wrote his MD thesis n returne to Lonon, where he persue his riens to susrie to hospitl or him. Tis
Mthieuout Delpeh (1777– (1777–1832 1832) ) in Montpellier, who rrie ivision o the teno Ahillis or lu oot etween 1816 n 1823. Tis involve n open opertion n, presumly euse o the lmost inevitle inetion, Delpeh onlue tht the opertion ws unjustie. Clu oot ontinue to e trete y splints n mnipultions. It is interesting tht the poet Lor Byron suere rom this onition. Delpeh went on to pulish n extensive stuy o one n joint isese, De L’Orthomorphie, one o the erliest texts evote to this sujet. He ws murere y mentlly ill ptient.
emeNtionl the RoylOrthopei Orthopei Hospitl, Hospitl, lter the Royl Lonon, whih is toy Me or orthopei surgeons. Although Stromeyer h only ivie the Ahilles tenon, Little vote tenotomy or ny tenon tht ws prouing eormity; Stromeyer lle him ‘the postle o tenotomy’. Little lso pulishe ppers on other eormities, inluing knok-knee n soliosis n esrie the spsti onition rising rom irth injury o the rin, spsti iplegi, whih is still known s Little’s isese. Interestingly, Little ile in his mition to get on the st t the Lonon Hospitl s surgeon;
An importnt vne ws me y George Frierih Stromeyer (1804–1876) o Hnover, who set up smll hospitl in tht ity or the tretment
inste, he swithe n ws eventully eletetotoeome the st ophysiin the Lonon, ut on the meil sie.
Though amputation is a measure very disagreeable both to the patient and to the surgeon, it has hitherto, with hardly any exception, been regarded as the only sae and ecient means o removing diseased joints which do not admit recovery. The idea o cutting out merely the morbid parts and leaving the sound portion o the limb, seems to have hardly ever occurred, or to have met with so many objections that it was almost instantly abandoned abandoned..
160 Orthopaedic surgery
Figure 10.13 John Hilton. (Royal College o Surgeons o England.)
In the pre-ntiioti er, tuerulosis o ones n joints ounte or lrge numers o ripple hil ren. Perivll Pott gve goo esription o its hilren. most serious mniesttion, mni esttion, involvement o the vertere (Pott’s isese o the spine, see Figure 6.13), whih ws oen omplite y jent tuerulous sesses tht oul result in prplegi rom
spinl or ompression. John Hilton (1805–1878) (Figure 10.13), surgeon t Guy’s Hospitl, elivere ourse o letures on rest n pin t the Royl College o Surgeons, Engln, in 1860–1862. Tese letures were erwrs pulishe in ook orm with the sme title n n still stil l e re with interest toy. Hilton pointe out the importne o rest in the mngement o mny hroni onitions. However, it ws Hugh Owen Toms, who we hve lrey mentione erlier in this hpter (Figure (Figure 10.2), 10.2), who enunite the importne o wht he terme ‘enore, uninterrupte n prolonge rest’ in the tretment o one n joint tuerulosis. Immoilistion ws ontinue until heling y rous nkylosis ws hieve hieve, , the t he lim eing now xe in position tht llowe resonle untion. Immoilistion ws ompnie y tive use o unete lims, ut the whole o the ete lim must e ple t rest. Tus, tuerulous tuerulo us knee woul e splinte the ull length o the leg, n tuerulous hip joint woul e trete y splint tht rehe rom the xill to the oot, ptten eing use so tht the norml leg, thus ‘elongte’, woul ensure non-weight ering o the isese is ese joint (Figure (Figu re 10.14). 10.14).
Figure 10.14 (a) Tuberculosis o the right hip with gross fexion deormity. (b) The solution – the ambulatory Thomas hip splint with a patten on the sound side. (Reprinted with permission rom Thomas HO: The Principles of Treatment of Diseased Joints . Philadelphia, WB Saunders, 1883.)
Elective orthopaedics 16 161 1
O ourse, ll this ws to e hnge y the introution o ntiiotis; streptomyin ws isolte y Selmn Wksmn (1888–1973) t Rutger’s University, New Jersey, in 1943 n introue into meil prtie in 1948. As meil stuent n newly qulie otor, I ws well milir with orthopei wrs lle with hilren, eing trete y tehniques li own y Toms (Figure 10.15). Within ew yers, suh senes woul ispper rom the hospitls o the Western worl. Te introution o ntisepti, n then septi, surgil tehniques enle not only rpi progress to e me in the opertive surgery o rtures ut lso llowe the evelopment o wht, until then, h een risky experiment – the opertive surgil orretion o orthopei eormities. Sir Willim Mewen (1848–1924) (Figure 10.16), 10.1 6), stuent o Lister t Glsgow n lter himsel to eome Regius Proessor o Surgery t tht University, ws n erly pioneer o septi surgery. Not only i he perorm the rst suessul resetion o n intrrnil tumour ( meningiom in girl o 14 in 1879) n the rst suessul pneumonetomy or tuerulosis in 1895, ut he lso pioneere the tretment o the gross eormities o genu vlgum (knok-knee) n genu vrus (ow-knee) (Figure (Figure 10.17) y 10.17) y iviing the tii n strightening the leg – the opertion o Mewen’s osteotomy (1875). At rst, his instruments were n orinryy rpenter’s hisel n mllet, ut he note orinr
Figure 10.16 William Macewen. (From Comrie
JD: History of Scottish Medicine Medicine. Baillière, Tindal Tindall l and Cox, 1932.) 19 32.). London,
tht the stright ege o the hisel i not proue n urte ut in the one, n moreover, the wooen mllet hnle rke with repete sterilistion n use. He thereore evelope speil evelle osteotome n h his instruments me o polishe steel. He perorme his opertion with suh exterity tht visitors to his thetre, inspeting the X-rys on the sreen, might mig ht well look roun to see the ptient eing wheele out, the opertion
Figure 10.15 A long-stay children’s orthopaedic ward in the 1940s. These hospitals were lled to
een Osteotomy eme hving populr n omplishe. useul opertion or treting other joint eormities, espei espeilly lly those resulting rom nkylosis (usion) o joints. Mewen lso pioneere the use o one grs, using rgments o one remove t n osteotomy or hil with owlegs to reple segment o humerus tht h een lost s result o osteomyelitis in 4-yer-ol hil. Tirty yers lter, the ptient ws still t work with n exellent untioning rm. By 1911, Russell His (1869–1932) o New York h revolutionise the tretment o gross spinl eormities resulting rom ongeni-
capacity with victims o tuberculosis o bones and joints and o poliomyelitis. (Photograph provided by MH Harrison, FRCS, Birmingham.)
tl soliosisInor1915, tuerulosis his spinl usion opertion. FreerikyAlee (1876–1945) o New York evise his well-known Alee gr.
162 Orthopaedic surgery
Figure 10.17 (a, b) Types o severe deormity o the knee ollowing rickets: (a) genu valgum, (b) genu varus, (c) Result o Macewen’s osteotomy in case (b). (From Macewen W: Osteotomy , 1880.)
Tis is n utogenous gr tken rom the sh o the ptient’s tii n implnte into groove ut through severl vertere ove n elow the isese spinl segment. Replement o isese joint y prosthesis, llowing movement to e restore, h long een surgil rem. Temistokles Gluk (1853–1942) t the Kiser un Kiserin Krnkenhus, K rnkenhus, Berlin, in 18911 ttempte to reple isese 189 ises e hip joint using n ivory ll l l n soket emente n srewe into
in the Unite Sttes use the Juet priniple ut reple the emorl he with n entirely metlli he n sh (see Figure 10.12 right) rig ht).. Tis ws stistory in the tretment o rtures o the nek o the emur ut ile in rthriti isese when oth sies o the joint were involve. It remine or George MKee (1906–1991) o Norwih n Sir John Chrnley (1911–1982) (Figure (Figure 10.18) 10.18) o Mnhester to proue suessul hip prostheses in the 1950s. Chrnley’s tehnique is still the
position, ut the pprtus ws(1899–1967) soon extrue. Attempts y Philip Wiles o the Milesex Hospitl in 1938 using stinless steel ll n soket were lso unsuessul. Mrius Smith Petersen (1886–1953) o Boston interpose vitllium up etween the one ens o the hip in 1939, gin with only temporry suess. Te rothers Juet (Jen, 1905–1995, n Roert, 1909–1980) in Pris reple the isese emorl he o rthriti hips with n n ryli he tthe to metlli metll i stem tht ws psse long the nek o the emur (see Figure 10.12 le). Tis le). Tis ws simple opertion opertio n with rillint erly results, ut unortu-
most metho usenek, toy.the Tisnek omprises steelpopulr emorl he inn eing emente into the upper sh o the emur using ryli ement, n high-ensity polyethylene up tht is emente into the rille out etulum (Figure (Figure 10.19). 10.19). Muh o the evelopment o his prosthesis ws rrie out in Chrnley’s workshop t his home. Chrnley ws peretionist. He note tht osionl isstrous eep inetion might our ollowing hip replement opertions, oen resulting rom ommon skin orgnisms, when the opertion ws rrie out uner norml ‘septi’ onitions. He otine the o-opertion
ntely, the metl stem rture er reltively short perio o use. Both Moore n Tompson
o Howorth Air Engineering to proue the rst ltere ir-operting enlosure with elorte
Elective orthopaedics 163
Figure 10.18 Sir John Charnley. (Royal College o Surgeons o England.)
‘spe-ge’ suits or the surgeon n his ssistnts, whih reue the risk o opertive inetion to very low levels inee. Chrnley Chr nley ws the rst rs t prtising orthopei ort hopei surgeon to e elete Fellow o the Royl Soiety. In more reent yers, highly suessul prostheses hve een evelope or other joint replements, prtiulrly o the knee (Figure 10.20) n the ngers. Orthopei surgeons, like the urologists n gyneologists, were quik to tke up the evelopment o re-optis re-optis or illumintion. Arthrosopes, Ar throsopes, rst or exmintion exmi ntion o joints n then or opertive interventions, hve me miniml interventionl
Figure 10.19 A Charnley total hip prosthesis removed at post-mortem many years later. The wire mesh in the acetabular cement was used to reinorce the weak inner wall o the pelvis. (Specimen in the Gordon Museum, Guy’s hospital.)
surgery possile or mny joint onitions, notly removl o mge rtilges n loose oies rom the knee n opertions on vriety o shouler lesions, prtiulrly the suprspintus synrome.
Figure 10.20 (a) X-ray o a patient’s knees, showing gross osteoarthritis. (b) X-ray o the same patient ater bilateral total knee replacements. (Case o John Older, FRCS.)
11 Breast tumours Muh o toy’s surgery is onerne with the tretment o enign n mlignnt tumours. Inee, muh o surgil history, espeilly in the pst 100 yers or so, is onerne with the evelopment o tehniques or the removl o orgns ete y these iseses: resetions o stomh, lrge owel, lung n so on. It woul tke ook muh lrger thn this to oument the history o the surgery o ll o the mjor tumours, n the senior uthor hs selete the story o the tretment o tumours o the rest s goo exmple. Te hoie ws very simple one. Aer ll, iseses is eses o the rest hve een stuie n oumente sine the erliest ys o surgery. Long eore ny surgeon oul even rem o tkling other ners, inee eore he ws wre tht mny even existe, he oul hrly il to oserve the growth, ulertion n spre o rest ner with the ultimte inevitle estrution o the ptient. In Hipportes we re: ‘A womn in Aer h rinom o the rest n looy ui rn rom the nipple. When the ishrge stoppe she ie’. Our knowlege o the Greo-Romn onept o ner n its tretment is erive rom the Romn enylopeist o the 1st entury entur y ad, Aulus Cornelius Celsus, whose De Medicina is ompenium o wht ws known o meiine t the time. He reors the vrious methos o eling with rest n other superil tumours n with poor prognosis o the isese: There is not so great danger o a cancer, unless it be irritated by the imprudence o the physician. This disease generally happens in the superior parts, about the ace, the nose, ears, lips and the
breasts o women… some have made use o caustic medicines, others o the actual cautery, others cut them out with a knie. Nor was any person perso n ever relieved by medicine, but ater cauterizing, the tumours have been quickened in their progress and increased till they proved mortal; when they have been cut out, and cicatrized, they have not withstanding returned and occasioned death. Whereas, at the same time, most people, by using no violent methods to attempt the extirpation o the disease, but only applying mild medicines to soothe it, protract their lives notwithstanding the disorder, to an extreme o age. ag e.
Over the enturies, removl o the t he rest tumour y the knie, the utery, omintion o the two or y mens o ustis ws rrie out. Henri e Moneville (1260–1320), or exmple, vote the use o pste me up o rseni n zin hlorie. In those pre-nestheti ys, mputtion o the rest h to e perorme s swily s possile. Wilhelm Fry von Hilen (1560–1624), the leing Germn surgeon t the time, invente n instrument tht onstrite onstrite the se o the rest while n tthe le mputte the orgn. He stresse the importne o ensuring tht the tumour ws moile eore he woul operte. Sultetus (1595–1645) psse hevy ligtures through the t he se o the rest to serve s trtion, mputte the rest with the sweep o knie n then use the utery to stop the leeing. Te ull u ll horror o this opertio opertion n is vivily shown in his illustrtion o this proeure in his (Figure Figure 11.1). Armamentarium Armamen tarium Chirurgicum Chirurgicum ( 165
166 Breast tumours
Figu re 11.1 Figure 11.1 Seventeenth century amputation o the breast using the knie ollowed by the cautery. (From Scultetus: Armamentarium Chirurgicum. Chirurgicum. Amsterdam, Jansson Waesberg, 1741.)
Te esription y Lorenz Heister (1683–1758) o mstetomy tht he perorme in 1720 gives us vivi ie o wht this opertion omprise in those ys. He isusses the reul pre-opertive preprtion, the mstetomy itsel, perorme t mximum spee, n the teious post-opertive ressings o the invrily suppurting woun (i the ptient ws luky enough to survive the opertion). His se report is interesting lso euse it shows tht times hve not hnge ll tht muh in the ptient’s ttitue to ner. So oen there is n ttempt to rtionlise or use; his ptient srie her tumour to ol ir on the rest when she ws in swet 16 yers eore the lump ppere n n while she ws pregnnt. All too oen ptients put their
ith in lterntive lterntive meiine; his ptient visite visite mny quks, who pplie plsters, ointments n omenttions. Although Heister ws onvine his ptient h ner, the esription o the tumour – its moility, the olour o the overlying skin, the t he osseltions, the sene o seonry eposits in the xill n the long survivl o the ptient – suggests tht the lesion ws, in t, n n exmple o ystosrom phylloes, slowly growing enign tumour o the rest tht my reh enormous proportions, lthough it my eventully turn mlignnt. We hve lrey met this extrorinry surgeon (see Figure 6.7). Te 6.7). Te illustrtion o his ptient is shown in Figure 11.2, n 11.2, n his esription o his se is s ollows:
Breast tumours 167
Figure 11.2 Massive tumour o the breast, probably an example o cystosarcoma phyllodes, submitted to mastectomy mastec tomy by Lorenz Heister, Hei ster, 1720. 1720.
A rmer’s wie me to me, the 21st or 22n o Jnury 1720, rom neighouring villge, out mile rom Altor, with nerous right rest; she ws out 48 yers o ge, o thin hit o oy, n o melnholi temperment, h een elivere o eight hilren; her rest ws o proigious size, nerly s ig gin s her he, very hr, unequl n eorme, n ttene with severe pins. It ws o rk rown, re olour, like mortie prt, n here n there severl lrge lote veins ppere; the rest ws not quite roun, the le-sie A, ws s ig s lrge person’s he, n next to it on the right-sie B, suh nother in sustne here, o the igness o hil’s he, whih extene itsel to her right-rm s esrie the gure. Upon the inerior prt o this lrge tumour, there were out 20 lrge exresenies o lkish olour,, n o the size n orm o the nipple, whih I ws not le to istinguish olour isting uish rom them: these, e to the shoking spet o the rest itsel in generl, renere the pperne more horri n rightul. Te womn ws extremely wek n int o hersel, ut the gret weight o her rest, whih weighe 12 pouns, ws so troulesome when she wlke, st own, or ly in e, pressing upon the thorx, tht the respirtion ws so muh ete, tht it ws with gret iulty she rethe t ll; this renere her yet more wek n int. She ompline too o violent shooting pin in her rest, shoulers n k, whih, y ontrting the thorx, ontriute to proue the gret nxiety n oppression she ompline o in rething: I onsiere n exmine every irumstne, reete upon the unommon mgnitue o the rest, n ning the tumour movele, without ny hesion to the ris or sternum, or I oul move it with ese rom sie to sie, upwrs n ownwrs, nor were the xillry glns enlrge or swelle, n s she ompline o no other prtiulr isorer, I oul o no otherwise thn inorm her riens, tht it ws impossile or meiine to e o ny use, n
168 Breast tumours
tht there ws no other metho o ure ut y mputtion; n tht this opertion woul o ourse e ttene with nger, nger, ut tht i she woul sumit to it, there were some hopes o ure, n o preserving her lie, or without tking o her rest, she woul, in ll proility, soon expire with the pin, ontinul restlessness, oppression, n wekness. When she her there were hopes o sving her lie, she egge o me most ernestly to o whtever I thought neessry, n I oringly promise to tke o the rest very soon; ut eing esirous to know in wht mnner she eme ete with this isorer, n how, rom time to time, it h inrese to the present enormous size, I enquire o her, n she relte to me, tht out 16 yers eore, uring the time o her lying in, eing lone t home 1 y, n in swet, person knoke t the oor, rising, in this th is swet, to see wht he wnte, she pereive the ol ir to strike upon the rest, n soon er oserve n hr movele lump, o the size o hzelnut, in the sme rest, ut without pin while in this stte, so tht she pi no regr to it, she h three hilren erwrs, who she sukle without pereiving the tumour to inrese; ut erwrs it inrese grully, n t the en o 12 yers, it eme e me s lrge s hen’s hen’s egg. She now egn to e pprehensive o the onsequene, n h pplie to mny quks, who h use, plsters, pls ters, ointments, omenttions, et. to resolve or isuss isus s the tumour or to ring it to suppurtion, ut without suess: it eme igger n igger, till t length, her rest ws s lrge s her he, n it egn to e very pinul, n the more it eme enlrge, the more pin it gve her: still she pplie to other people o this sort or relie, use wht they vise or time, ut without ny enet, ut, on the ontrry, the rest grew worse. Aout the en o Novemer, nother quk me to her, n promise ertinly to ure her, swering tht he oul soen the tumour, n ring it to suppurtion, n to tht intent he pplie emollient tplsms or month, whih, inste o eing serviele, h inrese the pin, n the smller tumour B, on the right sie o A ppere. She ws now, y this tretment, renere so wek tht she ws srely le to wlk wl k ross the room; her rest eore ws quite roun n equl, onsisting onsisti ng o the single tumour only. She ws in this miserle onition when she pplie to me. She lso inorme me tht, sine her rst lying in, she h lwys een troule with vrious tumours in her legs, whih went o grully with her menses, n oth entirely le her out yer go, when her rest eme so lrge. With regr to the ure o this th is terrile isorer, I oneive tht there ws inee no gret gre t hopes, s the tumour ws o suh n enormous size, whih in mputtion, woul require so lrge woun, n s the womn hersel ws so gretly eilitte y the onstnt pins n length o time she h een fite, tht sheexellent ws unle to wlk. Celsus, tht Romn physiin, hs intimte to his suessors, tht, in ngerous ses, it is etter to try outul remey, where the lest hopes o suess remins, thn none… I thought it visle to proee to the opertion; not ring to eer it ny longer, s the womn woul eome weker n weker, through the violene o the pin; muh less oul I think o putting o so onsierle n opertion till spring, s is ustomry in Frne, s the ptient might ie eore the spring me, or so wek s not to e le to unergo the opertion: or whih reson, notwithstning the ys were short, n the wether the olest in the yer, I thought it woul e ngerous to eer the opertion till the spring; n oringly, s neessity hs no lw, I xe upon 29 Jnury or the y. I prepre everything in the morning or the opertion, the neessry instruments, nmely knie, o my surgery; whih, though pretty lrge, I hose or the purpose, s the rest ws extremely lrge, n s with lrge knie I oul tke it o more expeitiously. I erwrs orere suh remeies to e got rey s were neessry to stop the leeing… A linen ompress e ippe in the power; spiritus ovist; tereinthine n pplie the ivie rteries; plegets o lint strewetowith the stringent o ihylum plster,tospre upon linen, 12
Breast tumours 169
slips oot n n inh ro, n nother piee oot squre; qurngulr so linen loths ole, two rollers 6 yrs long n our ngers ro. I h lso, in reiness, the uterizing irons to pply to the rteries i they shoul lee too violently. I lso orere the ssistnt surgeon to hve rey hete qurt o eer, ing three ounes o utter to it, to ip the lrgest olsters in, to pply over ll the other ressings, s Helvetius, in tretise on hemorrhges, reommens this pplition in mputtions o the rest, s o gret use in preventing inmmtions… Te whole pprtus eing in reiness, I now proeee to the opertion; pling the ptient in n rmhir in the mile o the room, n stning on the right sie, somewht kwrs, tht I might mke the inision t the inerior prt with greter onveniene, whih is ierent rom the ommon metho: I then esire n ssistnt to exten her right rm n rise it up, t the sme time pulling it kwrs; nother ssistnt kept her he xe: thir stoo eore, who I irete to hol the isese rest with oth hns, to rise, n, t the sme time, t ime, to pull it towrs him, tht I might with greter ese, ivie it rom the sujent musles: ourth ssistnt stoo on my sie with the instruments n ressings, n the h hel the oril meiines. I now enourge her to ehve with resolution, n tking hol o her rest with my le hn, pplie the knie pplie kn ie to the inerior prt with my right hn, ut through the integuments, n irete the ssistnt who hel the rest, to pull the t he rest towrs him; I rrie rr ie on the inision y the iretion o the nger o my le hn, till the rest ws extirpte, whih ws perorme in minute. (Figure 11.3) Te rteries, er the mputtion, leeing riskly, I pplie to them ompresses ippe in oil o turpentine, ireting the ssistnts to mke ompression upon them with their ngers: then I pplie
Figure 11.3 Heister’s mastectomy. (From his Medical, Chirurgical and Anatomical Cases , English edition, 1755.)
170 Breast tumours
to the rest o the woun, the plegets o lint strewe with the stringent power, n over this, lrge piee o ovist, till the whole woun ws overe thikly with it; over these, olsters o tow, strewe with the stringent power, whih I reirete to e gently ompresse y the hns o the ssistnts, till the leeing stoppe: while these ressings were pplying, I gve the ptient some o the oril julep, n hel the spirit spir it or smelling to, uner her nose; y whih wh ih mens she ws kept rom rom inting. Te ressings I xe with the 12 long slips o plster, n over these, I li the lrge squre ompress, n over this, two more lrge ompresses, wette with the hot eer n utter, n xe the whole with two-hee roller. Aer the ressing, she repete the oril n ws put to e. I orere n ssistnt to sit y her esie, to ompress the ressings with his hn extene, to prevent resh leeing n esire the ssistnts to relieve eh other every 2 hours. I weighe the rest erwrs, n oun it to weigh 12 pouns. A ew hours erwrs, the loo oring its wy through the ressings, I orere nother ompress to e pplie, n xe with roller in the mnner o the rst, whih stoppe the leeing quite…
Heister then goes on to esrie the prolonge perio o ressing the woun, whih inevitly suppurte, n nlly onlues The regimen I directed this woman to observe, was, or the rst ortnight thin soup and jellies; aterwards, when she had a better appetite, I permitted veal, boiled prunes, apples and pears, and eggs boiled sot; or ordinary drink, besides the vulnerary inusion prescribed above, I suered her to drink small beer, when thirsty; at meals, as above mentioned, I allowed her a glass o wine, and in another ortnight, permitted her to drink some Altdor
largest ever extirpated or described by authors.
Reing esriptions suh s this o mstetomy in the pre-nestheti er, it is not surprising tht surgeons, s well s quks, trie every oneivle oneiv le non-surgil proeure in i n n ttempt to tret ners o the rest. Tus, Alre A lre Velpeu Velpeu (1795–1867), who hel the Chir o Clinil Surgery in the Fulty o Meiine in Pris, gives n extensive list o remeies or meiines or rest ner in his A reatise on the Disea Diseases ses o the Breast and Mammary Region , pulishe in 1854 whih inlue: repete pplition o leehes, ure y hunger, hemlok, iron, mmonil solution o opper, rseni, merury merur y, Vihy
strong beer. I advised her to hersel quiet. She was regular askeep to stools and urine during the whole time; and, by the end o March, had recovered her strength so well as to be able to get up and walk about, was brisk and cheerul, had a good appetite, and complained o no pain all the month o o April. When I went to Helmstadt, I let directions with the surgeon to dress it with the dry lint and empl. saturninum only, till it should be healed; and a little time aterwards I was inormed that she was perectly
wter,, preprtions wter o gol, srsprill n itters. Mny oquinine, these heioine, trie himsel without suess. He writes
cured, a good state o health. and She enjoyed lived several years aterwards. This cancerous breast was the
tnt to our onept o o rest the pthology n ontriutions equte surgil tretment ner. Henri Le Drn Dr n (1685–1770 (1685–1770)) o the Chrité Chr ité Hospitl,
Severe dietary measures and purgatives are incapable o curing cancer; and i such a regimen does bring about a diminution o the size o the tumour, as also o the whole body, the cancer rapidly regains its volume as soon as the primitive rigor o the diet has been somewhat relaxed.
wo 18th entury entur y Frenh surgeons me impori mpor-
Breast tumours 171
Pris, tught tht ner o the rest ws lol lesion in its erliest stge, whih then woul spre through the lymphtis to the regionl lymph noes. One there ws involvement o the lymph noes in the xill, the prognosis woul e onsierly worse. Jen-Louis Petit (1674–1750) (see Figure 6.2), rst 6.2), rst iretor o the Frenh Aemy o Surgery, esrie the si tenets o n equte mstetomy – wie exision o the tumour n removl remo vl o the xillry x illry lymph noes. He wrote wrote The roots o the cancer c ancer were the enlarged lymphatic glands; that the gland should be looked or and removed and that the pectoral ascia and even some bres o muscle itsel should be dissected away rather than leave any doubtul tissue. The mammary gland too should not be cut into during the operation. Where the integuments are also aected and strictly joined to the cancer there is little lit tle hope to expect a perect perec t cure i they are not both clearly extirpated ex tirpated together. together.
Over the next entury, mny surgeons vote omplete mstetomy together with removl o the lymph noes in the xill. In 1784, Benjmin Benjmin Bell (1749–1806), surgeon t the Einurgh Royl Inrmry, Inr mry, in his six-volume textook, wrote: ‘Even when only smll portion o the rest is isese, the whole mmm shoul e remove. Te xillry glns shoul e issete y opening up the rmpit ut s muh skin s possile shoul e preserve’. In 1825, Sir Astley Cooper (1768–1841) (see Figure 6.26) wrote 6.26) wrote in his Lectures on the Principles and Practice o Surgery :
Note tht, lrey, the poor prognosis o extensive xillry xillr y involvement involvement ws well reognise. By 1844, Joseph Pnost (1805–1882) (Figure 11.4), proessor o surgery t Jeerson Meil College, Philelphi, ws vising still more ril surgery: involve musle shoul e remove, even ete portions o ris shoul e resete with the utting oreps or sw, n ‘suh o the xillry glns s re suppose to e sirrhous, or re even inurte n enlrge, shoul e tken wy’ (Figure 11.5). Mny experiene surgeons, however, pplle t the erly reurrenes they sw ollowing removl o the rest tumour, wonere whether surgery ws inite t ll in mny ses, n whether, in t, it oen i more hrm thn goo. Roert Liston (1794–1847), proessor o surgery t University College Hospitl, Lonon, n the rst surgeon to operte using ether nesthesi in Engln (see Chpter (see Chpter 7) wrote 7) wrote Recourse may be had to the knie in some cases but the circumstances must be very avourable indeed to induce a surgeon to recommend or warrant him in undertaking any operation or removal o malignant disease o the breast. When the disease has been o
It will be sometimes necessary necessar y to remove the whole breast, where much is apparently contaminated; or there is more generally diseased than is perceived and it is best not to leave any small portions o it, as tubercles reappear in them… i a gland in the axilla be enlarged, it should be removed, and with it all the intervening cellular substance. I several glands in the not axillasucceed be enlarged, their removal does in preventing the return o the disease.
Figure 11.4 Joseph Pancoast. (From Robbins GF: The Breast . Austin, Silvergirl, 1984.)
172 Breast tumours
Figure 11.6 Sir James Paget. (Royal College o Surgeons o England.)
Figure 11.5 Pancoast’s mastectomy technique. (From Pancoast J: Tr Treatise eatise on Operative O perative Surgery . Philadelphia, Carey and Hart, 1844.)
some standing there is a considerable risk o the axillary glands having become contaminated. No-one could now be ound so rash or so cruel as to attempt the removal o glands thus aected.
Tt wise surgeon Sir Jmes Pget (1814–1899) (Figure 11.6), o St Brtholomew’s Hospitl, Lonon, wrote in his Lectures on Surgical Pathology in 1853:
its perormance is justied by the probability that it will in some measure prolong lie and save the patient rom dreadul suering (2) on similar grounds the operation seems proper in all cases in which it is clear that the local disease is destroying lie by pain, prouse discharge or mental anguish, and it is not accompanied by evidence o such cachexia as would make the operation extremely hazardous. (3) In all cases in which it is not probable that the operation will shorten shor ten lie, a motive or its perormance is aorded by the expectation that part o the patient’s lie will be spent with less su ering and in hope, instead o despair, or when they are no longer sensible o their disease there are ew cancerous patients who will not enjoy the hope o long immunity, though it be most unreasonable and not encouraged.
We have come to ask ourselves whether whethe r it is probable that the operation will add to the length or comort o lie enough to justiy incurring the risk or its own consequences. I cannot doubt that the answer may be oten in the armative; (1) in cases o acute hard
On the other sie, there re mny ses in whih the lne is lerly ginst opertion:
cancer, the operation may be rightly perormed though speedy recurrence and death may be expected,
(1) illyInin well-evelope ol persons, it ishroni so littleners, proleespetht the opertion will either to the omort or
Breast tumours 173
to the length o lie tht its risk h etter not e inurre. Tese inee re the ses in whih the opertion my e longest survive, ut they re lso those in whih without opertion lie is most prolonge n lest urene. (2) In ses in whih the hexi or evient onstitutionl isese is more thn proportionte to the lol isese, the opertion shoul e reuse; it is too likely to e tl y its own onsequenes or possily y elerting the progress o ner in orgns more importnt thn the rest. On similr grouns n yet more ertin it shoul not e perorme when there is ny resonle suspiion o internl ner [i.e. the presene o metstses, Hrol Ellis]. (3) I there e no weighty motives or its perormne, the opertion shoul e voie in ll ptients whose generl helth (inepenently o the nerous ithesis)) mkes its risk unusully gret. ithesis Muh o this philosophy, written 150 yers go, is relevnt to surgil prtie toy. Pget went on to show tht in 235 ses he h h n opertive mortlity o 10%, n he si tht he h not seen se where reurrene ws elye eyon 8 yers. He h ollowe ol lowe the lie histories o 139 ptients with sirrhous rinom o the rest or s muh s 9 yers n h oun tht, exept or ew ses, those who h h no opertion live longer thn those who h h surgery. It must e rememere, o ourse, tht in those ys ptients woul rrely present themselves to the surgeon with the smll tumour o 1 m or less tht is so ommonly seen in the linis
Figure 11.7 Patient submitted to radical mastectomy by William Halsted Hal sted in 1912. 1912. Today, Today, this tumour would be regarded as technically inoperable. (From Halsted WS: Developments in the skin-grating operation or cancer o the breast. Journal of the American Medical Association Association 1913; 60, 416.)
whih is still o unknown etiology. He esrie 15 ses o isese o the nipple, ll o whih were ollowe y ner in the unerlying rest, now terme ‘Pget’s isese o the nipple’, n he lso esrie the rrer pre-mlignnt onition o ‘Pget’s isese o the penis’ pen is’.. He serve s oth oth ser jent surgeon to Queen Vitori n s presient o the Royl College o Surgeons o Engln. O ourse, the erly mstetomies were perorme without ny orm o nesthesi n without the enet o ntisepti surgery. One these twin lessings h een introue, mstetomies
toy; hs linil only to photogrphs re the seoesriptions or lookone t the ptients in the lst entury to relise tht the so-lle ‘erly’ rest tumours in the 19th n erly 20th entury were oen tully visile, with skin tthment n oen tully ulerte – so-lle Stge III tumours (Figure 11.7). Pget ws remrkle mn, eminent s pthologist, surgeon n teher. He qulie t St Brtholomew’s t the ge o 22 n spent the whole o his proessionl lie t tht mous meil shool. As stuent, he ws the rst to oserve the prsite richina spiralis in ptient’s musle.
oul e rrie out y mens o reul issetion n without the er o lmost inevitle suppurtion o the woun. Tus, in 1870, Joseph Lister (see Figure 7.15) wrote 7.15) wrote
He the originl esription in 1882 o the quitegve ommon onition o osteitis eormns, more usully terme ‘Pget’s isese o one’,
the dissecting room –where a practice I have or some years adopted the lymphatic glands are aected in the disease.
I have at present a patient about to leave the Inrmary three weeks ater the removal o the entire mamma or scirrhous, all the axillary glands having been at the same time cleared out ater division o both the pectoral muscles so as to permit the shoulder to be thrown back and the axilla reely exposed as is done in
174 Breast tumours
THE DEVELOPMENT OF THE RADICAL OPERA OPERATION TION In Germny, the onept evelope o ner issemintion vi the lymphtis, thnks to the work o Rihr von Volkmnn (1830–1889) o Hle (n erly exponent o ntisepti surgery in Germny) n Lothr Heienhin (1860–1940) o Berlin, who pulishe etile stuy o the spre o rest ner in 1889. Volkmnn himsel, y 1875, ws voting routine removl o the si over petorlis mjor together with the entire rest n n extensive portion o the overlying skin, together with removl o the entire tty tissue o the xill. I the unerlying musle ws oun to the t he tumour, thik lyer o musle ws lso exise. Grully, surgeons were moving to the onept o the ril mstetomy, whose etile tehnique ws evolve y Willy Meyer (1858– 1932) (Figure 11.8) o the New York Hospitl n Willim Stewrt Hlste (1852–1922) (Figure 11.9 n see lso Figure 7.11). Meyer 7.11). Meyer rew ttention to the nger o issemintion o the ner ells in the woun i the tumour ws hnle uring the opertion n in 1894 wrote
Figu re 11.9 Figure 11.9 William Halsted with his ex-residents in 1904 at the Johns Hopkins Hospital. Halsted is seated. Immediately behind him, without a surgeon’s cap, stands Har vey Cushing. To Cushing’s right is JMT Finney, wearing an early pair pai r o surgical gloves. Finney was a pioneer abdominal surgeon, who devised the pyloroplasty operation used today. To Cushing’s Cushing’s let is Joseph Bloodgood, ater whom the ‘blue-domed cysts’ o the breast are named. (From Fulton JF: Harvey Cushing, a Biography . Oxord, Blackwell, 1946.)
Since Heidenhain has shown that in a great number o cases o cancer o the breast the pectoralis major muscle is also involved by the disease and that, i let in place, the growth is more liable to recur, it has become, I believe, the duty o the surgeon always to remove this muscle with the breast and the axillary contents… within the lasttothree yearsonI have operated according this plan six emale patients.
Meyer inlue removl o petorlis minor in his opertive proeure, tehnique lter opte y Hlste. Te lrge woun eet ws trete y skin gring out 8–10 8–10 ys er the initil mstetomy. Hlste i muh to pioneer the opertion o ril mstetomy whih, in the Unite Sttes, ws oen terme the Hlste Hl ste mstetomy. In 1890, he wrote Figure 11.8 Willy Meyer. (From Robbins GF: The Breast . Austin, Silvergirl, Sil vergirl, 1984.) 1984.)
About eight clean years ago began notinonly to typically out Ithe axilla all cases o cancer o the breast but also
The development o the radical operation operatio n 17 175 5
to excise in almost every case the pectoralis major muscle or at least a generous piece o it, and to give the tumour on all sides an exceedingly wide berth. It is impossible to determine with the naked eye whether or not the disease has extended into the pectoral muscle. (Figure 11.10)
By 1898, Hlste ws vising issetion o the suprlviulr noes in the mjority o ses n even removl o the meistinl noes, lthough, in lter yers, he none the suprlviulr prt o the issetion. Hlste ws lso perorming immeite skin gring to the resultnt lrge rw re, hving use the ville skin to over the xillry ontents (Figure 11.11). By 1907, Hlste ws le to emonstrte the well-known reltionship etween the stging o the tumour n its prognosis. In series o 210 ril mstetomies, 60 ptients h xillry xil lry noes tht t ht were shown shown to e negtive or tumour, n 85% o these were live l ive 3 yers lter. In 11 1100 ptients with w ith xil xillr lryy noes involve, survivl roppe to 31%; in 40 ptients in whom oth xillry n suprlviulr noes were involve, the survivl ws only 10%. We hve lreyy note, o ourse, tht mny o Hlste’s solre lle ‘erly ses’ re wht we woul regr toy s lolly vne tumours, tu mours, n it is not surprising, thereore, tht there ws n overll 64% eth
Figure 11.11 A patient operated upon by Halsted. The massive skin deect was allowed to heal by granulation tissue or else grated.
rte with lol or istnt reurrene within 3 yers o mstetomy mste tomy.. Willim Stewrt Hlste ws n extrorinry mn. I hve lrey esrie his ontriution to septi surgil tehnique y the introution o surgil gloves n his work on lol nesthesi (Chpter 7). He 7). He lso me importnt vnes in other els: herni surgery, intestinl nstomosis n metiulous hemostti metho o opertive surgery. However, he ws unwre o the hitorming nture o oine n ws wene o his ition to the rug only y reverting to morphine n ws, or the rest o his lie, n ltere person, oen in inierent helth. Hrvey Hr vey Cushing (1869–1939) (Figure (Figure 11.9), 11.9), one o the thers o neurosurgery, n Hlste’s resient or 3 yers in Bltimore, wrote er Hlste’s eth:
Figure 11.10 The Halsted radical mastectomy. (From Halsted WS: The results o operations perormed or the cure o cancer o the breast per-
A man o unique personality, personalit y, shy, shy, something o a recluse, astidious in his tastes and in his riendships, an aristocrat in his breeding, scholarly in his habits, the victim or many years o indierent health, he nevertheless was one o the ew
ormed at the Johns Hopkins Hospital rom June 1889 to January 1894. Johns Hopkins Hospital Bulletin 1894–1895; Bulletin 1894–1895; 4, 297.)
American who may be considered to surgeons have established a school o surgery comparable, in a sense, to the
176 Breast tumours
school o Billroth in Vienna. He had ew o the qualities supposed suppos ed to accompany what the world regards as a successul surgeon. Over modest about his work, indierent to matters o priority, caring little or the gregarious gatherings o medical men, unassuming, having little interest in private practice, he spent his medical lie avoiding patients – even students when this was possible – and, when health permitted, working in clinic and laboratory at the solution o a succession o problems which aroused his interest. He had that rare orm o imagination which sees problems, and the technical ability combined with persistence which enabled him to attack them with promise o a successul issue. is sue. Many o his contributions, not only to his crat but to the science o medicine in general, were undamental in character and o enduring importance.
Figure 11.12 Sampson Handley. (Royal College o Surgeons o England.)
At out this time, Smpson Hnley (1872– 1962) (Figure 11.12) o the Milesex Hospitl, Lonon, pulishe his monogrph on Cancer o the Breast and Its Operative reatment . His philosophy ws to et the therpy t herpy o rest ner over the next hl entury n ertinly eeply inuene Hlste. Tis ws the ner permetion hypothesis – tht rest ner spres entriuglly, primrily in the plne o the suutneous tissues n long lymphtis (Figure 11.13). Bloo ws onsiere to the e lymphti unimportnt; one spre ourre y wy o plexus o the eep si, n even intr-ominl spre ws ue to permetion long the sheth o the retus musle o the ominl wll. It ws this onept tht le to the eeling tht, i only suiently wie sweep oul e me roun the tumour, the hnes o ure oul e inrese. Hnley himsel not only employe very wie ril mstetomy ut lso, rom 1920 onwrs, implnte rium neeles into the nterior interostl spes to el with the internl mmmry mmmr y lymph noes. Te pprent logil extension o these ptho-
Figure 11.13 Sampson Handley’s diagram o the area to be removed or adequate clearance
logil nings wsril to ttempt to inrese the rility o the mstetomy. Erling Dhl-Iverson (1892–1978) t the Rigshospitlet,
in breast cancer. The labels ABCD denote the extent o the skin incision in relation to N (nipple) (nipple) and P (tumour). (tumour).
The development o the radical operation 17 177 7
Copenhgen, in 1951 perorme n extrpleurl issetion o the internl mmmry noes, s i Mrio Mrgottini (1897–1970) o the Ntionl Cner Institute, Rome, the ollowing yer, while Owen Wngensteen (1898–1981) in Minnepolis vise splitting the sternum to remove the internl mmmry noes n issetion o the noes ove the lvile. But it ws Jerry Urn (1914–1991) t the Memoril Hospitl, New York, who perete mssive opertion tht omine ril mstetomy with en lo resetion o the internl mmmry hin y removl removl o prt o the sternum together with the inner ens o the seon to the h ri n with repir o the resultnt eet with si tken rom the thigh. Tis opertion took out 5 hours n require on verge three-pint loo trns t rnsusion usion (Figure 11.14). 11.14). So, or the rst hl o the 20th entury, the onept o entriugl entriug l spre o rest ner hel swy n with it the ult o ril mstetomy. Inee, ny progress seeme to epen on eveloping still
more ril ltions o the rest n its surrouns. It hs only een in omprtively reent yers tht the evelopment o ontrolle linil trils hs shown tht survivl ers no reltionship to the rility o the surgeon. Te permetion theory o spre o the tumour hs long sine een isple y the relistion tht it is loo-orne issemintion o the tumour tht is the vitlly importnt lue to prognosis. Tis in turn hs me us relise tht the nswer to progress in rest ner lies not with still more ril mstetomies ut hs two ims in min: rst, equte ontrol o the lol isese n, seon, the prevention or tretment o seonry spre o the tumour. Even in those erly ys there were osionl pioneers, usully regre s ngerous heretis, who were rey to try less mutilting proeures. Roert MWhirter (1904–1994) (Figure 11.15), proessor o riotherpy t the Einurgh Royl Inrmry, trete series o 757 ptients etween 1941 n 1945 y simple mstetomy ollowe y
Figure 11.14 The chest-wall deect let by Urban’s super-radical mastectomy. (From Urban
JA: Radical mastectomy in continuity with en bloc resection o the internal mammary lymph node chain. Cancer 1952; 1952; 5, 992.)
Figure 11.15 Robert McWhirter. (Royal College o Surgeons o England.)
178 Breast tumours
riotherpy. He ompre these ses with 411 ptients trete y ril surgery together with post-opertive riotherpy etween 1935 n 1940 n showe, i nything, tht survivl ws greter in the more onservtively trete group. I rememer well, s young surgeon, just not elieving tht nyone woul re not to o ril mstetomy on ptient with rest ner n, i he i, tht he shoul hve the temerity to lim tht his results resu lts were t lest no worse thn oul e otine y the ril opertion. Menwhile, Dvi Ptey (1899–1977), t the Milesex Hospitl, ws experimenting with preser vtion vtio n o petorlis mjor, mjor, exept exept in those ew ses where it ws inve y the tumour. In 1948, he reviewe his mstetomies perorme etween 1930 n 1943. Compring his ril mstetomies with ptients trete y his moie opertion, now oen lle the Ptey mstetomy, he showe there ws no ierene in the survivl rte or lol reurrene rte etween the two groups. Prophetilly, he wrote Until an ecient general agent or the treatment o carcinoma o the breast is developed, a high proportion o cases are doomed to die o the disease whatever combination o local treatment by surgery and irradiation is used, because in such a high proportion o cases the disease has passed outside the eld o local attack att ack when the patient rst comes or treatment.
perhaps in combination with conservative surgery, or treating cancer o the breast in i n its it s earlier stages. (Figure 11. 11.16 16))
Keynes’ results were entirely omprle with those otine y mstetomy, ut unortuntely his work ws interrupte y the outrek o the Seon Worl Wr, when he joine the Royl Air Fore, n the supplies o rium were isperse euse o the ngers o ir ris on Lonon. Interestingly enough, er the wr, review o the lte results o his ses showe tht these were omprle to those otine y ril surgery. However, o ourse, there ws signint gin in the qulity o lie o these ptients (Figure ( Figure 11.17). Rition therpy in the tretment o erly rest ner ws pioneere t the Curie Institute in Pris P ris roun 1936. In reent yers, pulishe results rom mny mjor entres hve enourge surgeons n riotherpists roun the worl to use lol exision o the tumour omine with riotherpy s sustitute or mstetomy. Te survivl rte or women trete y this tehnique hs een shown, in numerous trils, to e extly ext ly omprle to tht
Long eore these linil experiments, however, still more unonventionl orm o tretment ws eing evelope t St Brtholomew’s Hospitl, Lonon. Aer the First Worl Wr, Georey Keynes (1887–1 (1887–1982), 982), who we hve lrey lre y met s pioneer o loo trnsusion (Chpter (Chpter 9), 9), returne to Brt’s n investigte the use o the newly evelope rium neeles in the tretment o vne n inoperle rest ner. By 1927, he ws le to report 5-yer experiene in whih he h shown tht goo lol ontrol o the isese oul oen e otine. o quote his own wors: Having satised mysel that radium
Figure 11.16 Georey Keynes ‘technique o
could successully diseasebe wasused beyond surgery, Iwhen beganthe to wonder whether it might not be used,
radium implantation’. (From Keynes G: The radium treatment o carcinoma o the breast. British Journal of Surgery 1931–1932; 1931–1932; 19, 425.)
The treatment o the advanced disease 17 179 9
Figure 11.18 An early example o treatment o breast cancer by irradiation ir radiation (1908). The French radiotherapist wears no protection rom the X-rays. Many o these early pioneers, including includi ng Madame Marie Curie hersel, developed serious complications that included skin cancer and aplastic anaemia.
THE TREATMENT OF THE ADVANCED DISEASE
Figure 11.17 Patient treated by Keynes with radium implantation: (a) early result, (b) 7 years ater treatment. (From Keynes G: The radium treatment o carcinoma o the breast. British Journal of Surgery 1931–1932; 1931–1932; 19, 425.)
Brest ner shres with prostti tumours the strnge phenomenon phenomenon tht, in mny ses, the growth g rowth is sensitive to hnges in the sex hormone environment. George Betson (1848–1933) in Glsgow reporte regression o vne rest ner in ptients in whom he h remove the ovries. Hugh Lett (1876–1964) o the Lonon Hospitl reviewe 99 ptients thus trete; in spite o spetulr erly response to oophoretomy in severl, only one ptient h reltively long n omplete response.
whih is hieve y mstetomy, n this is not iult to unerstn. Deth rom rest ner results not only rom the lol isese ut lso rom rom the eets o seonry spre o the tumour. One the primry primr y lesion hs een ontrolle, ontrolle, whether this is y lol exisio exision, n, riotherpy or the most ril r il surgery tht surgeons n evise, the ptient’s te epens on whether or not su-linil issemintion o the isese h tken ple eore the pri-
Te isoltion o Huggins ortisone (1901–1997) s replement therpy llowe Chrles to perorm ilterl removl o the suprrenl glns ( (renlrenletomy) together with oophoretomy in 1952. Te rtionle o this proeure is tht, er removl o the ovries, the suprrenl ortex is soure o the emle sex hormone oestrogen. Huggins reeive the Noel prize in 1966, one o only nine surgeons ever to reeive this wr. wr . Lter, removl o the pituitry gln ws employe. In lrge series o ses, regression o isseminte rest isese woul e oun in out thir o ses ollowing these proeures, proeur es, some with quite rmti responses. In
mry lesion ws remove. Teinmens yeie whihthis the tumour is trete lolly n no wy vitl issue (Figure (Figure 11.1 11.18) 8)..
reent the evelopment new hormonl yers, gentshowever, n o ytotoxi nti-neor rugs nti-ner hs me these mjor surgil proeures osolete.
12 Cutting for the stone Te three ‘eletive’ opertions (tht is to sy, those rrie out or resons other thn the emergeny re o wouns n injuries) perorme rom the erliest ys o surgery were trephintion o the skull, irumision n utting or the ler stone. Te rst two were onsiere in Chpter 1, 1, irumision s ritul, religious, ertility or initition rite n trephintion, ertinly in mny ses, perorme or somewht mystil resons. Cutting or ler stone my thereore sely e pronoune s the most nient opertion unertken or the relie o spei surgil onition. Te olest ler stone so r isovere ws otine rom the grve o oy ge out
16 yers in the pre-histori emetery t El Amrh in Upper Egypt n ws te t out 4800 bc. It ws presente y its isoverer, Proessor Elliot Smith, to the museum o the Royl College o Surgeons o Engln (Figure 12.1). S to relte, this unique speimen ws estroye when the ollege ws ome in 1941. Desriptions o mens to relieve the ptient o the gonies o his ler l er stone hve ome own to us in nient writings. Inee, speilist spe ilistss must hve lrey een in existene in Anient Greee in the 4th n 5th enturies bc, sine in the Hipporti Oth, it is mentione tht the tretment o ptients with stone is to e le in their hns. ‘I will not ovet persons louring uner the stone, ut will leve this to e one y men who re prtitioners o this work’. Tere re three possile surgil pprohes to remove stone rom the ler: rst y utting own on to the se o the ler through the perineum, immeitely in ront o the retum; seon y pssing rushing instruments into the ler long the urethr; n thir y opening the ler through the lower omen. Eh o these pprohes hs long history stue with oth suesses n ilures.
PERINEAL LITHOTOMY
Figure 12.1 Bladder stone dated 4800 bc. The specimen was destroyed when the
Hunterian museum at the Royal College o Surgeons o England was severely damaged by a bomb in 1941.
Opening the ler through the perineum to remove ler stone (lithos, stone, otomy , to mke n opening openi ng into) ws prtise prtis e y the nient Hinu surgeons, the Greeks, the Romns n the Arins. Ammonius Alexnri rrie out the opertion out 200obc. Te Romn enylopeist Celsus (25 bc –50 ad) gve n exellent 181
182 Cutting or the stone
esription o the opertion in the 1st entury ad. He vise tht the opertion shoul only e perorme on hilren etween the ges o 9 n 14. Severl ys were rst spent on light or sting iet. Te ptient ws then instrute to wlk n jump out so tht the stone woul esen e sen to the nek o the ler. Te hil ws hel in the lp o strong n intelligent person who steie the ptient y pressing his hest ginst the hil’s shouler les (Figure 12.2). Te opertor stoo or st ing his ptient n inserte two ngers o the le hn (well ippe in oil) into the nus. Te right hn ws presse on the lower omen, pushing the ler n n thus oring the stone into the grip o the le inex nger within the retum so s to proue ulge in the perineum. An inision ws me in ront o the nus n rrie eeply into the region o the ler se; the t he stone
ws then pushe out y the nger in the retum. It might e neessry t this stge to use hook to isloge the stone. Te woun ws then resse with wool n wrm oil (Figure 12.3). Te Hinu surgeon Susrut o Benres gve goo esription o this opertion. Unortuntely, there is still ontroversy onerning the perio when he thrive, n his works hve een ttriute to tes tht rnge rom the 6th entury bc to the 6th entury ad. His instrutions were very similr to those o Celsus, ut he went into metiulous etil, suh s tht the surgeon shoul rst ensure tht his ngernils were losely ut. Aer extrtion extr tion o the stone, the ptient ws to e ple in th o wrm wter, n hemorrhge ws trete y irrigtion o the ler y mens o syringe.
Figure 12.3 The operation o the apparatus Figure 12.2 A child held in the lithotomy position. (From Ellis H: A History of Bladder Stone. Stone. Oxord, Blackwell, 19 1969 69.) .)
minor; the only requirements were a knie and a hook. (From Ellis H: A History of Bladder Stone. Stone. Oxord, Blackwell, 19 1969 69.) .)
Perineal lithotomy 183
Tis simple opertion, whih involve the use o no speil instruments, merely knie n perhps pir o oreps or hook to help extrt the stone, eme known s the lesser opertion or the pprtus minor. Antomilly, it involve involve opening the se o the ler immeitely ove the prostte, n it ws or this reson tht the opertion ws usully vise only or young oys, sine these sujets woul hve only only smll sml l prostte gln. Aout 1520, new tehnique o lithotomy ws introue y the Itlin surgeon Frnisus e Romnis o Cremon. Tis ws pulishe y his pupil, Mrinus Sntus (1490–1550), in 1522, so tht the proeure me to e esrie s the Mrin opertion. It ws lso terme the greter opertion or the pprtus mjor euse o the itionl instruments to e employe. Te pln o the proeure ws to pss groove st into the ler long the urethr n susequently to ut own upon this instrument, so tht yet nother nme or the opertion ws ‘utting on the st’. A vertil inision ws me in the miline onto groove in the st to open the urethr. Tis T is
woun ws then ilte, using series o instruments tht woul ter through the prostte n ler nek (Figure 12.4). Stone-holing oreps with two, three or our les were then psse into the woun to remove the stone, or, i this prove to e too lrge, it ws rst rushe with lrge oreps n the rgments remove with the soop or hook. Tose who survive the initil hemorrhge n sepsis were oen inontinent o urine with persistent rining n inete sinuses, n impotene ollowing the opertion ws not unommon. It seems inreile to us in these ys o smooth n n potent nesthetis tht nyone oul possily possily sumit himsel willingly wil lingly to suh torture. It ws, inee, only the terrile n protrte gonies proue y stone in the ler tht gve men suient ourge to ple themselves uner the lithotomist’s ruel instruments. One the ptient onsente to the opertion, there ws then the prolem, o ourse, o keeping him still enough to e ut or the stone. Tis usully ment trussing him up n using three or our strong ssistnts to hol him still (Figure ( Figure 12.5). 12.5). Te ol surgil writers esrie in epth the
Figure 12.4 The instruments or the operation o the apparatus major. (From Heister L : General System of Surgery . London, 5th English Engli sh edition, 1753.) 1753.)
184 Cutting or the stone
Figure 12.5 The surgeon and his three assistants or the apparatus major operation. The patient is in the lithotomy position. The surgeon’s instruments are conveniently at hand in his waist pouch. (From Heister L: General System of Surgery . London, 5th English Engl ish edition, 17 1753.) 53.)
re n preutions in ining n holing the ptient in the lithotomy position. Tus, the gret Amroise Pré, in 1575 1575,, wrote The patient shall be placed upon a rm table or bench with a cloth many times doubled under his buttocks, and a pillow under his loynes and back, so that he may lie hale upright with his thighs lited up and his legs and heels drawn back to his buttocks. Then shall his eet be bound with a ligature o three ngers breadth passed about his ankles,
or their ility on the rugy el stems rom the ys when it ws proly neessry to hoose one’s young ssistnts or rwn eqully well s rin? Te next step in the history histor y o lithotomy is perhps one o the strngest; it onerns the evelopment o the lterl perinel pproh to the ler y meilly unqulie Frenhmn o humle origin. Jques Beulieu ws orn in 1651, the son o poor pesnts, t Beuort in Burguny. He ws perhps inspire to surgery when s oy he ell ill n while in hos-
and with the heads thereo being drawn upwards to his neck, and cast about it, and so brought downe-wards, both his hands shall bee bound to his knees. The patient thus bound, it is t t you have oure strong men at hand; that is, two to hold his armes, and other two who may so rmely and straightly hold the knee with one hand, and the oot with the other, that he may neither move his limmess nor stirre his buttocks but be orced to keep the same posture with his whole body.
pitl itollehetught oulhow to help other Aer ptients n egge to lee. serving in the vlry s trooper, he le the rmy t the ge o 21 n eme pprentie to n itinernt Itlin surgeon, Puloni, who ws ut or the stone. In 1690, he hnge his nme to Frère Jques (Figure (Figure 12.6), opte 12.6), opte the hit o monk (lthough he never trine or the hurh), n in turn eme n itinernt lithotomist. In 1697, t the ge o 46, he rrive in Pris n pplie or permission to ut or the stone. Te surgeons t the Hôtel Dieu orere tht he rst emonstrte his skill on ver in whom stone h een
Coul it e tht the trition tht hs ie so hr in our meil shools o seleting stuents
introue into the ler vist the omen. He psse soli grooveless metl into the ler, then inise the perineum two ngers meil mei l
Perineal lithotomy 185
to the tuer ishii, rrying the ut orwr rom the sie o the nus. Te stone ws elt y nger in the woun, iltor ws psse into the ler n the t he stone remove y oreps. Susequent issetion y Méry, surgeon to the Hôtel Dieu, revele tht the inision h psse etween the ishio-vernosus n the ulovernosus musles, then through the prostte n the whole
with stone in the ler. Cure oure within 3 weeks, n Louis XIV ws so impresse tht he gve instrutions tht Frère Jques e loge with the Royl vlet n e given the King’s Liene to prtise. A short perio o suess ollowe, with its inevitle populrity, so tht gur o soliers ws require to keep the mss o spettors who rowe roun in some sort o orer. However, series o issters then eell the surgeon. From April to July 1698, he rrie out lithotomies in the Hôtel Dieu n t the Chrité: o these 60 ptients, 13 were ure n the rest remine in hospitl with inontinene, stule or other omplitions. No less thn seven ie in 1 y t the Chrité so tht Frère Jques ws tully riven to using the monks o poisoning his ptients. Post-mortem, however, revele no eviene o poison ut i emonstrte lers ut through in mny ples, the retum injure, the urethr ut o rom the ler se, the vgin lerte or mjor rteries ivie. Tt yer Frère Jques le Pris n resume his wnerings through Frne n Holln. Eventully, he returne to Versilles, where he ollorte with Fgon, surgeon to the king, n rom whom he proly lerne some muh neee ntomy. Experiments were rrie out on mny oies, s result o whih the originl opertion ws moie n groove st employe; 38 opertions were perorme t Versilles in 1701 without eth – remrkle reor (Figure (Figure 12.7). 12.7). Fgon ws not ispssionte in his interest in this proeure sine he himsel loure uner stone
length thethe nek o theitsel. ler n thene n inhointo ler In spite o the hl stistory opertion, the or reuse to grnt liene; this ws proly euse Frère Jques pi no ttention to the ritul o preopertive leeing or purging, n use no stringents, ut stte tht he relie inste on Go to hel the woun. Lterl lithotomy, even in this rue orm, ws ser thn the miline proeure in ults, sine it gve wier ess with less tissue trum. Moreover, the pre- n post-opertive tretment use y others t this time ti me proly i more hrm thn omplete onservtism!
in the ler. ith intht Frère wsshoul emonstrte y hisHis request hisJques ollegue remove his stone. Tis ws orien y the mily n the opertion ws eventully perorme y Mrehl. Another risis ourre in 1703 when he ws onsulte y the Mrehl e Lorges, utious mn, who rst wthe Frère Jques operte upon 22 poor ptients, ll o whom survive, eore sumitting himsel to lithotomy. All ws in vin, sine Mrehl suume suu me er surgery. surger y. Yet Yet gin, Frère Jques took to the ro, to Amsterm, Brussels, Genev, Nny, Liège, Strsourg, Vienn, Venie,
Frère Jques, his liene reuse, to Fontineleu where the ourt ws intrvelle resiene. Here he ws llowe to operte on shoemker
Pu n Rome. Hisretire prtie y no villge mens unsuessul, n he to ws his ntive t 69, ying there in 1714 welthy mn, n
Figure 12.6 Frère Jacques. He wears a priest’s habit and carries a bladder sound. This portrait hangs in the Royal College o Surgeons o England.
186 Cutting or the stone
Figure 12.8 Patient in the lithotomy position with sound in place. The position identical to that used by the early lithotomists was still employed in the 19th century. (From Thompson H: Practical Lithotomy and Lithotrity. Lithotrity. London, London, Churchill, 1863. 1863.))
Figure 12.7 Frère Jacques operating. (From Desnos E: Histoire de L’Urologie ’Urologie.. Paris, Doin, 1914.)
leving most o his money to vrious hrities. Tis remrkle surgeon is si to hve operte upon 4,500 ptients or ler stone n nother 2,000 or herni. herni. Te opertion o Frère Jques ws tken up n moie y Willim Cheselen (1688–1752), who ws ertinly the gretest lithotomist proue in Engln, i not in the worl, n who we hve lrey met in Chpter 6 6 (see Figure 6.10). As 6.10). As n expert ntomist, he me reul issetions n lerly esries the surgil ntomy o the lterl opertion: This operation I do in the ollowing manner: I tie the patient as or the greater apparatus, but lay him upon a blanket several doubles upon an horizontal table three eet high, with his head only raised (Figure I rst make as long an incision as 12.8). I can (Figure 12.9) beginning near the place where
Figure 12.9 The incision in the perineum advised by Sir Henry Thompson or lithotomy. The dotted line represents the skin incision and the continuous line the cut through the base o the prostate. This diers little rom the approach used by Cheselden Ches elden some 200 years earlier. (From Thompson H: Practical Lithotomy and Lithotrity . London, Churchill, Churchi ll, 1863.)
the old operation ends, cutting down between the musculus accelerator urinae and erector penis and by the side o the intestinum rectum colon. I then eel or while the sta, gut all the withholding one ordown two the ngers o my let hand and cut upon it in that
Perineal lithotomy 187
part o the urethra which lies beyond the corpora cavernosa urethrae and in the prostate gland cutting rom below upwards, to avoid wounding the gut; and then passing the gorget very careully in the groove o the sta into the bladder, bear the point o the gorget hard against the sta, observing all the while that they do not separate and let the gorget slip to the outside o the bladder; then I pass the orceps into the right side o the bladder, the wound being on the let side o the perinaeum; and as they pass, careully attend to their entering the bladder, which is known by their overcoming a straightness which there will be in the place o the wound; then taking care to push them no urther so that the bladder may not be hurt, I rst eel or the stone with the end o them, which having elt, I open the orceps and slide one blade underneath it and the other at the top; and i I apprehend the stone is not in the right place in the orceps, I shit it beore I oer to extract, and then extract it very deliberately so that it may not slip suddenly out o the orceps, and that the parts o the wound may have time to stretch, taking great care not to grip it so hard as to break it and i I nd the stone very large, I again cut upon it as it is held in the orceps.
not stick too long in the wound, and all the dressings during the cure are very slight, almost supercial, and without any bandage to retain them; because that will be wetted with urine and gall the skin. At rst I keep the patient very cool to prevent bleeding, and sometimes apply a rag, dipped in cold water to the wound, and to the genital parts, part s, which I have ound very useul in hot weather particularly. In children it is oten alone sucient to stop the bleeding, and always helpul in men. The day beore the operation I give a purge to empty the gut and never neglect to give a laxative medicine, or clyster a ew days ater, i the belly is at all tense, or i they have not a natural stool.
Cheselen pulishe the ollowing sttistis: ‘213 ptients ut t St Toms’ Hospitl, o the rst 50 only three ie. O the seon 50, three; o the thir 50, eight; n o the lst 63, six. Severl o these ptients h the smllpox uring their ure, some o whom ie, n these re not rekone mong those who h the opertion’. Te reson why so ew ie in the two rst 50s, Cheselen expline, ws tht t tht time very ew ses were oere the opertion, wheres lter, the opertion eing in gret emn, even the most ge n most miserle ses expete to e sve y it. Cheselen ens this remrkle oument y sying:
Here I must takethe notice, it is very convenient to have bladder empty o urine beore the operation, and i there is any quantity to fow out o the bladder at the passing in o the gorget, the bladder does not contract, but collapses into olds, which makes it dicult to lay hold o the stone without hurting the bladder, but i the bladder is contracted it is so easy to lay hold o it that I have never been delayed one moment, unless the stone was very small. Lastly, I tie the blood vessels with
I I have any reputation in this way I have earned it dearly, or no one ever endured more anxiety and sickness beore an operation, yet rom the time I began to operate, all uneasiness ceased; and i I have had better success than some others, I do not impute it to more knowledge but to the happiness o mind that was never rufed or disconcerted, and a hand that never trembled during an operation.
the help odressing a crooked needle, no other than a littleand bituse o lint besmeared with blood, that it may
omy ws still ( Figure o (Figure 12.10), 12.10), in lter yers, o eing ourse,perorme with the enet generl nesthesi.
Right up to the 20th entury, perinel lithot-
188 Cutting or the stone
Figure 12.10 Thompson’s illustration o lateral lithotomy. The original subtitle reads ‘Anatomy o parts interested in lithotomy. Mr Bagg has represented this very careully or me rom a dissection made expressly or the purpose’. (From Thompson H: Practical Lithotomy and Lithotrity . London, Churchill, Churchil l, 1863.)
SUPRAPUBIC LITHOTOMY
inee, tke his vie n tht o Hipportes eore him, who stte tht wouns o the ler were invrily tl. Other ojetions rise to the high opertion, s it ws lle, were tht urine rom the ler woul ow into the ominl vity, tht n inision into the ler woul not hel n tht intestines woul prolpse through the ominl woun. Inee, it ws not until the 18th entury tht Johnn Bonnet ws reporte to hve rrie out the suprpui opertion requently n with suess t Hôtel Dieu in Pris. Te thir surgeon to operte with suess ws Jn Groenvelt, Duth surgeon who settle in Lonon, hnge his nme to Greenel n, in 1710, wrote I once had a patient in Long Lane Moorelds, upon whom I was obliged to perorm this high operation and very successully extracted the stone making the incision near the groin, the patient soon recovering; which shows that wounds in the brous part o the bladder are not always mortal.
Te suprpui pproh to the ler vi low miline ominl inision, with the ler istene to push wy the peritoneum, is the usul open metho employe in the removl o ler stone toy. toy. It omines simpliity with the vnv ntge tht ny ssoite normlity within the ler n e elt with wit h t the sme time. Its story goes k over 400 yers. Te rst reore opertion o this kin ws rrie out y Pierre Frno (?1500–1561). As Protestnt, he ws ore to ee rom Frne n
Jmes Dougls, who esrie the pelvi peritonel pouh tht now rries his nme, stuie the ntomy o the surgil pprohes to the ler in 1717. His rother, John Dougls (ie . 1742), relise tht t ht the ler oul e opene extrperitonelly ove the puis when in the istene stte, rrie out the opertion in 1719 n pulishe ook on the sujet in 1720 tht rejoie in the title o Lithotom Lithotomia ia Douglassiana, or n ount o
prtise his in Lusnne lthough he lling eventully returne intoSwitzerln, Ornge in Frne to prtise. In the yer o his eth, he gve n ount o n opertion on hil o out 3 yers o ge who h stone in the ler out the size siz e o hen’s hen’s egg. He ws w s unle to remove the stone vi the perinel pproh euse the enormous stone oul not e pushe own into the nek o the ler. Te hil hil’s ’s prents egge him to try to relieve the smll ptient o his suerings, so he thereore pushe the stone up into the groin with his ngers in the retum, got his ssistnt to x the stone in this sitution n then ut own
new metho o mking high opertion to extrt the stone out o the ler. Tis is muh esier to the ptient, muh sooner one y the opertor, n the ure more ertin thn er ny o the other methos now in use. By whih severl o the most isml onsequenes o the ommon opertions re entirely prevente, suh s inontineny o urine, impoteny,, stule, impoteny stul e, et., were invente n suessully perorme y John Dougls, surgeon. Dougls ully reviewe pulishe ounts, oth or n ginst, tht preee his own work, then etile his suprpui pproh into the istene ler. He writes
immeitely the puis the lulus. Te little ptient ove reovere, ut into Frno vise others not to ollow his exmple! Most surgeons i,
My patient was wa s between betwee n 15 and 17 years o age and was cut two days beore last
Suprapubic lithotomy 189
Christmas and in a month’s time the wound was perectly Sicatrize’d, (i.e. healed). The operation was over in one minute and I believe will never n ever be above two. He now perorms all his natural aculties as well as he had never been troubled with the stone. There were two physicians, two surgeons, and an apothecary present at the operation but to save them the trouble t rouble o answering every little prig’s impertinent question I don’t think it is proper to mention them.
Te stone is illustrte in Dougls’ ook n mesure out 2 inhes y 1½ inhes. Avntges o this new opertion s liste y Dougls were: voine o impotene, inontinene n stul, no exessive loss o loo euse there ws no osion to ut ny o the gret vessels n no onsierle ore eing require to extrt the stone euse the inision oul e me s lrge s neessry. Tree o the rst our ptients operte upon y Dougls reovere sely. Dougls, who h eite his monogrph to the trustees n meil st o the Westminster Inrmry, oere his servies to tht institution on 21 Novemer 1721, n they were grteully epte; he eme onsultnt surgeon n the rst lithotomist on its st. At his own expense, he got the trustees o the Inrmry to pulish the ollowing vertisement on 7 Mrh 1722:
yer. Mr John rustrm, lerk to the Worshipul Compny o Brers, hs kinly sent me this extrt rom the Compny’s minutes o 26 April 1723: It is ordered that Mr John Douglas Surgeon and oreigne brother o this Company shall be admitted into the reedom and Livery o this Company and be discharged and acquitted rom holding or paying any ne or his reedom or Livery, or or all or any oces to the Parlour door as a Compliment to him or introducing the new method o Cutting or the Stone and to express the sense this Court hath o the useullness thereo.
In 1724, Dougls ws me Freemn o the City o Lonon. However, s we shll soon see, the high opertion ell into isvour, n in tht sme yer, he ws reple y Cheselen s lithotomist to Westminster. Te high opertion ws tken up with enthusism y Willim Cheselen in 1722, n he esrie the proeure in etil in his reatise on the High Operation or the Stone pulishe in 1723. In this he reully illustrte how the ler, when istene with wter, strips the peritoneum ove the puis, thus llowing itsel to e opene extrperitonelly (Figure (Figure 12.11). o 12.11). o ll the ler, he evise n ingenious syringe tthe to metl theter t heter y length o ox’s ureter. Beore opertion, the owel ws emptie y orering
A short ut rillint perio o me now ell
slener ietor out 2 ys, n lysters n (enems) ems) were given little eore the opertion. Te(en ptient ws lin on the e or on quilt ple upon tle, with his legs o the e n his thighs th ighs rise. A theter ws psse, n s muh rley wter s woul ll the ler to its utmost istension ws injete. An ssistnt grspe the penis to pre vent reux o wter, the theter ws withr withrwn wn n the ssistnt ontinue to ompress the urethr. Te rst inision ws me with rounege knie through skin n t n ontinue etween the reti own to the ler. A 4-inh inision ws vise or the ult. Te ler ws
to Dougls. He ws elete Fellowtheoreeom the Royl Soiety in Jnury 1722 n given o the Compny o Brer-surgeons the ollowing
then expose with stright slpel opene y mens o rooke knie while then wter owe out o the inision. A nger ws introue into
Notice is hereby given to the poor troubled with stone in the bladder that they will be received at the Inrmary in Petty France, Westminster, in order to there cure at all seasons o the year, without any other recommendation than a certicate under the hand o Mr John Douglas, surgeon, in Fetter Lane, Lithotomist to the said Inrmary.
190 Cutting or the stone
Figu re 12.11 Figure 12.11 Cheselden’s dissection to demonstrate that the distended bladder (A) extends extraperitoneally above the pubis. Illustrated also is his catheter (V) with its attached length o ox ureter (D). (From Cheselden W: Tr Treatise eatise on the High Hig h Operation for Stone. Stone. London, 1723.)
the ler inision, long whih very thin oreps ws irete to seize the stone. Te woun ws resse with so ompresses, kept on with loose nge n hnge every 6 hours until urine ese to ishrge. Cheselen reports on nine ptients ut in this wy. All were mle, with ges vrying rom 4 to 19 yers. Tere ws only one eth – John Clrk,
only with iulty or even lerte, n sometimes, the ler itsel urst rom injeting too muh wter. In 1737, 1737, t the very height heig ht o his me, Cheselen C heselen retire rom ll his previous hospitl ppointments n eme resient surgeon to the Royl Hospitl, Chelse, home, o ourse, o the Chelse Pensioners. He ie in 1752, his rther suen
o Brintree o h Essex, 18,stones who ws ut on He 12 July 1722 n twoge lrge remove. evelope heti ever ollowe y irrhoe n ie 25 2 5 ys post-opertively. pos t-opertively. At post-mortem, the woun n ler were helthy ut the right kiney ontine our ounes o pus n ten stones, with, in ition, one very lrge stone in the ureter on the sme sie. Only yer er the pulition o his ook, however, Cheselen ws no longer enthusisti or the ominl opertion, n he returne to his work on improving the perinel lithotomy, s lrey esrie. No out this ws s the
eth eing hot uns. Histtriute tom ntoerinking seen to le thiser y eting in the grouns o the Royl Hospitl. By 1850, Murry Humphry, o Aenrooke’s Hospitl, Cmrige, in perorming suessul suprpui opertion on oy o 14, oul ollet only 104 pulishe ses o this proeure, o whih no less thn 31 were tl. Te mjority h een perorme or very lrge stones. It ws not until the en o the 19th entury, orresponing to the looming o ominl surgery, in generl, tht the suprpui opertion egn to eome the routine n se proeure
result o issters nwhih ner the issters in his own n other hns in peritoneum ws opene, intestine prolpse n ws returne
it toy. For toy. this to–hppen, t he two the oons oismoern surgery nesthesi ngret sepsis – were require.
Transurethral lithotrity 19 191 1
TRANSURETHRAL LITHOTRITY Troughout the enturies, ptients tese y the gonies o ler stone n surgeons isstise with the iulties n ngers o utting or the stone reme o some mens o removing the lulus through the nturl pssge rom the ler – the urethr. Te nient Egyptins woul ilte the urethr y mens o wooen tue, the thikness o the thum, pushe in with onsierle onsier le ore lternting with w ith lowing own the urethr. Te stone ws presse ginst the tue y ngers in the retum n suke out. Whether this sueee or not is mtter o on jeture. jetu re. A numer o ptients exper experimente imente on themselves; one introue long nil into his ler, impinge the en upon the stone n struk hr with lksmith’s hmmer to split it. Generl Mrtin o Luknow isintegrte the stone in his ler in 1783 y 9 months o stey work using ne urve le. le. Sir Astley Cooper, o
Figure 12.12 Jean Civiale; medallion by David d’Angers.
Guy’s Hospitl, esrie how he remove multiple smll stones rom the ler, totl o 84, rom n elerly priest t repete sittings using speilly esigne ne urve ur ve oreps. oreps. Over the yers, numer o surgeons experimente on orpses using rushing instruments psse long hollow tue introue into the ler, ut it remine or rillint young surgeon in Pris to rry out the rst suessul opertion in mn – surely the historil eginning o miniml ess surgery ! Jen Civile (1792–1867) (Figure 12.12) h lrey ommene series o experiments in 1817 18 17,, when he ws stil s tilll seon-yer meil mei l stuent uner Bron Dupuytren in the University o Pris, in n eort to sertin whether it ws possile to rush stone in the ler without injuring its wlls. o him lls the honour o perorming the rst suessul lithotrity, on 13 Jnury 1824, t the Neker Hospitl in Pris. Civile’s instrument, the trile (Figure 12.13), onsiste o two metl yliners, one within the other, the smller o whih h three rnhes xe on its istl en y mens o hinges. Te inner tue ws projete into the ler, mnipulte to seize the stone, n then withrwn into the outer tue so tht its rnhes xe upon the stone, whih ws then perorte y gimlet. Numerous moitions were me over the next ew yers (Figure ( Figure 12.14). 12.14). Severl sittings were require to rek up the lulus, whih ws then psse per via natura natu ra in the urine. Bron Chrles Louis Stnisls Heurteloup (1793–1864), who eme violent instrument ntgonist o Civile, esigne rther similr lle the ‘pere-pierre’, in whih he hollowe out the stone inste o mking numerous seprte perortions into it (Figure (Figure 12.15) 12.15).. Heurteloup trvelle rom Frne to Engln in 1829, live in
Figure 12.13 Civiale’s trilabe. The stone was caught between the three blades and then drilled. (From Ellis H: A History of Bladder Stone. Stone. Oxord, Ox ord, Blackwell, Black well, 1969 1969.)
192 Cutting or the stone
Figure 12.14 ‘Un malade au moment de l’operation’ The calculus is trapped in the jaws o the trilabe and is being drilled by a gimlet activated by a bow. (From Civiale J: Tr Traité aité Pratique et Historique de la Lithotritie.. Paris, Baillière, 1847.) Lithotritie
Vere Street in Lonon, n ws the rst to perorm lithotrity in this ountry. Te rst ptient he trete in Engln ws Mr Wttie, ormer semn ge 64 6 4 yers, yers, o Upper Eury Street, Pimlio, who h two luli estroye in three sessions on 24 n 25 July n 20 August 1929, using the ‘pere-pierre’. Te opertion ws perorme in the house o Anthony White, surgeon t Westminster Hospitl. In 1831, Heurteloup pulishe Cases o lithotrity, or exmples o the stone ure without inision in English. Tere now ensue perio o tremenous
tretment. He my use lithotrite, lithotr ite, ut now he nee no longer ll upon the exquisite sense o touh o his preeessors, who lerne how to mnipulte the lulus linly etween the rushing les o the instrument within the ler. Moern tehnology llows the surgeon to o this uner iret vision y mens o re-opti illuminte il luminte viewing system. Finlly, the stone my e isintegrte within the ler using shok-wve ultrsoni em, the rgments o stone eing remove with ler irrigtor. One o the intriguing mysteries o ler
inventiveness n ingenuity on the prt o surgeons n surgil instrument mkers; grully, the rushing lithotrite s we know it toy ws evelope, the work eing priniplly rrie out y surgeons in Frne n Gret Britin. Eventully, the moern instrument ws evolve (Figure 12.16) in 12.16) in whih the t he stone, ught etween the jws o the instrument, woul e rushe y turning srew. Surgeons eme extremely skille in the use o these instruments n ountless ptients were, in onsequene, relieve o their suerings. Te surgeon toy hs hoie o tehniques
stoneoistheitspst requeny throughout meiltoy. history n yet its rrity in Europe Ol surgil writings wr itings oun with esriptions o lrge numers o vitims o the stone, espeilly hilren; inee, ommon use o rying in innts t night liste in the ol textooks ws ler stone – hrly the rst thing moern peitriin woul onsier! Bler stone hs virtu vir tully lly is isppe ppere re rom the hi hilren’s lren’s hospitls in this ountry. Riley Toms nlyse the totl iniene o vesil lulus n its requeny t ierent ge groups t the Norolk n Norwih Hospitl, using three 10-yer perios –
in with stone in the ler. Heimy theeling open ominl pproh, espeilly thereuse is some o-existent ler pthology tht requires
1871–1880, 1929–1938; in i-. tion, he gve1901–1910 the gures n or the 5 yers 1943–1947. 1943–1947 Figure 12.17, 12.17, whih is se on these sttistis,
Transurethral lithotrity 193
Figure 12.15 Baron Charles Heurteloup’s instruments: (a) on display; (b) in use. (From Heurteloup C: Cases of Lithotrity or Examples of the Stone Cured without Incision. Lond Incision. London, on, Underwood, Under wood, 1831.) 1831.)
shows vivily how the requeny o oth totl n innt ler stone hs roppe remrkly in
southern prts o Europe, suh s Siily n Greee. However, it persists s mjor prolem in urkey, Ini n Chin. One might ttriute the high iniene o stone in ults in the pst to the rvges o untrete or ly trete urinry ostrution rom striture o the urethr n enlrgement o the prostte, together with supere inetion. However, the
living memory. Bler stone is now extremely rre in northern Europe, lthough it is osionlly seen in
epiemi proportions o theperhps iseseietry, in thosewhih ys suggest some other tors, is not yet ully unerstoo.
Figure 12.16 Lithotrite used by Sir Henry Thompson and made by Charrière.
Cu tting 194 Cuttin g or the stone
Bler stone ws no respeter o soil position – kings or their poorest sujets, generls or their humlest troopers, svnts or their ilest stuents, ll might ll vitim to its rvges; mous ptients with enite or puttive ler luli ll the pges o history. Te philosopher Frnis Bon, sientist Is Newton, physiins Willim Hrvey n Hermnn Boerhve, the ntomist Antonio Srp, the writer Hore Wlpole, Peter the Gret, Louis XIV, George IV n Oliver Cromwell hve ll een si to hve h ler stone. Toms Syenhm (1626– 1689), who strte his reer ghting with the Puritn Army in the Civil Wr n who rose to eome the ‘Prine o Prtil Physiins’, suere rom stone. He wrote with personl eeling when he esrie the symptoms s ymptoms thus: ‘He suers until t lst he is worn out y the joint ttk o ge
At the ge o 20, while stuent t rinity Hll, Cmrige, in the summer o 1653, Pepys h violent ttk o renl oli. Tis he ttriutes to long wlk with his riens to Aristotle’s well, where they slke their thirsts with w ith gret rughts o ol wter. It ppers tht ollowing this ttk the lulus psse rom the kiney to the ler, n heneorth, he ws to e sujet to violent ttks o vesil pin. In spite o this, his ourting ilities remine pprently ppren tly unete, n he mrrie Elizeth Eliz eth St Mihel on 1 Deemer 1655. Te ol wether lwys ggrvte Pepys’ suerings n the prtiulrly winter o 1658 rought mtters to he; it ws ovious tht surgery h now eome inevitle. He ws ut or the stone y Toms Hollier Holl ier (1609–1690) (1609–1690) o St Toms’ Hospitl, on 26 Mrh 1658 t the home o his ousin, Jne urner, eing ortie or the proeure y rught ontining liquorie, mrshmllow, innmon, milk, rose wter n white o eggs. Te stone ws the size o tennis ll, weighe out two ounes n pprently ws ompose minly o urtes. Fortuntely, this ws suessul yer or Hollier, sine, o the 30 ptients ut or the stone uring those 12 months, ll live, ut Hollier ws not lwys so suessul; inee, in Septemer 1659, Pepys ttene the Jewish syngogue n there her ‘mny lmenttions me y Portugl Jews or the eth o Ferinno, the merhnt who ws ltely ut y the sme hn with mysel o the stone’.
ntoisese, s ie’. n the miserle wreth is so hppy Surely, the est known stone is tht o Smuel Pepys, who suere rom the lulus rom inny. ‘I rememer not my lie without the pin o the stone in the kineys (even to the mking o looy wter upon ny extrorinry motion) until I ws w s out 20 yers o ge’. ge’. Tere seeme to e mily teneny or the isese; his mother voie l lrge rge stone whi whih, h, to his is isppoi ppointntment, she threw into the re. An unt lso psse lulus, n his rother John t Cmrige ‘hth the pin o the stone n mkes looy
Hisinelivery hisle lulus turning point Smuel ’srom Smuel’s lie n eep ws impression. In er yers, yers , he gve inner eh 26 Mrh to those who h stoo y him hi m on tht momentous y; ‘my solemn est or the utting o the stone’, he lle it. Te stone itsel ws reully preserve, n in 1664, Pepys went ‘to look out mn to mke se or to keep my stone, tht I ws ut ut o in 1658’. 1658’. Tis ost 25 shillings n ws uly proue whenever ny o his riens neee enourgement to unergo similr opertion. Benjmin Frnklin, lthough not ormlly trine s physiin, ws prtiulrly intereste
wter with mine i’ i ’. gret pin in the eginning just s
in meiine the(he exile theter. owrsn owrs theinee en o his hinvente is long lie ie t ie the
Figure 12.17 The incidence o bladder stone in Norwich.
Transurethral lithotrity 19 195 5
ge o 84), he remrke ‘only three inurle iseses hve llen to my shre, viz, gout, the stone, n ol ge’. Symptoms o ler stone ppere in his mile 70s, n in 1784, when he ws 78, he wrote
Unortuntely, in spite o ll sorts o remeies, the symptoms i inee progress so tht the ollowing yer Frnklin wrote tht he ws ‘isle y the stone, whih in the esiest rrige gives me pin, wouns my ler n osions me to mke looy urine’. By the en o the utumn o 1789, he ws ‘fite with lmost onstnt n grievous pin pi n to omt, whih I hve een olige to reourse to opium, whih inee hs ore me some ese rom time to time, ut then it hs tken wy my ppetite, n so impee my igestion tht I m eome totlly emite n little remins o me ut skeleton overe with skin’ sk in’.. Althoughh he ws vise y his riens Althoug r iens to e ut or the stone, he reuse their vie n he ie, eoun, s result o pneumoni omplite
Further ttks o ysuri ourre in lter yers. In exile on St Helen, he h iulty with miturition n ws seen t times lening with his he ginst wll or tree n pssing urine in smll, pinul riles. ‘Tis is my wek spot, it is y this tht I shll ie’. Te post-mortem ollowing Npoleon’s eth t the ge o 51 on 5 My 1821 ws rrie out y Dr Dominique Antommrhi in the presene o 16 others. As well s sirrhous uler o the stomh, herent to the le loe o the liver, n heptomegly, Antommrhi reporte tht ‘Te ler, whih ws empty n muh ontrte, ontine ontin e ertin quntity o grvel, mixe with some smll luli. Numerous re spots were sttere upon its muous memrne, n the ots o the orgn were in isese stte’. Who n sy to wht extent history hs een ltere y these strnge onretions o the ler? Who n sy wht might hve hppene in the Russin Cmpign in 1812 i moern surgil skill h een ville in those ys, to relieve Npoleon o his stones? How mny personlities hve een ltere, eisions hnge, jugements ete or genius thwrte y the torturing pins, the hroni sepsis n uremi renl mge resulting rom ler stone? On the other hn, without this strnge enturies-long enturieslong epiemi o ler stone, how r might the progress o surgery hve een elye? Aer ll, it ws upon this pthology tht the rt r t o surgery evolve, rom the rst primitive uts into the perineum up to the sophistite instrumen-
y Npoleon lung sess. Bonprte suere with urinry requeny n ysuri or mny yers. Te t tht he woul oen sleep or no more thn 2–3 hours t time ws ttriute y Constnt, his vlet, not to ny superhumn power ut to the esire to get up n pss his wter. At the ttle o Boroino in the Russin Cmpign o 1812, he h to ismount rom his horse requently; he h persistent thirst, swelling o the legs n gret iulty i ulty pssing his urine, whih ws no less thn one-thir seiment.
ttion o n to some o the erliest ssys onthe thelithotritists surgil rehing o the ominl vity. Bler stone will no out eventully ie out, to eome surgil rrity throughout the worl, just s it hs lrey one in this ountry. Its ountless vitims through the ges, however, might erive some post-mortem stistion rom the thought tht their suerings hve ontriute in some smll wy to the progress n goo o humnity.
It is true as you have heard that I have the stone, but not that I had thoughts o being cut or it. It is as yet very ver y tolerable. It gives me no pain but in a carriage, on a pavement, or when I make some quick movement. I I can prevent its growing larger, which I hope to do, by abstemious living and gentle exercise I can go on pretty comortably with it to the end o my journey which can now be o no great distance.
13 Thyroid and parathyroid Te thyroi gln ws known to Glen, who thought it proue ui to lurite the lrynx. It ws esrie y Veslius (1514–1564), who lle it the glnule lryngis n gree with Glen out its untion. It ws nme the thyroi (Greek thyreos, shiel) y Toms Whrton (1614–1673) o Lonon (who lso esrie the ut o the sumniulr sumniulr slivry s livry gln), who elieve it ws esigne y nture to give women eutiully roune nek ! Astley Cooper (1768–1841) (see Figure 6.26) 6.26) ppers to hve een the rst to elieve tht the orgn perorme some enite untion. He note the lrge lymphtis tht psse rom it to the thori ut n postulte tht they onveye the seretion rom the gln. Enlrgement o the thyroi gln proue suh n ovious physil hnge in the nek tht it hs een oserve sine erly times. Ol nmes pplie to suh swelling were strum (Ltin or swollen gln), ronhoele ( ysti mss in the nek) n goitre (rom the Ltin gutta , throt); this lst term is oen use toy. One ommon use o thyroi enlrgement is ioine eieny. Ioine is oun in se wter wter,, n it is not surprising tht ioine-eient res in the worl re r remove rom the se n prtiulrly our in elevte inln zones. Goitre is si to hve een known in Chin s r k s 2700 bc, where it ws oun in mountinous regions. As long go s the 4th entury ad, Chinese physiins reommene the use o sewee or this onition, n, o ourse, sewee is rihisin the the Unite Kingom, Deryshire s ioine. r wyInrom se s one n get, n s young resient surgil oer in
Sheel, the uthor eme well quinte with ‘Deryshire nek’, so nme in the 18th entury. Meil visitors to Northern Ini, Nepl n to the Ethiopin highlns will e struk y the high iniene o lrge thyroi msses, n this ws ertinly my experiene s exminer mny yers go in the University o Ais A n lso in visits to Nepl or the British Counil. Although goitre ws not ommon long the shores o the Meiterrnen, it ws well reognise even y non-meil Romn uthors to e eture o resients in the Alps; thus Juvenl, in the 1st entury ad wrote ‘Who woners t swelling in the nek in the Alps?’ Celsus, lso in the 1st entury ad, ene ronhoele n esrie ysti goitre in mountinous regions. Goitre ws so ommon in Switzerln tht it is oen seen in pintings n sttues rom tht t ht ountry. Inee, stnr tehnique to kill Swiss prisoner ws to slit open his goitre (Figure ( Figure 13.1 13.1). ). Here, Here, s in other ivilise res, ioine-eient goitre hs een ll ut olishe y iointion o tle slt, ut it ws in Switzerln tht so muh o the surgery o the thyroi gln, s we shll see, ws evelope. In the Unite Sttes, goitre ws enemi in the mi–West, n it is to this tht we owe the expertise in thyroi surgery o the Myo rothers o Rohester, Minnesot, n o George Crile in Cleveln, Ohio. Shkespere gives hrteristilly onise esription o goitre n its geogrphil ssoition: Whenwoul we were oys,tht there were Who elieve mountineers, 197
T hyroid and parathy 198 Thyroid parathyroid roid
Figure 13.1 Swiss patients with enormous goitres. The thyroid mass o the girl on the right has ulcerated through the skin. The lowermost
picture is o the same child ater thyroidectomy. (From Kocher T: Zur pathologie and therapie der Kropres. Deutsche Zeitschrift für Chirurgie 1874; Chirurgie 1874; 4, 417.)
Dewlpp’ like Dewlpp’ li ke ulls, whose throts h hnging t ‘em Wllets o esh? (Te empest III.3, 43–47.)
1st entury ad, reporte tht t ht opertion or removl removl o suh mss ws ngerous. Alusis, the 11th entury surgeon o Coro (see Chpter 4), lso 4), lso speks o extirption o the gln. Certinly, the surgeons o Slerno in the 12th entury were trnsxing lrge goitres with setons, thres psse through the mss to proue suppurtion, s well s treting these ptients with sewee, either rie or urne. Guy e Chuli (see Chpter 4) 4) in the 14th entury use the utery n setons or goitre tretment. Lorenz Heister (see Figure 6.7), 6.7), in his General System o Surgery o o 1753, pointe out tht these msses were pinless n, inee, regre mong the yrolese s n ornment rther thn isgurement. It is unlikely tht ptients woul hve oere themselves or ril tretment unless the mss ompressing the trhe ws using sphyxition. Te rst well-oumente prtil thyroietomy ws rrie out y Pierre-Joseph Desult (see Figure 6.3) in 6.3) in 1791. He remove 4-m imeter mss rom the thyroi through vertil inision, tying o the superior n inerior thyroi rteries n then isseting the gln rom the trhe. Te woun suppurte ut hele within month. Bron B ron Guillume Guil lume Dupuytren Dupuyt ren (1777–1 (1777–1835) 835) ttempte totl removl o the thyroi in 1808, tying ll ll our rteries; r teries; the ptient ptient ie o shok. In the 19th entury, the mortlity o thyroi surgery ws over 40%, n mny leing surgeons vise ginst the opertion. Tyroietomy ws onemne y the Frenh Aemy o Meiine in 1850. Teoor Koher ollete reports o 146 opertions1850 on the rrie etween n thyroi 1877 n noteout nworlwie opertive mortlity o 21%. Even when nesthetis eme ville, mny surgeons elieve tht opertions on the thyroi gln were too hzrous to e ttempte. Tus, Smuel D Gross (1805–1884), proessor o surgery t Jeerson Meil College, Philelphi, wrote in his System o Surgery in in 1866:
SURGERY
In a word, can the thyroid gland, when in a state o enlargement, be removed with a reasonable hope o saving the patient?
Te surgil tretment o goitre n nient, lthough in its erly stges rtherhsuninteresting history. Celsus, the Romn enylopeist o the
Experience emphatically answers, no. This conclusion is not invalidated by the act that the operation has, in a
Surgery 199
ew instances, been successully perormed… every step he takes will be environed with diculty, dicult y, every every stroke s troke o his knie will be ollowed by a torrent o blood, and lucky will it be or him i his victim lives long enough to enable him to nish his horrid butchering. Should the patient survive the immediate eects o the operation, i thus it may be called, death will be almost certain to overtake him rom secondary haemorrhage, or rom infammation o the cervical vessels, oesophagus and respiratory organs. When the tumour is large, the wound is o rightul extent, ex tent, involving all the most important and delicate structures o the neck and rendering it almost impossible, rom the constant motion o the windpipe and oesophagus, that much o it would unite by rst intention. Thus, whether we view this operation in relation to the diculties which must necessarily attend its execution, or with reerence to the severity o the subsequent infammation, it is equally deserving o rebuke and condemnation. No honest and sensible surgeon, it seems to me, would ever engage in it.
Figure 13.2 Theodor Kocher. (From Zimmerman LM, Veith L: Great Ideas in the History of Surgery . New York, Dover, 1961.)
Teoor Billroth (see Figure 8.5), 8.5), while proessor o surgery in Zurih etween 1861 n 1867, perorme 59 thyroi opertions, inluing 20 enuletions, mostly or soli noules. O these ses, eight ptients ie, seven rom sepsis. Disture y these gures, Billroth prtilly none the opertion when he move to Vienn, exept in ses o ptients thretene with sphyxi, rrying out only 16 opertions over the next 10 yers with wit h ve eths. eth s. He only strte eletive elet ive thyroi surgery gin in 1877 er he h een onvine y, n h opte, the ntisepti tehnique. Tyroi surgery surger y s we know it toy owes muh to one mn, the Swiss surgeon Teoor Koher (1841–1917) (Figure 13.2). He ws orn in Berne, the son o n engineer. He ttene meil shool
the linis o Billroth Bil lroth n Lister, he spent the whole o his proessionl lie in the ity o his irth. He ws ppointe s proessor o surgery t the University o Berne t the ge o 31 31 n ie, still st ill in oe, t the ge o 76. He ws quiet, serene, rther rt her ustere mn n, prt rom n interest in pinting, eite e ite his lie to surgery. As teher, tehnil surgeon n investigtor, he me numerous ontriutions. He esrie his well-known suostl inision or exposure o the gll ler, whih is requently use to this y. He populrise the ollr inision or thyroietomy, whih ers his nme n whih reple the ugly vertil miline inision use y previous surgeons. He esrie the tehnique or moilistion o the uoenum y ivision o its lterl peritonel tthments, or whih Amerin surgeons hve invente the phrse ‘Koheristion o the uoenum’. In 1870, he wrote long rtile in whih he esrie his metho o reution o islote shouler, still populr toy, whih oul e rrie out lmost pinlessly, without nesthesi or ssistne: ‘Ben the rm t the elow, press it ginst the oy, rotte outwrs ‘til resistne is
therethe n, prtmeil rom shools yer erogrution touring gret Vienn, Berlin, Pris n Lonon where, mong others, he visite
elt, li the s externlly rotte orwrs, upper rmn in the sgittl plne r s possile nlly turn inwrs slowly’.
200 Thyroid and parathyroid parathyroid
He wrote populr, eutiully illustrte n wiely trnslte Operative Surgery (Figure (Figure 13.3), in whih his prooun knowlege o ntomy is emonstrte y its etils o surgil pprohes to every joint. However, it ws Koher’s ontriutions to the surgery o the thyroi gln tht onstitute his gretest lim to me n erne him the Noel Prize or Meiine in 1909.
We hve lrey mentione tht Switzerln, eing mountinous n lnoun, is n ioineeient region. Beore iointion o tle slt ws introue, enormous goitres, oen ssoite with retinism, were enemi. Koher’s rst hllenge ws to el with these gignti noulr enlrgements o the gln, whih, prt rom their osmeti isgurement, oen proue respirtory ostrution. ostrut ion. Koher tught preise ntomil
Figure 13.3 Illustration o various incisions rom Kocher’s Te Textbook xtbook of Operative Surgery , 2nd edition. London, Black, 1903. The uppermost incision is Kocher’s incision or gall bladder surgery.
Surgery 201
Figure 13.4 Kocher’s thyroidectomy technique. (a) Isolation o the superior thyroid vessels; the instrument is Kocher’s gland dissector. (b) Application o Kocher’s crushing orceps to the thyroid isthmus beore ligation. (From Kocher T: Textbook of Operative Surgery , 2nd English edition. London, Black, 1903.)
issetion s the sis or thyroi surgery, with preliminry ligtion o the two prinipl rteries rteries o the gln on eh sie, whih gretly reue the mount n nger o leeing (Figure 13.4). His suessive reports o his results showe progressive improvement rom mortlity rte o 12.8% in 1883 to level o less thn 0.5%. In series o ses, reporte in 1898, there ws only single eth in 600 onseu onseutive tive ses, n this ws ue to n nestheti omplition (Figure (Figure 13.5). 13.5). Ril removl o the thyroi gln my m-
o myxoeem. Tis will e isusse urther in the setion on the prthyroi glns. It is sinting reetion on the opertive tehniques o the two erly pioneers o thyroi surgery, Billroth n Koher, tht Billroth i not enounter hypothyroiism in his ses ut h high iniene o tetny, wheres Koher h the opposite experiene. Willim Hlste (see Figure 7.11), who 7.11), who ws rien o Koher n h wthe him operte on mny osions, osions, expline this nomly in his Te Operative Story o Goitre (1919):
ge the reurrent lryngel nerve with glns onsequent horseness, remove the prthyroi with resultnt tetny or result in hypothyroiism i insuient untioning thyroi tissue remins. Koher pointe out tht gret re must e tken to voi the reurrent nerve n n wrote: ‘Sine we hve here stritly to this th is proeure, the horseness, ormerly so requently oserve er opertion, hs now eome exeptionl’. When Koher ommene his thyroi surgery, the untion o the gln ws poorly ppreite, n it ws not until 1882 tht the onsequenes o its ril removl were rst unerstoo. Te
I have pondered this question or many years and conclude that the explanation probably lies in the operative methods o the two illustrious surgeons. Kocher, neat and precise, operating in a relatively bloodless manner, scrupulously removed the entire thyroid gland, doing little damage outside its capsule. Billroth, operating more rapidly, and, as I recall his manner, with less regard or the tissues and less concern or haemorrhage, might easily have removed the
prthyroi glns were not even reognise t this stge, n the symptoms o tetny tht ollow their removl were onuse with the etures
parathyroids or atsupply, least have with their blood and interered have let ragments o the thyroid.
202 Thyroid and parathyroid
Figure 13.6 Cretinous inant beore and ater treatment with thyroid extract. (From Singer C, Underwood EA: A Short History of Medicine, Medicine, 2nd edition. Oxord, Oxord University Press, 1962.)
Many inants are aected, who besides their innate simple mindedness, the head is now and then misormed, the tongue
Figure 13.5 Goitre patient o Kocher beore and ater thyroidectomy. (From Kocher T: Uber kropextirpation und ihr olgen. Archiv für Klinische Chirurgie 1883; Chirurgie 1883; 29, 254.)
immense and tumid, a struma oten in the throat, they show a deormed appearance; and seated in solemn stateliness, staring, and a stick resting between their hands, their bodies twisted variously, their eyes wide apart, they show immoderate laughter and wonder at unknown things.
Toms Blizzr Curling (1811–1888), surgeon t the Lonon Hospitl, pulishe report in 1850 title wo Cases o Absence o the Tyroid Body Connected with Deective Cerebral Development
HYPOTHYROIDISM Te story tht rings together the omplex thres o thyroi eieny – retinism, myxoeem, the mlign results o ril thyroietomy n the tretment o these onitions with thyroi extrt extr t – is long in yers n sinting in i n ontent. Cretinism (Figure 13.6) ws esrie in Switzerln in the 16th entury y Josis Simmler (1530–1576) n Johnnes Stump (1500–1558). Felix Pltter (1536–1614), who qulie in Montpellier n then returne s proessor o meiine to Bsle,mentlly his ntive nt ive ity, esrie in 1602 the e, um, eetive retins seen in the nton o Vlis:
whih n he esrie hilren, ge 6inmonths the other two 10 yers, who,one t postmortem, prove to hve sene o the thyroi gln n ommente ‘whih my e regre s tening to onrm the more moern opinion respeting the onnetion etween retinism n ronhoele’, n rhi term or mss in the thyroi gln. Hypothyroiism in ults ws rst esrie y Sir Willim Gull (1816–1890), physiin t Guy’s Hospitl, who pulishe pper in 1873 title On a Cretinoid State Supervening in Adult Lie in Women. He reporte ve ses, two in etil
n others seen onesriptions only one oro two sions.three Tese re peret whtows newly isovere isese. It ws ne piee o
Hypothyroidism 203
oservtion to reognise, on linil grouns only, tht in relity this n retinism were one n the sme isese, or none o his ses were tl, n he sttes tht ‘rom the ols o t out the nek I m not le to stte wht the ext onition o it (the thyroi) ws’ w s’.. In pssing, we shoul note note tht Sir Willim Gull Gu ll ws remrkle linil oserver who esrie the etures o tes orslis, syringomyeli n norexi nervos, the lst o whih he nme. He insiste on ollowing his hi s tl ses to post-mortem post-mortem exmintion, n Sir Willim Hle-White, in his Great Doctors o the Nineteenth Century , reltes A patient o his let the hospital; one Saturday aternoon, Gull heard that this patient had died at his home 20 miles rom London. Gull at once sent a note to his house physician at Guy’s asking him to breakast on Sunday and telling him to bring tools to make a post-mortem examination. This he did, the two drove to the patient’s house and, ater much opposition, which Gull overcame, the post-mortem examination was made and the diagnosis established.
It ws Willim Miller Or (1834–1902) o St Toms’ Hospitl, Lonon, who use the term ‘myxoeem’ in 1877, to esrie the jelly-like swelling o onnetive tissues seen in this onition. Perhps it is unortunte tht this nme is so oen use to esrie hypothyroiism sine mny ptients o not hve this lssil eture.
Figure 13. 13.7 7 Jacques-Louis Reverdin. (Photograph provided by Dr Guy Saudan, Lausanne.)
Two or three months ater the operation the patients have presented or the most part with a state o weakness, pallor, anaemia and, in two o them, oedema o the ace and hands with albuminuria; in one case there was pupil contraction, melancholy and prostration and in another acies resembled that seen in cretins.
At the sme meeting, it ws reore tht
stuies Menwhile, were eing importnt rrie outexperimentl y Morritz Shi (1823–1896) in Genev. In 1859, he showe tht (1823–1896) totl removl o the thyroi in ogs resulte in eth er week, lthough guine pigs woul survive little longer. Ftlity ws not relte to inetion or to mge o the reurrent lryngel nerve. He went on in 1884 to emonstrte tht trnsplnt o thyroi tissue intr-ominlly prevente this tl eet. Te rst well-oumente ourrene o hypothyroiism ollowing thyroietomy ws me y Jques-Louis Reverin (1842–1929) (Figure 13.7),
Teoor Koher reporteollowing tht heng h seen se o epression n wekness ollowi thyroietomy. Te ollowing yer, Reverin, together with his ousin n personl ssistnt, Auguste Reverin (1848–1908), oumente in metiulous etil the results o his rst 22 goitre opertions. No less thn ve o their ptients evelope these untowr symptoms. All o them h unergone totl thyroietomy. Reverin pointe out tht these etures resemle the synrome esrie y Sir Willim Gull n me the importnt reommention tht only prtil removl o the thyroi gln shoul e perorme.
who reporte meeting o1882, the Meil o Genev on to 15Septemer hithertoSoiety unesrie symptoms ollowing goitre surgery:
Genev k to Koher, stuy hiser owntheses n meeting, reporte went similr phenomenon t the 12th Congress o Surgeons
204 Thyroid and parathyroid
in Berlin in 1883. O the 34 ptients upon whom totl removl o the gln h een perorme, 18 returne or exmintion n ll ut two o these revele the eviene o myxoeem. Tose with prtil resetions h espe (Figure 13.8). He wrote As a rule, soon ater discharge rom the hospital, but in occasional cases, not beore the lapse o our or ve months, the patients begin to complain o atigue and especially o weakness and heaviness in the extremities… in addition there is a sensation o coldness. The mental alertness decreases. Children who were ormerly among the brightest pupils suddenly all back. There is gradually increasing slowness o speech and o all other movements… i we are to give a name to this picture we cannot ail to recognise its relation to idiocy and cretinism; the stunted growth, the large head, the swollen nose, thick lips, heavy body and clumsiness o thought and speech undoubtedly point to a related evil.
Koher terme this synrome the rther izrre nme o ‘hexi strumipriv’, while Reverin
introue the muh more pt title o ‘opertive myxoeem’. In Novemer 1883, Sir Si r Felix Feli x Semon (1 (1849–1921 849–1921), ), lryngologist t St Toms’ Hospitl, suggeste t meeting o the Clinil Soiety o Lonon tht the three onitions o myxoeem, retinism n hexi strumipriv were ll use y loss o untion o the thyroi gln. His opinion ws riiule t the time, n pulition pulition in the t he trnstions o the Soiety ws reuse. However, his pper ws pulishe lter tht yer in the British Medical Journal . o settle the mtter, the Clinil Soiety ppointe ommittee to investigte the whole sujet. A memer o this ommittee ws Vitor Horsley (1857–1916), who we hve lrey met s pioneer o neurosurgery (Chpter (Chpter 8). At 8). At tht time, he ws superintenent o the Brown Institution in Lonon. Between 1884 n 1886, Horsley rrie out series o ruil experiments on monkeys. Tyroietomy Tyroi etomy in these nimls nim ls resulte in eth within withi n 1–2 months with wit h etures o myxoeem, myxoeem , inluing inltrtion o the suutneous tissues with stiky n jelly-like mteril. It is interesting tht the linil piture ws somewht osure sine some o the etures, suh s tremors whih ollowe 5 ys er surgery, we now know were ue to onomitnt removl o the prthyrois. Horsley mistkenly onlue tht the thyroi must serete some sustne neee or the proper nutrition o the entrl nervous system. At this time, s we hve lrey note, Morritz Shi ws treting nimls y gring the t he thyroi thyroi
Figure 13.8 Kocher’s rst patient noted to have post-operative myxoedema. (a) The patient and her younger sister beore her operation. (b) Nine years ater surgery. The younger sister is now ully grown, in contrast to the stunted patient.
into the omen er thyroietomy n Horsley repete these stuies. Te results were only temporrily suessul sine the trnsplnte thyroi tissue ws sore. In 1891, George Remyne Murry (1865–1939), pupil o Horsley who ws then proessor o pthology in Durhm n lter eme proessor o meiine in Mnhester, employe suutneous injetions o glyerine extrt o sheep’s thyroi in womn o 46 with ovious myxoeem, with rmti results. In t, uner thyroi tretment, this ptient live to the ge o 74. In the ollowing yer 1892, Hetor Mkenzie (1856–1929) n, inepenently,
(From Kocher T: Uber kropextirpation und ihre olgen. Archiv für Klinische Chirurgie 1883; Chirurgie 1883; 29, 254.)
Ewr Lwrene Foxthyroi (1859–1938) suessul ses in whih extrtreporte ws given g iven y mouth inste o y injetion. On Christms y,
Hyperthyroidism 205
1914, Ewr Kenll (1886–1972) t the Myo Clini isolte the tive priniple, thyroxine, rom the thyroi, mking the tretment o hypothyroiism one o the simplest, sest n most rewring in the whole el o therpeutis. Interestingly enough, Kenll went on to isover ortisone n ws wre the Noel Prize or Meiine in 1950.
HYPERTHYROIDISM At the en o the 18th entury strnge ssoition etween enlrgement o the thyroi, plpittions o the hert n protrusion o the eyes egn to e reporte (Figure 13.9). Te rst lssil esription esriptio n o this ws given y Cle Hillier Prry Prr y (1755–1822), physiin t the Generl Hospitl in Bth. In 1786, he oserve ptient with goitre, plpittions n protrusion o the eyes. He ollete seven urther ses, in whih enlrgement o the thyroi ws ssoite with plpittions ut not exophthlmos. His ount o these eight ptients, title Enlargement o the Tyroid Gland in Connection with Enlargement or Palpitation o the Heart , ws pulishe er his eth in 1825.
He sttes: ‘My ttenne on the three lst ptients rst suggeste sugges te to me the notion o some some onnetion etween the mly o the hert n ronhoele’ (i.e. thyroi enlrgement). Te next importnt ontriution ws me 10 yers lter y Roert Grves (1 (1796–1853 796–1853)) o the Meth Hospitl, Dulin, who, together with his ollegue, Willim Stokes (1804–1878), is knowlege s the ouner o the Dulin Shool o Meiine.oInthe1835, he with pulishe short o pper Palpitation Heart Enlargement the
Figure 13.9 Exophthalmos in hyperthyroidism. (Patient o the author at Westminster hospital.)
Tyroid Gland, in whih he esrie three ses
o plpittion ssoite with goitre, in one o whom exophthlmos ws present. O this ptient, he wrote A lady aged 20 became aected with some symptoms which were supposed to be hysterical… ater she had been in this nervous state about three months, it was observed that her pulse had become singularly rapid. This rapidity existed apparently without any cause and was constant, the pulse being never under 120 and oten much higher. She next complained o weakness upon exertion and began to look pale and thin. Thus she continued or a year… it was now observed that her eyes assumed a singular appearance appearan ce or the eyeballs were apparently enlarged, so that when she slept or tried to shut her eyes they were incapable o closing. When the eyes were opened, the white sclerotic could be seen to a breadth o several lines around the cornea.
Grves ws onvine tht the enlrgement o the thyroi gln ws use y hypertrophy, in ontrst to the usul type o goitre tht omprises mss o noules. He writes I have lately seen three cases o violent long continued palpitations in emales in each o which the same peculiarity presented itsel, viz., enlargement o the thyroid gland. The size o the gland, at all times considerably greater than natural, was subject to remarkable variations in every one o these patients. When the palpitations were violent, the gland used notably to swell and became distended, having all the appearances o being increased in size… the swelling immediately began to subside as the violence o the paroxysm o palpitation decreased and during the intervals the size o the gland remained stationary.
A ourth se,o ssoition emle ptient proviing nother exmple with exophthlmos, ws oserve y Grves in 1838. It ws in his
206 Thyroid and parathyroid
honour tht Armn rousseu (1801–1867), the istinguishe Prisin physiin, use the term ‘Grves’ isese’ in 1860. In 1840, Krl von Bseow (1799–1854) o Merseurg esrie three emles n one mle with exophthlmos, plpittions n enlrgement o the thyroi gln n esrie the hypertrophy hyper trophy o the ellulr tissues o the orit. He lso note emition, menorrhoe, exessive sweting, irrhoe, tremor n lol myxoeem o the legs. It is interesting tht in Germny the isese is requently lle Bseow’s isese, wheres Grves’’ isese is use in English-spe Grves Engl ish-speking king ountries. Another rther ol-shione term still in ommon use is ‘thyrotoxiosis’, suggesting some toxi prout o the thyroi gln, use in the ys eore it ws relise tht the etures o the isese, prt rom the exophthlmos, n e expline y exessive proution o thyroxine. Te term ‘hyperthyroiism’ ws introue y Chrles Myo (1865–1939) in 1907; it is ertinly the most sensile nme or this onition, n the one I will lwys personlly use. It shoul e rememere rememere tht until the erly 20th 20 th entury, the whole onept o utless system o glns (the enorine system) prouing internl seretions ws only vguely unerstoo, inee the term ‘hormone’ ws rst use y the physiologist Sir Ernest Strling St rling (1866–1927) (1866–1927) in 1907. Tis ws in spite o the t tht s long go s 1690, Freerik Ruysh (1638–1731), elerte ntomist o Amsterm, suggeste tht orgns suh s the thyroi poure into the irultion sustnes whih
hzrous inee. Ptients were not onsiere or surgery until lrey extremely ill, n mny ie immeitely er the opertion with hyperpyrexi, unontrolle thyri n hert ilure. Te Miwest sttes o the Unite Sttes hve prtiulrly high iniene o goitre, n hyperthyroiism seems espeilly ommon there. It is not surprising, thereore, tht it ws two Miwest surgeons who me importnt import nt ontriutions to the prolem o surgery in this onition. George Crile (1864–1943) (Figure 13.10), ouner o the Cleveln Clini, Cleveln, Ohio, perorme his rst thyroietomy in 1898. Dismye y the high mortlity ollowing opertions on ptients with vne hyperthyroiism, he introue his tehnique o ‘steling the goitre’ in 1907. Te ptient ws hevily sete or severl ys, not inorme o the time or even te o the opertion, ut ws nesthetise in the wr eore eing tken to the operting operti ng thetre (or even operte upon in the wr itsel), with grtiying improvement in results. Crile lso rrie out importnt import nt work on surgil shok n in the evelopment o ril lok issetion o the nek in ner o the he n nek.
were o importne. Grves himsenlrgement himsel, el, quite wrongly, o ourse, srie the thyroi in his ptients to overtion o the hert. An importnt oservtion ws pulishe in 1884 y Luwig Rehn (1849–1930) o Frnkurtm-Min, who reporte three ptients ure iniently o their plpittions when the thyroi gln ws remove or yspnoe. He propose, thereore, tht it ws overtion o the thyroi tht ws responsile or the onition n tht thyroietomy ws thus the logil metho or tretment. Tyroietomy is tehnilly emning proeure. Operting on the thyroi in ptient with vne the ys eetive rugs hyperthyroiism were ville to in ontrol the eore metoli omplitions o the overtive gln ws
Figure 13.10 George Crile. (Royal College o Surgeons o England.)
Hyperthyroidism 207
Menwhile, in Rohester, Minnesot, Chrles Myo (1865–1939) (Figure 13.11) h perorme his rst thyroietomy in 1890 with his rother Will (1861–1939) (Figure 13.12). Te ptient ws 60-yer-ol mn with goitre tht hung own onto his hest n ore his he kwrs s r s it woul go. He ws suering rom severe rething iulties. By 1908, Chrles Ch rles Myo oul oul report 234 thyroietomies or hyperthyroiism with mortlity tl ity o 11.5%. 11.5%. He vote the tehnique o stge surgery introue y Koher: t the rst stge, the loo vessels to the thyroi gln were tie on one or oth sies, t seon stge, one loe might e remove n t the thir stge the other. A rmti vne ws me y Myo’s meil ollegue, Henry Plummer (1874–1937), who showe tht ministrtion o ioine in the orm o potssium ioie rpily rought the toxi symptoms o hyperthyroiism uner ontrol. Tis renere the multiple-stge opertion no longer neessry euse most ptients oul e me rey or one-stge opertion rom 10 ys to 3 weeks. Te ree post-opertive risis ws verte, n
Figu re 13.12 Figure 13.12 William Mayo. (Royal College o Surgeons o England.)
mortlity roppe to less thn 1%. Aer thorough testing o this metho or yer, Plummer reporte the remrkle results to meeting o the Assoition o Amerin Physiins in 1923. Te introution o the ntithyroi rug thiouril in 1943 n then o the ser rimzole in 1960, n the use in reent yers o et-loking rugs whih llow rpi ontrol o the plpittions n thyri in this onition, hve me the pre-opertive preprtion o ptients with hyperthyroiism strightorwr str ightorwr proeure. Nowys, surgery in this onition is ssoite with miniml mortlity n moriity. moriity. Moreover, Moreover, in 1942, rior iotive ioine ws rst use to tret the onition. oy, mny ptients re mnge y wht, to them, is the simple usiness o rinking glss o wter tht ontins this tsteless n olourless mteril, mirle o moern therpeutis t herpeutis! I nnot mention the Myo rothers in ook on surgil history without wor o tht meil phenomenon, the Myo Clini, whih is unoutely the est known meil entre in the Unite Sttes, i not in the worl. Te story Figu re 13. Figure 13.1 11 Charles Mayo. (Royal College o Surgeons o England.)
egins in the yer emigrte 1845, when Willim Myo (1819–1911) rom Slor,Worrll then villge vil lge outsie Mnhester, M nhester, to the Unite Sttes o
208 Thyroid and parathyroid
Ameri. Myo rst prtise s phrmeuti phrmeutil l hemist in New York ut soon turne to the stuy o meiine. Aer quliying in 1854, he worke in vrious ities until the opportunities ore y the evelopment o the North-West erritories inue him to settle in Rohester, Minnesot, then very muh rontier town. Inee, in 1862, Dr Myo ws one o the leers involve in quelling rising o the t he Sioux Inins. Willim Will im Myo ws orn in 1861 n his rother, rother, Chrles, in 1865. Te two oys helpe their ther in his surgil prtie, n, in er yers, they were wont to reount how Chrles use to stn st n on isuit ox to ssist in opertions. Long eore the oys entere their orml trining, they h een reeiving prtil instrution rom their ther. Willim grute t the University o Minnesot in Minnepolis in 1883 n Chrles t the NorthWestern University in Chigo in 1885. In August 1883, Rohester ws evstte y torno. Dr Willim Myo senior took hrge o n improvise hospitl with suh eieny tht it ws suggeste tht he shoul estlish permnent hospitl in Rohester. In 1889, thereore, ol Dr Myo, then ge 70, n his two sons opene St Mry’s Hospitl with 27 es n ve nurses. Other physiins n surgeons joine the st, n this ws the eginning o the Myo Clini, rillint experiment in group prtie. In 1919, the Myo rothers turne over their personl ssets to estlish the Myo Fountion with n entirely
slrie st. A grute meil shool h lrey een opene in 1915, n this ws ollowe y n unergrute shool in 1972. Inreily, this little town o some 50,000 people in the mile o the rming Miwest remins ‘meil me’ – the whole inustry o the town, or prtil purposes, eing the pursuit o meiine, with ptients n stuents oming rom ll over the worl. worl. I, H.E, rst visite vi site the lini in 1972, rriving in smll ommu ommuter ter plne rom Chigo. It ws met y group o porters with strethers n n wheelhirs wheel hirs to el with the pssengers leving the plne in plster sts, with nsogstri tues or nge hes. I ws the only person to wlk o tht plne n one porter si to me ‘s you n wlk, you must e visiting otor’. O ourse, he ws right.
THE PARATHYROID GLANDS Te prthyrois re our (sometimes three, sometimes ve) smll noules, out hl entimetre in length, oun two on eh sie on the posterior spet o the thyroi gln (Figure 13.13). Osionlly, one or more o the glns my e oun elsewhere in the nek or even in the superior prt o the thorx. Antomilly, they were only ully reognise in mn t the eginning o the 20th entury, n severl more ees psse eore their physiologil importne ws ully unerstoo.
Figu re 13.13 Figure 13.13 The parathyroid glands. (From Ellis H: Clinical Anatomy , 11th 11th edition. Oxord, Blackwell Black well Science, 2006.)
The parathyroid glands 209
In 1862 Sir Rihr Owen (1804–1892), then onservtor t the Royl College o Surgeons in Lonon, reporte in the ransactions o the Zoological Society o London his issetion nings in the oy o n Inin rhinoeros tht h ie t the Lonon Zoo (Figure 13.14). He esrie ‘ smll, ompt, yellow glnulr oy tthe to the thyroi t the ple where the veins emerge’. Tese glns were lso note in mn y Ruolph Virhow (1821–1902), pthologist t the Chrité Hospitl in Berlin. No ttention ws given to either o these esriptions. In 1880, Yvr Snström (1852–1889), while meil stuent t Uppsl, Sween, Swee n, issete 50 humn oies, me niml stuies, rrie out histologil exmintion n reporte his nings o two glns, one on eh sie, in 43 out o his 50 humn sujets. He nme these ‘glnule prthyroiee’, ut gin this stuy ws ll ut ignore.
In 1891, Eugène Gley (1857–1930) o Pris note the prthyroi glns in the rit n showe them to e essentil to lie, lthough he onlue, wrongly, tht their untion ws the sme s tht o the thyroi. It ws Gley who reisovere n gve ue reognition to Snström’s esription. By 1909, numerous workers, inluing Giulio Vssle (1862–1912) o Moen, Itly, Dvi Welsh (1865–1948) in Einurgh n Willim Hlste (see Figure 7.11) 7.11) in Bltimore h shown tht removl o the prthyrois resulte in tetny, ws ssoite with rop in the serum lium n ws relieve y injetion o either lium slts or prthyroi extrt. It ws now relise tht the phenomenon o ‘tetni thyreopriv’, not inrequently tl, tht ollowe the erly thyroietomies – rst reporte rom Billroth’s lini in 1880, then y Reverin in 1882 n y Teoore Koher in 1883, s well s ourring in the experimentl thyroietomies perorme y Shi n y Horsley roun 1885 – ws simply the result o mge to the prthyroi glns t the time o thyroi surgery. Creul opertive tehnique, with preservtion o the posterior spet o the thyroi loe on eh sie, ll ut ovite this post-opertive postopertive omplition. umours o the prthyroi re usully enign enoms. Tey re not ommon, ut when they o our they proue their eets y exess seretion o prthyroi hormone. Tis moilises lium rom the skeleton, prouing one rretion n yst ormtion n, s more requent mniesttion, results in stone ormtion in the renl trt
Figu re 13.14 Figure 13.14 Part o the larynx and trachea o a rhinoceros showing the lateral lobe o the thyroid with a parathyroid attached to its upper extremity and partly embedded in its substance. This is almost certainly the specimen in which Richard
rom the exess seretion o lium urine. Generlise elition o in thetheskeleton ssoite with yst ormtion (osteitis ros ysti) ws rst stuie systemtilly y Frierih von Reklinghusen (1833–1910), proessor o pthology suessively t the universities o Konigserg, Würzurg n then Strsourg. In 1891, he gve n urte esription o three ptients with this onition, lthough, t tht time, he h no ie o its etiology. In 1903, Mx Asknzy (1865–1940), pthologist in Genev, isovere prthyroi tumour in ptient with this onition, lthough, interestingly enough,
Owen made the rst observation o the parathyroid. (Specimen L 331. 331.1 in the Hunterian H unterian Museum o the Royal College o Surgeons o England.)
he i not ssoite the twoopthologies. Further reports o the ssoition the two onitions le to the suggestion tht removl o the tumour
T hyroid and parat 210 Thyroid parathyroid hyroid
woul e the orret tretment or this onition, now oen lle von Reklinghusen’s isese o one, ut it ws not until 1925 tht Felix Mnl (1892–1957) perorme the rst removl o prthyroi tumour. His ptient ws mn with vne osteitis ros ysti who ompline o generlise one pin, tigue n musle wekness. Mnl explore the nek n oun tumour mesuring 2.5 m y 1.5 m lying on rnh o the inerior thyroi rtery. rtery. A pthologil exmintion prove this to e n enom o the prthyroi gln. Te ptient immeitely lost his symptoms n remine well or 6 yers. Te symptoms reurre in 1932, with the evelopment o renl stones. Mnl explore the nek one gin ut oun no prthyroi normlity; the ptient ie rom renl ilure. At utopsy, it ws oun tht eth ws ue to renl isese isese n no norml prthyroi tissue oul e oun. However, y now, enough suessul opertions h een perorme to estlish this proeure. In 1932, lso, Fuller Alright (1900–1969) in Boston ignose prthyroi enom in emle ptient with renl stones, who ws oun to hve gretly rise serum lium level. Te nek ws explore, prthyroi enom remove, n the lium level returne to norml. oy, sophistite imging tehniques mke m ke it possile to lolise the prthyroi tumour preopertively
in the mjority o ses with gret egree o ury. A ew wors out the pioneer o prthyroi surgery – Felix Mnl (1892–1957) ws orn in Brno, then in Austri, now in the Czeh Repuli, the son o n inustrilist. His meil stuies t the University o Vienn were interrupte y the First Worl Wr, uring whih he serve on the Austrin ront s n mulne mn. He qulie in 1919. Four yers lter, he ws ppointe ssistnt to Julius von Hohenegg, istinguishe ut utorti n ntnkerous ntn kerous hie t the University University Clini, n it ws here tht the prthyroi work ws perorme. In 1932, Mnl ws ppointe surgeon to the newly opene Cnning Chil Hospitl n Reserh Institute or the Stuy o Cner, prestigious promotion, ut his time there ws ll too short. In 1938, me the Anshluss – the Nzis mrhe into Austri. Mnl, Jew, ws ismisse rom his post n, inee, his lie li e ws in nger. He ws ortunte in eing le to espe to wht ws then Plestine, uner the British Mnte, n ws promptly ppointe proessor o surgery t the prestigious prestigio us Hssh Hosp Hospitl itl in Jeruslem. Aer the wr, he ws invite k to Vienn to eome iretor, in 1947, o the reuilt Emperor FrnzJose Hospitl. He ie suenly o hert ilure in 1957, in his 65th yer; remrkle reer.
14 Thoracic and vascular surgery LUNG SURGERY Te erly history o hest surgery, s with so mny other els o surgil enevour, is the story o the tretment o trum n inetion. In the rst prt o this hpter, we shll meet in this ontext, one gin, numer o the surgil pioneers who hve ppere in previous hpters. Pneumothorx n ollpse o the lung, s well s requently severe hemorrhge rom lrge vessels n rom the hert itsel, me open wouns o the hest prtiulrly lethl injuries. Tus, tht oyen o trum surgery Amroise Pré (see Figure 9.4 9.4)) wrote in 1585: We may know that the lungs are wounded by the oaming and spumous blood coming out both at the wound and cast up by vomiting. He is vexed with a grievous shortness o breath and with a pain in his side. We may perceive the heart to be wounded by the abundance o blood that cometh out o the wound, by the trembling o all the whole body, by the aint and small pulse, paleness o the ace, cold sweat, with oten swooning, coldness o the extreme parts and sudden death.
Te rst written report o hest injuries is to e oun in the Ewin Smith ppyrus (see Figure 2.4), 2.4), whih tes rom out 1550 bc ut is lmost ertinly opy o muh more Anient Egyptin text. O its 48 se reports, three involve hest wouns. In the 13th entury, Teoori n his pupil, Henri e Moneville, oth vote suturing
wouns o the hest in orer to prevent ir entering through the thori vity. Others, suh s Guy e Chuli (see Figure 4.7), 4.7), oppose immeite losure to llow the espe o loo. Amroise Pré ws lso ginst immeite suture o hest wouns, lthough he gree tht this ws ontroversil topi. He esries n interesting se o hest injury tht he elt with in the mpign in urin in 1537: While in Turin in the service o the late M de Montejan, I was called to treat a Parisian soldier soldie r named L’Evesque, L’Evesque, under command o Captain Renouart, who was wounded with three severe sword thrusts. One great wound under the right breast penetrated the chest cavity. A great quantity o blood collected on the diaphragm, which impeded respiration and he could speak only with great pain. He had a high ever and with it all he spat blood and had severe pain in his wounded side. The surgeon who rst treated him had sewn up his wound so nothing could come out. The next day I was called to see the patient, and seeing the complications and death approaching, I was constrained to open the wound, at the orice o which I ound blood clot. Then I had the patient’s legs lited, with the head and upper part o the body leaning over the bed, resting one hand on a stool lower than the bed. Being so placed pla ced I had him close his mouth and nose and infate the lungs. The diaphragm, intercostal and 211 1 21
21 212 2 Thoracic and vascular vascular surgery
epigastric muscles contracting, caused the blood collected in the chest to jet through the wound. And to help him do it better, I put my nger deep in the wound to break up the coagulated blood and seven to eight ounces o etid and corrupt blood drained. Then I put him in bed and injected the wound with barley water in which rose, honey and sugar candy had been boiled. Then I had him turn rom side to side and nally to lie head down as beore. Then one saw little thrombi and clots o blood come out with the irrigation. This done, the complications diminished and little by little ceased… to conclude, this injury was so well handled that beyond my expectation, the patient recovered.
Both leing lei ng surgeons on the Frenh n British sies in the Npoleoni wrs, rom their own experiene, eme onvine tht losure o thori wouns ws eneil. eneil. During the Egyptin Eg yptin mpign o 1798–1801, Bron Lrrey (see Figure 9.7) 9.7) wrote The number o soldiers that died o haemorrhage in consequences o wounds penetrating the chest and injuring the lungs induced me to attend minutely to such accidents. A soldier was brought to the hospital o the ortress o Ibraym Bey immediately ater a wound o this kind made by a cutting instrument that penetrated the thorax between the th and sixth true ribs, and ollowed their direction; it was about eight centimetres in extent; a large quantity o rothy and vermilion blood escaped rom it with a hissing noise at each inspiration. His extremities were cold, pulse scarcely perceptible, countenance discoloured, and respiration short and laborious; in short, he was every moment threatened with a atal suocation. Ater having examined the wound, and the divided edges o the parts, I immediately approximated the two
lips o the wound and retained them by means o adhesive plasters, and a suitable bandage round the body. In adopting this plan, I intended only to hide rom the sight o the patient pati ent and his comrades the distressing spectacle o a haemorrhage which would soon prove atal and I thereore thought, that the eusion o blood into the cavity o thorax, could not increase the danger. But the wound was scarcely closed when he breathed more reely, and elt easier. The heat o the body soon returned and the pulse; in a ew hours he became quite calm and to my great surprise grew better. He was cured in a very ew days and without diculty. At the hospital o the imperial guard, we had two cases exactly similar.
George Guthrie (see Figure 9.10), 9.10), vetern surgeon o the Npoleoni wrs, esrie severl ses o open wouns o the hest trete suessully y eep interrupte suture, ompress n nge. He summe up his experiene in his monogrph On Wounds and Injuries o the Chest , whih he pulishe in 1848 n whih represents the rst ook in the English lnguge evote entirely to the surgery o the hest. hest . His generl onlusions were tht ll wouns o the hest shoul e lose s quikly s possile, pos sile, ut tht i the pleurl vity lls with loo n proues respirtory respirtory istress, the woun shoul e re-opene n the loo evute. Serous olletions o ui in the hest shoul e rine, n or this, the tror n nnul n e use. In spite o this experiene, tretment o wouns o the hest remine ontroversil, ontroversil, n, inee, i nee, in the erly yers o the First Worl Wr, hest wouns were trete onservtively uner the re o the physiins. Not surprisingly, mny o the injure evelope n empyem n, o these, 50% ie. By 1916, 19 16, it ws relise tht hest wouns neee to e trete in the sme mnner m nner s wouns elsewhere, y exision o mge tissue, hemostsis, removl o oreign oies n then losure. Dringe ws not use t this time sine the unerwter rin h not yet een evise, s we shll isuss lter. By the en o the wr, George Gsk (1875–1951),
Lung surgery 213
lter to eome the rst proessor o surgery t St Brtholomew’s Hospitl, ws le to report lrge series o penetrting hest wouns ssoite with injury to the lung with totl mortlity o 20%. Tis ompre with mortlity o 79% or hest wouns in the t he Crimen Wr. Empyema, enoting olletion o pus in the pleurl vity, is n ol term ting k to the Anient Greeks (Greek en, in, pyon, pus), n still ommonly use toy in preerene to the more sienti term pyothorx. Its linil etures were well esrie in the Hipporti writings o the 4th entury bc: In the rst case the ever does not go o but is slight during the day and increases at night, and copious sweats supervene, there is a desire to cough and the patient’s expectorate nothing worth mentioning, the eyes become hollow, the cheeks have red spots on them, the nails o the hands are bent, the ngers are hot, especially their extremities, there are swellings in the eet, they have no desire o ood and small blisters occur over the body.
Note the esription ‘the nils o the hns re ent’, whih surely reers to the luing o the t he ngertips tht my our with hroni lung sepsis. A test o gret ntiquity is Hipporti suussion, splshing soun proue y shking the t he ptient, who shoul e in the sitting position. posit ion. It ours only when ui n ir re present within the hest vity. With regr to tretment, Hipportes vises ringe y the use o the utery or y inision, while Celsus vises ‘on the sie where there is the gretest swelling hot iron must e pushe in until it rehes the pus n the mtter is rwn o’. o ’. Osionlly, the sess woul point n rin spontneously through the hest wll; on other osions, it might rupture into the ronhil tree. An exmple o this is esrie y Amroise Pré: Benedict de Vallé, native o Turin, aged 25 years, ell ill o pleurisy which sups uppurated and made an empyema. He coughed severely, expectorating etid pus or 6 weeks, then it ceased or
20 days, at the end o which when he he bent over or shook himsel, one heard a sound in his body like a hal-lled bottle… nally he called me and having studied his illness, I advised him to have a rib opened to drain the pus. He agreed to do this when he was a little stronger. Some days later nature drained the pus by great vomiting, ollowing which he recovered completely by the grace o God and o nature. At present he is as well as i he had never been ill.
Lorenz Heister (see Figure 6.7) 6.7) in his General System o Surgery o 1743 illustrtes tror n nnul very muh like the t he instrument use toy to e employe or or the evution o pleurl pleur l olletions. Te use o wie ore neele or spirtion ws introue y Toms Dvies (1792–1839) o Lonon in 1835, n y 1844, report rom the newly opene Brompton Hospitl in Lonon reporte nine ses trete y this metho with only one eth. Surgil ringe o hroni empyem ws rrie out either y n interostl inision or y trephining ri. It ws Willim Aruthnot Lne (see Figure 10.7), 10.7), while House Surgeon to the Vitori Hospitl or Chilren in Chelse, who showe the importne o ri resetion in this opertion. He pulishe ve ses in hilren with our suesses. It took some yers eore this eme stnr proeure when experiene showe tht there ws no inrese risk o severe inetion or nerosis o the ut ens o the ris. In the mjority o ses o empyem, ertinly in hroni isese, the pleur is thikene n the lung xe y hesions to the hest wll. However, i the norml hest is opene, either y trum or y the surgeon’s knie, the negtive pressure in the pleurl spe tht keeps the lung hel to the hest wll is olishe olishe, , ir rushes into the pleurl vity n the lung ollpses. Moreover, the meistinum meist inum my swing with eh respirtory movement, prouing the shok o meistinl utter. Gotthr von Bülu (1836–1900) o Hmurg solve this prolem with his unerwter rin (Figure (Figure 14.1). 14.1). When the ptient rethes out, the intr-pleurl pressure rises n the ir, loo or pus in the pleurl vity rins through the tue elow the
21 214 4 Thoracic and vascular vascular surgery
Figure 14.2 Evarts Graham. (Royal College o Surgeons o England.)
Figure 14.1 Underwater chest drainage. (From Sauerbruch F, O’Shaughnessy OL: Thoracic Surgery . London, Arnold, 1937.)
unerwter sel. When the ptient inspires, the wter in the hmer rises in the tue n min-
the mortlity to 15%. We shll meet Grhm gin lter in this hpter s pioneer o lung resetion, ut in ition to his ontriutions to hest surgery, he is rememere s the inventor o holeystogrphy, the riologil emonstrtion o the gll ler using ioine-lelle phenolphthlein. Tis sustne is exrete y the liver into the
tins the sel, preventing irisentering theroutinely pleurl vity. Tis simple pprtus use toy to y er hest surgery, thori trum or in ringe o intr-pleurl olletions. Te immense vlue o the unerwter rin ws unerline y the work o Evrts Grhm (1883–1957) (Figure 14.2), proessor o surgery t Wshington University in St Louis. During the inuenz epiemi o 1918, there were numerous ses o ute streptool empyem mong the Amerin troops. In this onition, the pus is thin, ompre to the thik mteril seen in hroni empyem n in the more ommon ute stphylool empyem. Open
gll ler, where it isthe onentrte, rio-opque, outlines vity o then, gll eing ler. Tis metho hs only reently een reple routinely y ultrsonogrphy.
ringe ssoite withGrhm n extremely high mortlity,ws s muh s 70%. use lose ringe with the unerwter system n reue
risk o ying, nyoung o seeing my ontemporries – meil stuents, otors, nurses – fite y this isese (Figure (Figure 14.3) 14.3).. At the en o the 19th
TUBERCULOSIS It is iult or helth workers toy to relise the enormous impt o tuerulosis, espeilly o the lungs, in the pre-ntiioti er eore the 1950s. As young stuent, H.E. ws only too wre o the sntori eing ull o young men n women o my ge, inrerte or yers, with signint
Resect Resection ion o the lung 215
Figure 14.3 A tuberculosis sanatorium; the Maitland Sanatorium in Berkshire, 1910. (Photograph provided by the late Roger Parker FRCS [ENT surgeon, Reading].)
entury, surgil mens were introue to ollpse, n thereore to rest the isese lung, s well s to oliterte vitting isese. In 1882, the sme yer tht Roert Koh (1843–1910) nnoune the isovery o the illus o tuerulosis, Crlos Forlnini (1847–1918), physiin in urin who lter move to Pu, suggeste the use o n rtiil pneumothorx to ollpse the lung n egn to perorm the proeure in 1888. He use oxygen t rst ut, euse o its rpi sorption, swithe to nitrogen. Te proeure
RESECTION OF THE LUNG Erly ttempts t removing ll ll or prt pr t o lung were rrie out or hroni inetion – tuerulosis, ronhietsis n lung sess. MH Blok (ie
ws tken upFigure with enthusism Chigooylung JB Murphy (see 14.22). Otherinmethos 14.22). Other ollpse were ivision or rushing o the phreni nerve, to prlyse the iphrgm, n pneumoperitoneum. A more ril metho o ollpsing the lung ws the opertion o thoroplsty, in whih the ris on the ete sie were resete, usully in stge proeures. Tis ws rst perorme y Eour e Cérenvelle (1843–1913) o Lusnne in 1885 n populrise y Ferinn Suerruh (1875–1951) o Berlin n y mny other thori surgil pioneers. All these tehniques were employe until the introution o
Figure 14.4 Chest X-ray o a patient ater extensive surgery or pulmonary tuberculosis; thoraco-
eetive nti-tuerulous rugs, still see the osionl elerly ptient whon hs we unergone thoroplsty (Figure 14.4).
plasty on the let, plombage on the right using lucite spheres. X-ray provided by Jules Dussek FRCS, Guy’s Hospital.
21 216 6 Thoracic and vascular vascular surgery
1883) o Dnzig rrie out pneumonetomies in rits in 1881, showe tht the nimls oul sur vive n onsiere, thereore, tht the opertion woul e possile in the humn. He then operte on his emle ousin who h tuerulosis o the pies o oth lungs. She ie post-opertively post- opertively n Blok, in espir, shot himsel, utting short wht woul proly hve een rillint reer. Domenio Bioni (1855–1914), proessor o surgery in Pu, soon erwrs pulish pulishe e extensive niml stuies o pneumonetomies in numer o speies, n in 1884, reporte suessul removl o the lung in nimls in whih he h previously inue tuerulosis. Teoore uer (1857–1929) in Pris suessully resete tuerulous pex o the lung in 1891, n this proeure ws soon ollowe y numer o other surgeons. Te rst surgeon to remove n entire lung, the opertion o pneumonetomy, ws Sir Willim Mewen (see Figure 10.16), who, 10.16), who, in 1895, simply soope out lung tht h een lmost estroye y tuerulosis. Four weeks lter, he oliterte the gret spe le ehin y perorming two-stge thoroplstyy n the ptient thoroplst pt ient ws well 11 yers lter. Te pioneers o lung resetion e two severe tehnil prolems. Te rst ws how to el with the peile o the loe or o the hilum o the lung with its lrge pulmonry vessels n the ivie ronhil stump. Initilly, tourniquet ws use t the hilum to proue nerosis o the loe, with susequent removl o the e tissue. Lter, the hilum ws lmpe n mss ligture ws use,
Figure 14.5 Sauerbruch’s low-pressure chamber or thoracic surgery. (From Sauerbruch F: Zur Pathologie des oenen Pneumothorax. Mitteilungen aus den Grenzgebieten der Medizin und Chirurgie Jena, Jena, volume 14, 1904.)
ssistnt to Johnn von Mikuliz in Breslu, introue negtive pressure hmer tht ontine the oy o the ptient plus the surgil tem. Te ptient’s he projete through n opening in the hmer n ws ville or the nesthetist. Te negtive pressure in the hmer overme the prolem o the pneumothorx in the opene hest, ut the negtive pressure inet proue lmost impossile onitions or the opertive tem n the positive pressure through the e msk inte the stomh s well s the lungs o the ptient (Figure 14.5). It ws the evelopment o the enotrhel
ollowe lter stilltheyeventul suturingevelopment the hilum over tourniquet, with o the moern tehnique o isseting out eh o the min strutures n losing them iniviully y ligtion or suture. Te seon, n even more iult, hzr ws nesthetising the ptient or hest surgery, sine opening the thorx resulte in ollpse o the lung. Te stnr tehnique ws simply to use tightly tting msk over the ptient’s mouth n nose. Ruolph Mts (1860–1957) o New Orlens use ellows system through trheostomy tue to inte the lungs, n in 1899, his
tuethe yFirst IvnWorl MgillWr n (see Stnley Rowothm uring t he Chpter 9) tht relly 9) tht pve the wy or moern thori nesthesi, while the evelopment o the ue enotrhel tue y Rlph Wlters (1883–1979) o Mison, Wisonsin, n Arthur Gueel (1883–1956) o Los Angeles enle the nestheti to e given vi the norml lung while the ronhus o the ete lung ws sele o y the u (Figure ( Figure 14.6). Te rst suessul eletive loetomies were perorme y Temistokles Gluk (1853–1942), iretor o the Kiser n Kiserin Hospitl, Berlin, in 1901. Te rst se h resetions o the le
ollegue, FW Prhm, use thewll pprtus to remove growth rom the hest with suess. Ferinn Suerruh (1875–1951), while n
lower nseon prt ows the or le gngrene upper loeoor tsis; the theronhiele lower loe ollowing septi pulmonry inrt. In 1907,
Resect Resection ion o the lung 217
Figure 14.6 A rubber-cued endotracheal tube. Nowadays, these are made o plastic. (Westminster Hospital.)
Gluk resete the right lower loe o 5-yer-ol or tuerulosis. Te rst issetion loetomy, the tehniquee use toy o eling iniviully with tehniqu the strutures o the hilum, ws perorme in 1912 y Morriston Dvies (1879–1965) o University College Hospitl, Lonon. Te ptient, who h rinom o the lung, unortuntely ie o empyem, ut utopsy showe tht the ronhil stump ws intt. It ws not until the 1930s tht this metho eme the tretment o hoie. Hugh Morriston Dvies h remrkle reer. A rillint stuent, he ws ppointe to the st t University College Hospitl t the ge o 29. He stuie uner Suerruh in Berlin n
Figure 14.7 The rst pneumonectomy or lung cancer. Diagram o the resected lung, showing (A) the location o the tumour in the upper lobe bronchus. The location o numerous small abscesses is also demonstrated. (From Graham EA, Singer JJ: Successul removal o an entire lung or carcinoma o the bronchus. Journal of the American Medical Association Association 1933; 101, 1371.)
in 1912 Kingom. perormeInthe1916, rst he thoroplsty the Unite suere in severe inetion o his right hn er operting on septi se, n this ppere to e the en o his surgil reer. He resigne his hospitl ppointment n purhse sntorium or tuerulosis in North Wles, ut, ning tht there ws nooy there to operte on his ptients, tught himsel to operte with his le hn n me his sntorium entre or the surgil tretment o pulmonry tuerulosis, t uerulosis, ontinuing to work until the ge o 80. Te lnmrk yer or the moern issetion
in theGrhm post-opertive his1957. surgeon; himselperio ie on lungoutlive ner in In the sme yer s Grhm’s suess in 1933, Willim Rienho (1894–1980) o the Johns Hopkins Hospitl, Bltimore, perorme two suessul issetion pneumonetomies. His rst ws or enign lung tumour in hil o three n his seon or rinom o the lung. It ws Rienho who li own the moern priniples o eling with the hilum; he ligte the pulmonry vessels iniviully, iniv iully, ivie the t he ronhus with the knie n not the utery, thus voiing mge to its loo supply, lose the ronhus with wit h inter-
pneumonetomy ws 1933onwhen Evrts Grhm (see Figure 14.2) operte 14.2) operte 40-yer-ol ostetriin with lung ner (Figure 14.7). Te ptient
rupte sutures, rine thenhest n showe tht the opposite lung will expn exp to oliterte the e spe within the thorx.
survive n empyem n ronhopleurl stul
21 218 8 Thoracic and vascular vascular surgery
CARDIAC SURGERY
CONSTRICTIVE PERICARDITIS
o the ly puli, n opertion on the hert seems to e the ultimte mystery. Inee, even to the surgeons who h lrey onquere the other mjor orgns, the onept o operting on this onstntly eting n vitl musle seeme istnt rem, espeilly when rrest o the loo irultion or more thn ew minutes, uner norml onitions, ws known to e tl. Even tht gret pioneer o moern sienti surgery, Teoor Billroth (see Figure 8.5) wrote 8.5) wrote in 1893: ‘Any surgeon who woul ttempt n opertion on the hert shoul lose the respet o his ollegues’. Te surgery o the hert n its gret vessels n e ivie hronologilly into our rther overlpping phses: the rst is the surgery o the peririum, the rous s surrouning the hert, n o the jent gret vessels; the seon, ‘lin’ surgery o the eting hert itsel; the thir, open hert surgery using either hypothermi, hert ypss or omintion o the two; n nlly, trnsplnttion o the hopelessly mge hert. Tis ourth topi is elt with in Chpter 15.
A onition o gross rous or li thikening o the peririum, oen ue to tuerulosis, ws rst esrie y Rihr Lower (1631–1691) o Oxor, who perorme erly niml experiments in loo trnsusion. trns usion. He wrote o n utopsy in 1669: ‘Te peririum o the whole hert ws everywhere losely herent, so tht with the nger it ws srely possile to seprte it rom the hert; urther this memrne ws thik, opque n s i trnsorme into llus’. Luwig Rehn (1849–1930), o Frnkurt m Min, who we shll meet shortly s the rst surgeon suessully to el with st woun o the hert, pulishe report in 1920 o our ptients with onstritive periritis, one o whom h een operte on 7 yers previously. Te ollowol lowing yer Viktor Shmieen (1874–1945) pulishe etile esription o the opertion, whih he ompre to the peeling o n ornge. By 1937, he ws le to report on 22 ses tht he h operte upon with eight opertive eths, six ptients returning to ull tivity n the reminer hving h mrke improvement.
EXTRACARDIA EXTR ACARDIAC C SURGER SURGERY Y
PERSISTENT DUCTUS ARTERIOSUS
A smll st woun o the hert my prove tl, not only rom the ri hemorrhge itsel, ut lso rom the pressure on the hert rom the loo olleting in the periril s. Tis onition, hemoperirium, ws rst esrie
Te utus rteriosus, etween the pulmonry rtery n the ort, is one o the shunts present in the etl irultion (Figure 14.8). Normlly, it loses ew hours er irth n is ompletely oliterte within ew weeks, leving persis-
y GiovnniJen Morggni (1682–1771) in 1769. Dominique Lrrey, Npoleon’s surgeon (see Figure 9.7), 9.7), in 1810 operte on solier with tmpone ollowing sel-inite knie woun o the hest. Operting 45 ys er the injury, injur y, Lrrey opene the le hest through the ourth interostl spe, opene the peririum with istoury n evute tin sin ull o serous ui mixe with ol loo lots. Te ptient’s onition improve onsierly, ut unortuntely he ie 3 weeks lter rom the lmost inev itle post-opertive inetion. By the en o the 19th entury, it ws well reognise tht this on-
tentitsrous strn, theoligmentum s reli. Persistene the utus isrteriosum, one o the ommon orms o ongenitl hert isese. I smll, it my remin symptomless, the only risk eing o lter inetion – suute teril enrteritis. rteriti s. I lrge, however however,, it results in progressive progres sive pulmonry hypertension s loo t high pressure in signint mounts is pumpe into the pulmonry irultion. Te tehnique o eling with this onition surgilly ws worke out y John Monroe (1858–1910) t us Meil Shool in Boston n pulishe in the Annal Annalss o Surger Surgery y in 1907. He showe, in neworn ver isse-
ition shoul trete y spirtion or surgil ringe, n e some 400 ses were reore with 10% survivl.
tions, howsternotomy the hert oul pprohe through mein ne how the utus oul e ligte, ut never h se reerre to him.
Coarctation o the aorta 21 219 9
Figure 14.8 (a) A diagram o a persistent ductus arteriosus. (b) Coarctation o the aorta. (From Ellis H, Mahadevan V: Clinical Anatomy , 13th edition. Oxord, Wiley, 2013.) 2013.)
Surprisingly, thereore, it ws not until 1938 tht the opertion ws suessully perorme y Roert Gross (1905–1989) while hie resient t the Boston Chilren’s Hospitl. Te ptient ws n unernourishe girl o seven who h eome rethless er moerte exerise n whose physil tivities h thus een onsierly limite. Te meistinum ws pprohe through the le hest, n the short utus ws tie with rie silk ligture. A sterile stethosope ws use t the opertion, n this onrme tht the
COARCTATION OF THE AORTA
extremely ontinuous murmur h pere. Telou opertion ws uneventul, the isploo tken rom onor eore the opertion ws not use, n the girl me n uneventul reovery. In 1940, Gross reporte nother three suesses, n over the next 20 yers, no ewer thn 1,500 1,5 00 ses o persistent utus were trete y ligtion t this entre, with mortlity o only 3%. In his 1940 report, Gross ws outul whether ptients lrey ete y teril enoritis oul e regre s suitle or opertion; however, Oswl us (1908–1993), t St Brtholomew’s Hospitl, Lonon, using the sulphonmie sul-
Corttion o the ort is ongenitl nomly in whih the ort in the t he region o the utus rteriosus is grossly nrrowe (Figure 14.8). One theory o its etiology is tht it represents n extension o the rosing proess tht loses the utus soon er irth. Te prolem my present s hert ilure in inny, ut more oen eomes mniest some yers lter s gross hypertension, the su jet hving surv survive ive euse o the evelopment o n extrorinry system o ollterl hnnels etween the rnhes o the ort ove n elow the onstrition. Te high loo pressure, inientlly, is the result o poor perusion o the kineys. It ell to Clrene Croor (1899–1984) o the Krolinsk Institute in Stokholm to rry out the rst resetion o orttion in 1944. Te ort ws ross-lmpe ove n elow the stenosis, the segment exise n iret suture o the ivie ens rrie out. Te rst ptient ws oy o 12, n the seon ptient, ew ys lter, 27-yer-ol rmer. Both opertions were suessul. Te ollowing yer, Roert Gross, who ws
phpyriine, rst reporte ligte nsixinete utus in 1939 n y 1943 survivors in nine ses.
proly unwre o Croor’s suesses (rrie out, rememer, uring Worl Wr II), resete orttion in 5-yer-ol oy who ie o hert
220 Thoracic and vascular surgery
ilure. Te ollowing week he operte suessully on 12-yer-ol girl. Gross went on to show, in 1948, tht preserve segment o ort oul e use s homogr to restore ontinuity er resetion o long orttion.
FALLOT’S TETRALOGY In 1884, Etienne-Louis Fllot o Mrseilles esrie three ses o tetrlogy o ongenitl nomlies o the hert, now reognise to e one o the ommonest uses o ‘lue ies’ – innts who re ynose rom irth euse o eetive oxygention o the loo. Tis results either rom shunting o the loo through eet in the septum etween the right n le sies o the hert, or euse o ostrution o the pulmonry trunk, with resultnt eieny eieny o lung perusion, or omintion o the two. Fllot’s tetrlogy (Figure 14.9) omprises stenosis o the pulmonry trunk, hypertrophy o the right ventrile, ventriulrr septl ventriul sept l eet n n the t he ort over-riing oth the ventriles. Te rst opertion to el with this prolem represents one o the mjor steps in the evelopment o moern hert surgery. Russell Brok wrote: ‘It showe tht ynoti ongenitl hert isese, previously inurle n lwys tl, oul e ure y surgery. Tis inspire n stimulte the enormous vne in ri surgery tht ollowe with lmost rethless rpiity within very short time’.
Te story strts with Dr Helen ussig (1898– 1986), proessor o peitris t the Johns Hopkins Hospitl, Bltimore, who is regre s the ‘mother’ o peitri riology. She h note tht ies with Fllot’s tetrlogy, who h n ssoite persistent utus rteriosus, were in etter onition n survive longer thn hilren without this itionl eet. She relise tht the utus ws ting s shunt, llowing oxygente rteril loo rom the ort to enter the pulmonry rtery r tery istl to the stenosis. Tis suggeste to her tht mn-me shunt might serve the sme purpose. She put the proposition to Roert Gross, with his expertise on the surgery o ptent utus rteriosus, ut he regre hilren with Fllot’s tetrlogy s eing inoperle. She thereore turne to Alre Bllok (1899–1964), who ws ppointe to the st o her hospitl in 1941 n who h lrey rrie out some experimentl stuies in whih he h perorme n en-to-en nstomosis o the sulvin rtery to the pulmonry rtery in ogs to stuy pulmonry hypertension. Bllok s youngster h h pulmonry tuerulosis trete y pneumothorx, n his erly eution ws severely isrupte. Aer trining t Bltimore, Blti more, he spent 3 yers s s proessor o surgery t Vnerilt University, where he rrie out importnt stuies on shok, showing how losely the linil piture oul e orrelte with loo loss. Inspire y ussig, he proue experimentl pulmonry hypertension in ogs n showe tht the ynosis ws relieve y sulvin to pulmonry rtery nstomosis. Te rst ptient to e sumittey to the proeure, in 1944, ws 15-month-ol whose onition ws gretly improve, ut who ie ollowing urther shunt opertion tht ws require requ ire ew months lter. Te ollowing yer, two urther opertions were perorme on hilren ge 6 n 11. In these ses, the rhioephli rtery ws nstomose ento-sie into the pulmonry rtery. Both ses were suessul n, y 1952, no less thn 1,000 o these Bllok–ussig opertions h een perorme t the Johns Hopkins Hospitl with n opertive mortlity o just over 15%. In 1947 ussig n Bllok leture n em-
Figure 14.9 The tetralogy o Fallot. (From Ellis H, Mahadevan V: Clinical Anatomy , 13th edition. Oxord, Wiley, 2013.)
onstrte in Lonon, Pris Stokholm,their n opertion it ws rpily tken up y n the Europen surgeons, prtiulrly Russell Brok
Surgery on the beating heart 221
(Figure 14.13) 14.13) t Guy’s Hospitl n Chrles Duost (Figure (Figure 14.28) t 14.28) t the Broussis Hospitl in Pris. Something o the t he exitement engenere engenere y this opertion is ught y this esription o the visit o Bllok n ussig to Lonon y Russell Brok: Alred Blalock and Helen Taussig gave a combined lecture in the Great Hall o the British Medical Association; the huge hall was packed. Dr Taussig delivered her address impeccably, ollowed by Dr Blalock who presented his surgical contribution. The silence o the audience betokened their rapt attention and appreciation. The hall was quite dark or projection o his slides which had been illustrating patients beore and ater the operation, when suddenly a searchlight beam traversed the ull length o the hall and unerringly picked out on the platorm a Guy’s nursing sister dressed in her attractive blue uniorm, sitting on a chair and holding a small cherublike girl o two and a hal years with a halo o blond curly hair and looking pink and well; she had been operated on at Guy’s by Blalock a week earlier. The eect was dramatic and theatrical and the applause rom the audience was tumultuous.
Not ll ses were suitle or this proeure, espeilly very smll innts in whom the sulvin ville rtery wst too tehniques thtsmll time. or In the 1946,surgil Willis Potts (1895–1968) o Chigo, using n ingenious lmp, perorme iret sie-to-sie nstomosis etween the ort ort n the pulmonry trunk. trun k. In susequent yers, mny o these ptients, who woul otherwise hve ie, h enitive reonstrutions o their ri eets one openhert surgery eme possile, n the shunt opertions hve now psse into history.
SURGERY ON THE BEATING HEART Over romonsiere the time tl. o Glen, wounstheo enturies, the hert were With the vent o nesthesi n ntisepti surgery,
the ltter prt o the 19th entury sw n explosion in the surgery o the ominl vity, o the hest, skull n the lims, yet the hert ws onsiere to e ‘no go’ region o the oy. Teoor Billroth (see Figure 8.5), the 8.5), the ther o moern surgery rom Vienn, stte, ‘Te surgeon who woul ttempt to suture woun o the hert shoul lose the respet o his ollegues.’ While in Lonon, Stephen Pget wrote, in 1896, ‘No new metho n no new isovery n overome the nturl iulties tht tten woun o the hert. It is true tht hert suture hs een vguely propose s possile proeure n hs een one in nimls, niml s, ut I nnot n tht it hs ever een ttempte in i n prtie’. However, just yer lter, Luwig Rehn (1849– 1930), proessor o surgery t Frnkurt m Min, reporte the se o young mn who h een ste in the le hest through the ourth interostl spe n ws mitte to hospitl rethless, ple n shoke. Rehn opene the hest through the le ourth interspe, resete the h ri n opene the peririum. Bloo B loo ws seen to e emerging through periril lertion, n enlrgement o whih revele lrge mount o lot n n 1.5 m woun in the le ventrile. He wrote I used a ne needle with silk thread. At the beginning o diastole the needle was passed deeply through the muscle about the wound and at the next diastole the thread was tied… ater the rst suture the bleeding was diminished. By pulling up on the rst suture a second was easily applied. It was rightening to note that the heart stopped ater each suture was tied in place. Ater insertion o the third suture, which was specially dicult to insert because o the movement o the heart, the bleeding stopped completely. The heart now seemed to unction well and we could breathe again.
Te periril vity ws pke with iooorm guze. Te ptient evelope n empyem, whih ws rine, n, in spite o this, went on to mke ull reovery. Rehn reporte his suess German Archives o Clinical Surgery oth the Lancet n ininTe uner uner the title ‘Te suessul tretment o woun o the hert’.
222 Thoracic and vascular surgery
Soon er Rehn’s suess, Prrozzni in Rome reore seon suess, whih ws lso reporte in Te Lancet y y GS Brok, who e s omment: Happily it is only in Italy that surgeons have many opportunities o practicing cardiac surgery – opportunities that they owe to the terrible requency to which the dagger is resorted to in this country in the quarrels o the lower orders.
Wht woul Brok hve thought o the sene in our streets in this ountry toy? In 1907, 10 10 yers yers er er his suess, sues s, Rehn ws w s le to review no less thn 124 reore ses o opertions on ri st wouns, with reovery rte o 40%. O the tl ses, 44% 4 4% ie o hemorrhge hemorrhge n shok n 40% rom inetion. inet ion. He vise tht the wepon, i still present, shoul e le in ple until the peririum oul e opene ully. He vote single interostl inision rrie outwrs rom the sternl ege n pssing through the externl woun rther thn the lrge p use y some other surgeons. I more room ws neee, the skin inision ws enlrge y onverting it to n L-shpe long the outer mrgin o the sternum, iviing the expose ostl rtilges rti lges n orily orily retrting the p o skin n one. Rehn’s suessul opertion n the susequent suesses o other surgeons showe tht there ws nothing ‘sre’ out the hert – putting sutures into it ws iult ut not impossile.
o ll, Alexis Crrel (1873–1944) (see Figure 15.4) 15.4) in 1909 n 1910 perorme experimentl proeures on the og’s hert, whih inlue igitl explortion o the insie o the hert hmers, ilttion o the mitrl vlve, inision n suture o the ventriulr wll n preprtion o oronry rtery or nstomosis. In his pper On the Experimental Surgery o the Toracic Aorta and the Heart, he ntiipte oronry ypss surgery y
mny yers, writing In certain cases o angina pectoris, pectori s, when the mouth o the coronary coronary artery is calcied, it would be useul to establish a complementaryy circulation or the lower complementar part o the arteries. I attempted to perorm an indirect anastomosis between the descending aorta and the let coronary artery. It was, or many reasons, a dicult operation. On account o the continuous motion o the heart, it
At the eginning o the t he 20th were numer o suggestions tht entury, stenosethere vlves o the hert might e trete surgilly. Sir Toms Luer Brunton (1844–1916), physiin t St Brtholomew’s Hospitl, Lonon, perhps est known or introuing myl nitrte in the tretment o ngin, wrote letter to Te Lancet in in 1902 hee A Preliminary Note on the Possibility o reating Mitral Stenosis by Surgical Surgi cal Methods, whih ollowe experiments on e ogs with instruments psse through the hert wll. Aruthnot Lne (see Figure 10.7) 10.7) wrote enthusistilly to in response to this n ws keen to try tr y Te Lancet in
was not easy to dissect and suture the artery. In one case I implanted one end o a long carotid artery, preserved in cold storage on the descending aorta. The other end was passed through the pericardium and anastomosed to the peripheral end o the coronary artery. Unortunately the operation was too slow. Three minutes ater the interruption o the circulation brillary contraction appeared but the anastomosis took 5 minutes. By massage o the heart the dog was kept alive ali ve but died 2 hours later. As we shll see, iret oronry rtery surgery i not eome estlishe until the lte 1960s! In the 1920s, two surgeons perorme opertions or mitrl stenosis with reovery o the ptient. In Boston, Elliott Cutler (1888–1947), who ws to suee Hrvey Cushing s hie o surgery t the Brighm Hospitl, inserte nrrow knie through the wll o the right ventrile in n 11-yer-ol girl n linly ut the stenose mitrl vlve. Te hil reovere n survive sur vive or 4 yers, lthough she remine isle y repete epi-
utting the vein. vlve None with olong knie psse the jugulr the physiins t own Guy’s woul ever reer ptient to him ! Most remrkly
soes o hert ilure nptients n hrly e regre s suess. wo wo ur ther urther who sumitte to the sme proeure ie post-opertively.
Surgery on the beating heart 223
It ws Sir Henry Sessions Souttr (1875–1964) (Figure 14.10), o the Lonon Hospitl, who in 1925 rrie out the rst trns-uriulr mitrl vlvotomy, n opertion tht woul not e revive until 1948. His ptient ws girl o 15, uner the re o Lor Dwson, who ws mitte in prlous stte with ynosis n hert ilure. Te hert ws pprohe y turning lrge skin p on the le hest outwrs, n p o three ris inwrs (Figure 14.11). Te mitrl vlve ws ilte y
(Figure 14.12) 14.12) whih ws then lose with silk ligture. Te girl me smooth reovery n live in ir helth or 5 yers. She then h ererl inrt, proly rom lot in the le uriulr ppenge, rom whih she ie. Souttr wrote: ‘It ppers to me tht the metho o igitl explortion through the uriulr ppenge nnot e surpsse or simpliity n iretness. Not only is the mitrl orie iretly iretly to hn, ut the orti vlve itsel itsel is most ertin ert inly ly within withi n reh, through th rough the mitrl orie’. Souttr ws keen, o ourse, to repet the proeure ut never i so. He live long enough, however, to see his opertion revive y others. In his 83r yer, he wrote: ‘I i not repet the opertion euse I ouln’t get nother se. Tough my ptient me n uninterrupte reovery the physiins elre tht it ws ll nonsense n in t tht the opertion ws unjustile’. Te urrent meil opinion o tht time ws tht the symptoms o vlvulr isese o the hert were proue y ‘exhustion o the hert musle’ rther thn the ostruting eets o the vlvulr isese. Progress in iret surgery o the hert now h to wit until the Seon Worl Wr. A numer o exmples o suessul removl o oreign oies loge in the hert were reporte uring the First Worl Wr, or exmple, y the Frenh surgeons Pierre Duvl (1874–1941) n Henri Hrtmnn (1860–1952) n y Berkeley Moynihn (see Figure 8.16). 8.16). Duvl inientlly lso pioneere the removl o oreign oies o wrre loge in
nger psse through the t he le uriulr ppenge
the lung. However, it ws the Seon Worl Wr
Figure 14.10 Henry Souttar. (Royal College o Surgeons o England.)
Figu re 14.11 Figure 14.11 Souttar’s mitral valvotomy, the approach. (a) Skin fap raised. (b) Chest wall fap with pleura turned inwards. (c) Pericardium opened to reveal the let auricular appendage.
224 Thoracic and vascular surgery
Figure 14.12 Souttar’s mitral valvotomy; the procedure. (a) Sot clamp applied to the base o the let auricular appendage. Antero-posterior incision made. (b) Let orenger inserted into the incision. Clamp was then removed to allow the nger to enter the let atrium. (From Souttar, H: The surgical treatment o mitral stenosis. BMJ 1925; 1925; 2, 603.)
tht provie extensive experiene o this type o surgery. At the time o the Normny Lnings in 1944, young surgeon, Dwight Hrken (1910– 1993) o the Brighm Hospitl, Boston, who h een surgil registrr t the Brompton Hospitl in Lonon eore the wr, ws ppointe the hie o surgery t the Unite Sttes Army Chest Center in Engln. In 1946, he pulishe his stonishingly goo results o surgery perorme or missile wouns o the meistinum. Tese omprise 78 missiles lote in n roun the gret vessels, 56 in the hert wll or peririum n 13 within the hert hmers themselves. Every ptient reovere. Aer the wr, there ws renewe interest in the
Also in 1948, n inee within ew months o eh other, our surgeons rrie out suessul opertions or mitrl stenosis resulting rom rheumti ever. Hore Smithy (1914–1948), o Chrlotte, revive the Cutler opertion using punh psse through the right tril ppenge
possiility o operting on Toms ptients with stenosis o the hert vlves. In 1947, Holmes Sellors (1902–1987) o the Milesex Hospitl operte on 20-yer-ol ptient with Fllot’s tetrlogy. He oun tht the stenose pulmonry vlve pro jete into i nto the pulmonry pul monry tru trunk nk with w ith eh et o the hert. He psse tenotomy tenotomy knie through th rough the inuniulum o the right ventrile, ivie the stenose vlve n the ptient i well. Russell Brok (1903–1980) (Figure 14.13), erly in the next yer, n proly unwre o Sellors’ suess, use speilly esigne iltor in three ses o pulmonry stenosis. Lter in the sme yer, he esigne punh resetssoite the inuniulr musle stenosis tht istooen with Fllot’s tetrlogy.
Figu re 14.13 Figure 14.13 Russell Brock. (Portrait in the Gordon Museum, Guy’s Hospital.)
Open-heart surgery 225
to remove portion o the mitrl vlve. Chrles Biley (1910–1993) t the Hhnemnn Hospitl, Philelphi, Dwight Hrken in Boston n Russell Brok t Guy’s ll opte the nger rture tehnique use y Henry Souttr in 1925. It ws this tehnique tht ws wiely opte, lthough lter moitions inlue using nger knie, mehnil iltor or ne sissors. Mny thousns o these ‘lin’ opertions were perorme until the introution o hert ypss me iret surgery on vlves possile. Russell Brok ws w s one o the gret nmes in postwr thori t hori surgery. He ws stuent t Guy’s n spent the whole o his surgil reer there n t the Brompton Hospitl or Diseses o the Chest. It ws the yer he spent with Evrts Grhm (see Figure 14.2) in 14.2) in St Louis with Rokeeller ellowship in 1929 tht evelope his interest in hest surgery. He me importnt ontriutions to the etile ntomy o the lung – so importnt in segmentl resetion – n in the tretment o lung sess, s well s his ri work esrie erlier. He ws shy mn with rusque mnner, ut ws entirely eite to his work. In 1965, he ws ppointe Lor Brok o Wimleon.
By 1950, opertive proeures perorme either linly through the hert wlls or y shunting o mjor loo vessels h rehe their limits o hievement. Further progress epene on eing le to open the hert hmers n rry
o ourse, is tht, eprive o its irultion, the rin is irreprly mge in 4–5 minutes. wo possiilities were now explore, hypothermi or hert ypss pump. Cooling the oy prolongs the time tht the irultion n e interrupte, sine ol tissues require less oxygen thn norml. Hypothermi ws inue y pling the nesthetise ptient in n ie-wter th, giving hlorpromzine to prevent shivering. A temperture o 30°C llows the surgeon 10-minute perio o ri rrest; enough to rry out simple tril eet repir, or exmple. Initil experimentl work y WG Bigelow (1913–2005) o oronto, pulishe in 1950, reporte tht ogs oole to 20 °C llowe 15 minutes o ri rrest; in 11 ogs upon whom shm opertions were perorme on the hert, six survive er reovery. wo yers lter, John Lewis, ssiste y Rihr Vro (ontemp.) n Wlton Lillehei (1918–1999) t the University o Minnesot in Minnepolis oole 5-yer-ol girl to 27 °C n repire n tril eet with survivl. sur vivl. Hypothermi remine the sole metho o open-hert surgery rom 1952 until 1954, when riopulmonry ypss eme ville. Te story o the evelopment o the hert pump is one o gret enevour on the prt o hnul o pioneers. Te prolems were immense, prtiulrly how to oxygente the loo without lling it with ngerous ngerous ules o gs n how to pump the loo without the pump itsel mging the loo orpusles. Muh o the erly work, in t, ws rrie rr ie out y one mn, John Gion (1903–1973 (1903–1973), ),
ireteet surgery, exmple, suture In or pth outseptl – or‘hole in thetohert’. 1951, Roert Gross, super tehniin, esrie his ingenious tehnique in whih he suture plsti well on to the right trium through whih he opene this hmer; loo woul rise up in the well ut not overow rom this low-pressure vity. Trough the well, he oul pss nger into the trium to plpte the septl eet n, with his gret skill, oul suture it through the pool o loo. Oviously, this ws iult opertion n ny error in ignosis – i the eet, in t, involve the ventriulr septum, or exmple –
ssiste yommene his wie, who wsin 1934 lortory tehniin. Tey work when Gion ws surgil reserh ellow t the Msshusetts Generl Hospitl in Boston. He strte with seonhn ir pump to irulte the loo n n oxygentor tht omprise rotting rum to proue thin lm o loo expose to oxygen ross mesh sreen. It ws not until 1939 tht the Gions oul hieve long-term survivl o ts sujete to omplete interruption o their irultion. Te work ws interrupte y the wr, ut reommene in 1945, y whih time Gion ws proessor o surgery t Jeerson Meil College
woul proeure impossile. Howrener then the to stop the hert n llow surgery on the now quiet n empty pump? Te prolem
in Philelphi. 1948, he ws le to repir rtiilly proueBy ventri ventriulr ulr septl eets in ogs. In 1953, Gion n his tem use the pump to
OPEN-HEART SURGER SURGERY Y
226 Thoracic and vascular surgery
operte on ve ptients with septl eets. Only one, the rst, n 18-yer-ol girl, survive er her tril eet ws repire with ontinuous silk suture uring 26-minute ri rrest perio. Disourge y the issters o the sueeing our ptients, Gion none urther ri surgery t the ge o 53. A yer lter, in 1954, Wlton Lillehei (1918– 1999) in Minnepolis introue revolutionry ie; he use onor (usully the hil’s prent) s the ‘pump oxygentor’, linking the onor’s irultion to tht o the ptient, n utilising the onor’s lungs s the mens o oxygention (Figure 14.14).
Assiste y Rihr Vro (1912–2004), he rrie out losure o ventriulr septl eet in hil uner ross irultion rom the ther. Te opertion went well, ut the hil ie o pneumoni on the 11th y. Te seon n thir ptients survive, n totl o 45 omplex ongenitl hert nomlies were repire with resonle results. For exmple, ve out o ten hilren with reonstrution reons trution o their Fllot’ Fllot’ss tetrlogy tetrlog y survive. sur vive. Not surprisingly, the opertion me uner serious ritiism rom the morl point o view; it ws lle n operti opertion on with poten potentil til mortlity risk o 200%, with the istint nger tht oth the
Figure 14.14 Intra-cardiac surgery on a child using cross circulation rom the parent. (From Lillehei CW: The birth o open-heart surgery. Cardiovascular Surgery 1994; 1994; 2, 308.)
Articial heart valves 227
ARTIFICIAL HEART VALVES
Figure 14.15 Schematic diagram o the De Wall– Lillehei bubble oxygenator ox ygenator.. (From Nae AP: The Story of Thoracic Surgery . Bern, Hans Huber, 1990.)
ptient n the onor might perish. Inee, one mother potentil onor h iult nestheti inution with ri rrest. She reovere, lthough suering prtil prlysis, pr lysis, n the opertion ws nelle. Aprt rom this, there ws, in t, no onor moriity. However, the suesses i revive interest in the use o ypss pump. Inee, Lillehei himsel, with Rihr R ihr e Wll, Wll, evelope n eetive pump using the tehnique o uling oxygen through the loo n then removing the ules in hmer ontining silione nti-om sustne. Tis pprtus ws rst use linilly in 1955 (Figure 14.15). Menwhile, t the Myo Clini in Rohester,
As erly s 1949, Chrles Hungel (1917–1989) evelope prostheti ge ll vlve n rrie out the rst humn vlve implnt y inserting his pprtus into the esening ort, leving the mge vlve in situ. By 1952, now t the Georgetown University in Wshington, he ws le to report 23 opertions with 17 survivors. One open-hert surgery h een me possile, the wy ws open or iret vlve replement, n the rst suessul su-oronry orti vlve implnt ws rrie out y Dwight Hrken in 1963. Vlve surgery ws unoutely populrise y Alert Strr (1926–) in Portln, Oregon. He onstrute his own ptent o ll vlve with n engineer, Lowell Ewrs (who h esigne the uel pump use in Amerin ghter plnes in the Seon Worl Wr) n, y 1967, 1,800 Strr– Ewrs vlves h een implnte worlwie (Figure 14.16). Other orms o vlve replement were the tilting is or hinge vlve (Figure 14.16), pioneere t the Krolinsk Hospitl in Stokholm y Viking Bjork (1918–2009), n the use o hert vlves tken rom the pig n l evelope y Donl Ross (1922–2014) t the Ntionl Hert n Guy’s Hospitls in Lonon. Tese ‘iologil vlves’ hve the vntge tht the ptient oes not require susequent ntiogultion therpy to prevent lotting. However, they hve more limite liespn ompre with mehnil vlues n re thereore use in the oler ge group o ptients.
Minnesot, John Kirklin n his pump. tem investe hevily in improving the Gion Te initil results were rnkly terrile; ll ve o Kirklin’s ptients ie immeitely or soon er surgery. O the next ten, ve survive, ut within 2 yers, the mortlity ws elow 10%. Now n mzing sitution existe. Troughout 1955–1956, there were only two ples in the worl, some 90 miles prt, where it ws possile to oserve vnt-gre surgeons o the y perorming open-hert surgery. Visitors rom ll over the worl ommute etween Rohester n Minnepolis to wth Kirklin n Lillehei perorm wht seeme e yers, mirulous surgery. O over the nexttoew the mhines nourse, tehniques spre throughout the worl.
Figure 14.16 Prosthetic heart valves. Flap valve on the let and ball valve on the right. (Guy’s Hospital.)
228 Thoracic and vascular surgery
THE SURGERY OF CORONARY ARTERY DISEASE Attempts to revsulrise the hert musle, the myorium, in oronry rtery isese (now, o ourse, one o the ommonest uses o eth in the Western worl) ommene in the 1930s. Inee, Clue Bek (1894–1971), proessor o surgery t the Western Reserve University, Cleveln, evote most o his proessionl lie to this. Aer extensive niml experimenttion, he perorme the rst humn opertion in this el in 48-yerol mn with severe ngin in 1935. Bek rie the sure o the le ventrile with urr n suture to it peile gr o petorlis mjor musle. Seven months lter, the ptient returne to work s grener. Over the next 2 yers, Bek r rrie out totl o 20 suh opertions. O the rst 16 ses, eight ie, lthough the lst ve ptients in the series ll survive. In 1941, Bek introue the use o sestos power to proue hesions etween the hert musle n peririum. Others use tl, rorunum power n other irritnts n, until the vent o oronry ypss surgery, this proeure remine the ommonest opertion or oronry isese. In 1955, Bek reporte 75 suh opertions with linil improvement in 90% o ses. He lso went on to evise vein gr gr etween the esening ort n the oronry sinus, the min venous ringe o the hert, to peruse the hert musle in retrogre mnner. Menwhile, in Lonon, Lwrene O’Shugnessy
Figu re 14.17 Figure 14.17 Laurence O’Shaugnessy. (Royal College o Surgeons o England.)
outrek o the wr, he joine the Royl Army Meil Corps (RAMC) n ws kille t the evution o Dunkirk in 1940, trgi t rgi loss to surgery. Not surprisingly, the opertions o Bek n O’Shugnessy met with onsierle ritiism on the grouns tht hesions normlly eome vsulr n tht ny improvement oserve in the ptients woul e purely sujetive. I ws
(1900–1940) (Figure 14.17)stuies ws rrying experiments n linil on theout useog o the omentum s vsulr gr to the ishemi hert (rio-omentopexy). O’Shugnessy ws Newstle grute who h worke s surgeon in Sun. While on leve rom there, he visite Suerruh in Berlin n ws inspire to tke up ri surgery. On returning to Engln, he set up riovsulr lini t Lmeth Lonon County Counil Hospitl. He showe tht greyhouns who h unergone oronry rtery ligtion h norml exerise tolerne ollowing n omentl gr. By 1938, he oul report 12 humn omentopexy
prtiulrly intereste in this, euse in 1958, while rrying out experimentl stuies on postopertive ominl hesions or my otorte thesis, I showe tht hesions etween the omentum n evsulrise intestine oul proue suh extensive vsulr nstomoses tht the ishemi intestine oul survive with its new loo supply. I suggeste tht the sme phenomenon my well hve tken ple in these opertions on ishemi herts. ishemi Another pproh pproh to myoril revsulristion ws evise y Arthur Vineerg (1903–1988) t MGill University in Montrel. In this oper-
opertions; there were three opertive eths, isut the rest o the ptients, ll with severe ri ese, showe rmti linil improvement. At the
tion, the internl mmmry moilise n implnte into(thori) the hert rtery muslews in n eort to proue ollterl nstomoses. Aer
o coronary The surgery o coronary artery disease 229
extensive niml experiments, he rrie out the rst humn opertion in 1950, n in 1964 omine this proeure with omentopexy. He ws le to show eviene in post-mortem injetion stuies o the evelopment o new vsulr ommunitions into the herts. All these proeures were, o ourse, to e reple y iret surgery on the oronry vessels themselves – proeure tht shoul e rememere – suggeste s long go s 1910 y Alexis Crrel Cr rel (see Figure 15.4 n 15.4 n p. p. 221). 221). It ws to e hl entury eore Crrel’s experimentl work woul e relise linilly. In 1956, Chrles Biley (1910–1993) t the Hhnemnn Hospitl, Philelphi, rst perorme oronry rtery enrteretomy, removing lolise lok in the vessel. Tis ws perorme suessully without riopulmonry ypss. Te rst opertion o this nture using ypss ws rrie out y Chrles Duost (1914–1991) in Pris (see Figure 14.28), who relieve syphiliti ostrution t the mouth o the right oronry rtery. Te rst
oronry ypss, using segment o vein, muh like the Crrel opertion, ws rst perorme y Dvi Siston (1924–2009) in 1962 (Figure 14.18), 14.18), ut the ptient ie ie 3 ys lter o ererovsulr ient. Mihel DeBkey (1908–2008) o Houston hieve the rst suess t this opertion in 1964. Te other tehnique use to ypss n ostrute ostr ute oronry rtery is to employ the istl en o the internl mmmry (thori) rtery s shunt rom the sulvin rtery (Figure 14.18). Tis ws rst perorme y Vsilii Kolesov (1904–1992), hirmn o surgery t the First Leningr Meil Institute. Te ptient ws 44-yer-ol mn with severe ngin who h his le internl mmmry rtery nstomose to the irumex oronry rtery without using ypss. Tere ws no reurrene o his symptoms t 3 yers. Kolesov went on to evise irulr mehnil suturing evie or oronry surgery surger y in 1967, 1967, rrie rr ie out the proeure on ptient with n ute myoril inrt in 1968 n perorme ilterl gr in
Figure 14.18 Diagram o coronary bypass grat procedures. A reversed saphenous vein grat is shown
on the right coronary artery and an internal thoracic artery (mammary) shunt on the anterior descending branch o the let coronary artery. (From Ellis H, Calne RY, Watson C: Lecture Notes in General Surgery , 13th edition. Oxord, Blackwell, 201 2013.) 3.)
230 Thoracic and vascular surgery
1969. Inee, etween 1964 n 1968, Leningr ws the only entre in the worl perorming this opertion. Poor Kolesov ! His pioneer work ws not reognise in his own ountry, let lone in the rest o the worl. At the All Union Criologil Soiety meeting in Leningr in June 1967, where he presente his work, resolution ws opte, whih stte ‘tht the surgil tretment o oronry hert isese ws impossile n without prospets or the uture’. Te ollowing yer, Chrles Biley perorme the rst internl mmmry ypss gr in the Unite Sttes. oy, the oronry ypss gr opertion, oen using oth sphenous vein n internl mmmry rtery, is r n wy the hert opertion most ommonly perorme.
ARTERIAL SURGERY For nerly 2,000 2 ,000 yers, rteril rteril surgery onsiste o ligtion o mjor rteries or trum n neurysm, n we hve given exmples o this in severl previous hpters. Mentione y the Romn enylopeist Celsus in the 1st entury ad, rteril ligtion or hemorrhge ws populrise y Amroise Pré in the 16th entury (see Chpter 9) 9) to reple the rue n ruel use o the utery. Te rst mention o ligtion in the tretment o neurysm is ttriute to Aetius, who ourishe in the 2n entury ad. His works hve een lost, ut rgments re oun in lter Byzntine ompiltions. He vise ligtion ove n elow the neurysm, n then opening n evut-
ostruting the lumen o the rtery (Figure 14.20). 14.20). In 1903, in n extensive rtile in the Annals o Surgery , he showe tht this tehnique oul e pplie with suess to sulr neurysm. When pplie the s ws usiorm, the ories o the eeing vessels were suture rom withi within n the lumen o the neurysm n the s ws then oliterte (Figure 14.21). 14.21). Tis remine the only metho o onservtive tretment o neurysm until the
ing the lotwith rom within thesurgery s. Fmous ssoite this type o inluenmes John Hunter (Figure (Figure 6.15) who 6.15) who tie the emorl rtery in the su-srtoril (Hunter’s) nl or poplitel neurysm n Astley Cooper (Figure (Figure 6.26) 6.26) who perorme suessul roti ligtion or neurysm, esrie n pproh to the ili vessels n tie, sly unsuessully unsuessully,, the ominl ort or mssive ili neurysm. Tis ltter opertion ws to e perorme with suess y Ruolph Mts (1860–1957) (Figure 14.19) o New Orlens in 1925, entury lter. It ws Ruolph Mts who took the rst steps
1950s when, we shll neurysm wssintrou introue. e.see, gr replement o oy, the routine tretment o woun o mjor rtery is repir rther thn ligtion. Yet, ligtion ws the ommonly perorme opertion in the Seon Worl Wr, n vsulr repir only eme reltively ommon uring the t he Koren onit (1950–1953 (1950–1953). ). Tis is somewht surprising, sur prising, sine the rst repir o gunshot woun o the emorl rtery ws suessully perorme in Chigo in 1897 y JB Murphy (1857–1916) (Figure (Figure 14.22). His 14.22). His se report omes t the en o 15-pge esription, whih etils experiments he perorme in
in reonstrutive rteril surgery. In 1888, he perorme the rst ure o n neurysm y opening the s n oliterting it with sutures without
ogs, lvesonn sheep, n en-to-en in whih hesuture esries his stuies lterl repir, n pposition y invgintion o the roti n the
Figure 14.19 Rudolph Matas. (Royal College o Surgeons o England.)
Arterial surgery 231
Figure 14.21 The Matas procedure or usiorm aneurysm. The sac is obliterated rom within by
successive rows o sutures. (Matas R: An operation or the radical cure o aneurysm based upon arteriorrhaphy. Annals of Surgery 1903; 1903; 37, 161.)
Figure 14.20 The Matas operation or saccular aneurysm; the communication with the sac is sutured rom within without obliteration o the main artery. The sac is then closed by a series o sutures rom within. (Matas R: An operation or the radical cure o aneurysm based upon arteriorrhaphy. Annals of Surgery 1903; 1903; 37, 161.)
ort. Fine silk on smll neeles ws the suture most oen use. Te ptient ws n Itlin pelr ge 29 who h een shot in the groin. wo ys er the injury, the pulstions in the rteries elow the emorl were extremely wek, n t the groin, thrill oul e elt n ruit oul e her. Te ollowing y, Murphy explore the groin n oun n rterio-venous neurysm o the emorl vessels (Figure (Figure 14.23). 14.23). Te vein ws repire; one hl inh o the mge emorl rtery ws resete n the proximl en invginte into the istl or one-thir o n inh with our ouleneele rowthe o sutures ws then ple roun sutures. the egeA o overlpping istl en (Figure 14.24). Pulstion 14.24). Pulstion ws immeitely restore
Figure 14.22 John B. Murphy. (From Davis L: Surgeon Extraordinary, the Life of JB Murphy . London, Harrap, Harr ap, 1938.)
232 Thoracic and vascular surgery
Figure 14.23 Murphy’s repair o a gunshot wound o the emoral artery; the sites o arterial
the mjority o the other oys h t lest two initils n so, etermine not to e inerior, he e the ‘B’ to his nme. He stuie meiine t Rush Meil College in Chigo n spent the rest o his reer in tht ity prt rom 2 yers in Vienn stuying uner Billroth. Most o his work ws rrie out t the Mery Hospitl. Murphy vne surgil knowlege o lmost every region o the oy. He ws intereste in the surgery o the lung n ws the rst in Ameri to rry out rtiil pneumothorx. He ws intereste in the surgery o ones n joints, n he vne our mngement o peritonitis, or whih he use ui replement y mens o retl rip. He lso invente the Murphy utton, n ingenious evie or eetive intestinl nstomosis tht hs reently een reintroue, now in n sorle orm, n i muh to populrise erly surgery or ute ppeniitis. For this, he esrie the ‘Murphy sequene’: pin t the umilius, vomiting, ollowe y pin moving to the right ili oss – sequene tht is, o ourse, lssil o this onition. Aer severl minor ttks o oronry thromosis, he suume to mjor inrt inr t t the ge o 59. o o my min, it ws this se o rteril repir, se on metiulous n extensive experimentl stuies, whih ws his most importnt ontriution to surgery. Te next vne ws unoutely the metiulous experimentl work o Alexis Crrel, whih ommene in Lyon in 1901 n ontinue t the Rokeeller Institute in New York, whih he joine in 1905. We We will wil l esrie his tehniques tehn iques or en-toen-to-
in the rtery elow the line o suture n oul e elt in the pulses t the nkle. Te time or the opertion ws pproximtely 2½ hours. A month lter, the ptient ws le to wlk out the wr n h no isturne o irultion. JB Murphy ws unoutely one o the most olourul hrters o Amerin surgery. Even his nme reets something o his hrter; he
en suture o loo vessels,inwhih ormhpter the sis(see o moern rteril surgery, the next Figures 15.5 n 15.5 n 15.6). It is interesting tht ll this work ws rrie out eore n eetive ntiogulnt ws ville so tht the surgeon ws onstntly e y the prolem o lotting within the olue rtery. Heprin ws isolte rom the liver in 1916 (hene its nme – Greek hepar , liver). However, it ws not put into eetive linil use or urther two ees, t tht t ht ertinly hinere the evelopment o reonstrutive rteril surgery. In spite o the sene o n eetive nti-
ws orn on humle Irish immigrnts on Murphy. rm in Wisonsin ws hristene plin John However, when he went to shool, he notie tht
ogulnt, theemolus opertion o emoletomy – the removl o n impte in, n ostruting, mjor rtery – ws ttempte unsuessully unsuessully
and venous (From Murphy JB: Resection arteries and injury. veins injured in continuity – end to o end suture – experimental and clinical research. Medical Record 1897; 1897; 51, 74.)
Arterial surgery 233
Figure 14.24 Murphy’s repair o gunshot wound o the emoral artery; steps in the vessel repair: (a) the two cut arterial ends with partial thickness sutures passing through them and (b) invagination o one cut arterial end onto another in an end-to-end ashion orming an end-to-end anastomosis. (From Murphy JB: Resection o arteries and veins injured in continuity – end to end suture – experimental and clinical research. Medical Record 1897; 1897; 51, 74.)
y Berkeley Moynihn (see Figure 8.16) 8.16) in Lees n y Smpson Hnley (see Figure 11.12) t 11.12) t the Milesexx Hospitl, Lonon, in 1907. Te rst suMilese esses were reporte y Ernest Mosny (1861–1918) in Frne in 1911 n y Einr Key (1872–1954) in Stokholm the ollowing yer. Te rst suessul se in the Unite Kingom ws not hieve until 1934, when Sir Georey Jeerson (1886–1961) o Mnhester suessully suessu lly remove n emolus rom the rhil rtery. However, even er the introution o heprin, surgery oen ile euse o iulty in removing lots tht h propgte own the ostrute rtery eyon the emolus. Te prolem ws only overome in the erly 1960s y the introution o the lloon theter y Toms Fogrty (1934–), whih he evise when he ws young surgil resient t the University o Oregon in Portln. Tis is ne theter tht is three own the lumen o the rtery er removl o the emolus. A tiny lloon is inte t the tip o the theter, whih is then withrwn, removing the ostruting lot with it. Beore reonstrutive surgery oul e ontemplte or egenertive rteril pthology, y r the ommonest use o peripherl rteril isese, it ws neessry to elinete the site o the ostrution, its extent, n whether there ws vessel pteny
mteril into the rtery ove the lokge. Tis ws rrie out rst y the neurologist Antonio Moniz (1874–1955), who perorme the rst roti ngiogrm in Lison in 1927, n then y Reynlo Dos Sntos (1880–1970) who perorme the rst ortogrm in the sme ity 2 yers lter. It ws his son, Joo Si Dos Sntos S ntos (1907–1 (1907–1975), 975), who rrie out the rst enrteretomy o the emorl rtery in 1946, gin in Lison. Tis opertion utilises the plne o levge within the mei lyer o the rteriosleroti rtery, rter y, whih llows removl o the entrl thromus n the isese inner i nner lyer o the rtery with reonstitution o the outer helthy wll o the vessel. As with so mny other si proeures in vsulr vsul r surgery, it ws Alexis Crrel, with his o-worker Chrles Guthrie, who showe experimentlly tht segment o vein or piee o preserve rtery oul e use use s n rteril gr. g r. Inee, one or two surgeons rrie out suh proeures in ptients. An erly pioneer ws Jmes Hogrth Pringle (1863–1941) o the Glsgow Royl Inrmry, who trete two ptients in 1912, one or n neurysm o the poplitel rtery n the seon, oy o 19, or n extensive injury o the rhil rtery. Te rst ptient ws mle ge 49, whose poplitel neurysm ws syphiliti in origin n who lso h oule orti murmur.
istl to the ostrution. Tis ws– X-rys me possile y the evelopment o ngiogrphy o the vsulr tree er injetion o rio-opque ontrst
Te wsws exise segment gret sphenouss vein usen to reple theorteril trunk (Figure 14.25). Te 14.25). Te gr remine ptent until the
234 Thoracic and vascular surgery
Figure 14.26 A saphenous vein bypass grat or emoral artery obstruction. Figure 14.25 The specimen o popliteal artery grat using saphenous vein, Hogarth Pringle’s case. On the right is the resected aneurysm. (Museum o the Royal College o Surgeons o Edinburgh.)
ptientt ie 3 yers ptien yers lter o vlvulr vlv ulr hert her t isese.
they were oun to egenerte with time. t ime. Tey were soon reple with ri grs, me initilly rom nylon, orlon n eon. Knitte or woven ron is urrently use, s is Goretex (expne polytetruoroethylene). In the erly ys, grs
In the seon s eon Pringle reple mptient o the mge rteryse, withPring veinle gr, n 6the returne to work s lksmith lksm ith 2 months lter. However, it ws not until 1948 tht Jen Kunlin (1904–1991) o the Hôpitl Foh t Suresnes, ner Pris, perorme the rst ypss o loke emorl rtery using the ptient’s own gret sphenous vein. O ourse, it ws neessry to reverse the vein so tht its vlves woul not olue the ow o loo. Tis opertion is still populr toy (Figure 14.26). Te Koren Wr prove n enormous inentive to vein gring n it ws rpily estlishe tht
were homeme rom shows the surgeon’s own mnunylon shirttils. Figure 14.27 shows 14.27 n orti gr ture y the thetre nurses rom my shirt; or ll I know, it is the only one still in existene.
mny lims oulreeze-rie e sve yrteries suh tken proeure. For lrger vessels, t ken rom vers were use, ut their populrity wne s
tion. young mysel, I oul hrlyInee, elieve s tht suh nsurgeon opertion ws possile, hving seen primitive ttempts ttempts t eling with w ith this
AORTIC ANEURYSM SURGERY In 1951, Chrles Duost (1914–1991) (Figure (Figure 14.28) 14.28) perorme the rst suessul resetion o n ominl orti neurysm. Tis report gretly inuene surgeons throughout the worl, who, until then, h regre regre this entity s eing outsie the ouns o surgil removl n reonstru-
Aortic aneurysm surgery 235
Figure 14.27 An aorto-iliac grat manuactured rom the tail o my nylon shirt (let). On the right is a modern Goretex trouser grat used or this purpose.
ormile prolem y introuing oils o wire into the neurysml s or otherwise hving stoo y n wthe the ptient exsnguinte rom his rupture neurysm. Te report o the opertion ws pulishe in La Semaine des Hpitaux de Paris in Septemer Se ptemer 1951, 6 months er er the t he opertion h een perorme n, unusully, ws reprinte in trnsltion in the Unite Sttes, in the Archives o Surgery in in 1952. Te ptient ws mle ge 50 who presente with lrge pulsting mss in the omen n with gross vsulr isturne in the legs. One yer previously, he h myoril inrtion. An ortogrm showe tht the neurysm ommene just elow the kineys n extene s r s the iurtion o the ort. Te le ommon ili rtery ws loke, n the right, lthough ptent, h two smll neurysml ilttions t its origin. Te opertion ws perorme through le thoroominl inision n the ort expose extrperitonelly. An enormous neurysm ws expose n ontrolle y lmps proximl to it, immeitely elow the renl rteries, n y isolting the externl n internl ili rteries. Te s ws exise, leving rgments herent to the inerior ven v n the ommon ili veins. Reonstrution Reonst rution ws perorme using usi ng gr gr tken rom the thori ort o 20-yer-ol girl remove n rozen 3 weeks previously. Te gr ws suture to the ort ove n to the right ommon ili rtery elow, while the stump o the le ommon ili rtery ws nstomose to the sie o the gr (Figure ( Figure 14.29). Tree 14.29). Tree months er the opertion, theinptient ws in goo helth with strong pulses elt oth legs. Te suess o this opertion opene the wy or eletive surgery on similr ses n then s n emergeny proeure in wht ws previously n inevitly tl sitution – rupture o the neurysm. Homogrs were soon reple y syntheti grs, n the opertion ws muh simplie when it ws relise tht the s itsel nee not e remove ut merely opene, the gr inserte n the s wll wrppe roun the prosthesis. Chrles Duost ws orn in Pris, stuie in
Figure 14.28 Charles Dubost. (From Blondeau P: Necrologie de Charles Dubost. La Presse Médicale 1991; Médicale 1991; 20, 397.)
the pitl eore the Seon Worl Writy, n qulie won the just Croix e Guerre s young meil lieutennt in 1940. He joine the
236 Thoracic and vascular surgery
ussig–Bllok opertion, n Duost pioneere the opertion in Frne. He lso perorme the rst oronry enrteretomy uner ri ypss. Duost ws interntionlly reognise s leing ri surgeon o Frne. He eme n oer o the Légion ’Honneur n ws elete oth to the Aemy o Meiine n Aemy o Siene.
ENDOVASCULAR SURGERY Figure 14.29 The operative drawings o Dubost’s resection o an aortic aneurysm. (From Dubost C, Allary M, Oeconomos N: Resection o an aneurysm o the abdominal aorta reestablishment o the continuity by a preserved human arterial grat, with result ater ve months. Archives of Surgery 1952; 1952; 64, 405.)
Hôpitl Broussis er the wr s generl surgeon n in 1947 ommene ri surgery in smll speil ‘lue y’ unit t this hospitl. We hve lrey note tht it ws tht yer tht Alre Bllok, on his Europen tour, emonstrte the
Reent yers hve seen exiting vnes in the evelopment o miniml ess surgery o rteril isese. Anres Gruntzig (1939–1985) in Zurih evelope lloon theter tht oul e psse through stenose rtery n then lown up to ilte the onstrite segment. He rrie out the rst ngioplsties o the ili n emorl rteries in 1972 n o the oronry rteries in 1977. In the pst ee, tehniques hve een evelope to insert prostheti stents into ostrute rteries er their preliminry ilttion or er reming out the ostruting segment, n lso to repir neurysms y stenting gr within the lumen o the s.
15 Organ transplan transplantation tation For enturies men reme o the possiility o repling isese isese or mge orgn y mens o helthy gr. Inee, in populr le, this ws tully hieve y the ptron sints o meiine, the twins Cosms n Dmin. Tey prtise in Aleppo in wht is now Syri, reuse to give up their ith n were mrtyre uner u ner Dioletin Dioletin in the 4th entury ad. Visitors to their tom reporte mirulous ures n their oies were tken to the hurh o their nme in Rome. Tere mn with gngrenous leg prye t their tom, where
mirulous opertion took ple: the mn’s isese leg ws remove n tht o lkmoor who h reently ie ws gre onto the stump. When the ptient woke in the morning, he h two soun legs – one white n one lk. Tis extrorinry gr ws the sujet o hunres o pintings, some y the gret msters (Figure 15.1). Mythologil surgery prt, it ws to e mny enturies eore orgn trnsplnttion s we know it toy ws to eome relity. relit y. Surgeons were e with numer o importnt, inee pprently
Figure 15.1 The brothers Cosmas and Damian ater transplanting the leg o a Moor. Far in the back-
ground on the let the crowd inspect the Moor’s body. The amputated limb lies in the oreground. (Miniature in a 15th century choir book attributed both to Andrea Mantegna and Guido de Ferrara. Copyright o the Society o Antiquities, London.) 237
238 Organ transplantation
overwhelming, tehnil prolems. Tere ws the ovious surgil iulty o mintining the loo supply o the reple orgn n joining up its vrious uts to the reipient. Ten there ws the iulty o otining suitle onor orgn n the t tht gr gr other thn rom the sujet himsel woul soon ie, phenomenon whih we now know is ue to immunologil rejetion. Some tissues n e trnserre rom one prt o the oy to nother n will stimulte the loo supply rom the host tissues; skin n one re two exmples o this. Te looless orne oes not set up n immunologil immunologi l retion in the reipient’s tissues, so tht ornel grs n e perorme suessully in ompletely unrelte sujets. eeth set up reltively wek retion; s long go s 1771, John Hunter (1728–1793) (see Figure 6.15 6 .15)) o St George’s Hospitl, Lonon, trnsplnte trnspl nte helthy teeth, otine t prie rom inigent onors, to the gums o welthier ptients, where the gr woul ‘tke’ or onsierle time.
SKIN GRAFTING We hve lrey mentione the work o the Hinu surgeon Susrut, who evise skin p to reple the nose (see Figure 2.11). 2.11). Tis ws tken up y Gspro gliozzi (1 (1546 546–1 –1599) 599) who, 2 yers eore his eth, pulishe ook tht esrie his tehnique in etil. He rst shione the sure o the stump o the mputte nose, then ut pper pttern o the new nose whih he li on the rm in the re to e hosen or the reonstrution.
Figure 15.2 Reconstruction o the nose using an arm fap, perormed by Tagliacozzi. (From Calne RY: Renal Transplantation. Transplantation. London, Arnold, 1963).
ws exhume n thrown out o the holy groun in whih it h een urie. ur ie. However, lter sttue
A skin on the rm ws then utthe to the ext size o the p pttern n suture into nsl eet. Te rm ws then rmly rm ly splinte ginst the he (Figure 15.2). Te stithes were remove when heling h tken ple, out 5–7 ys er surgery,, n the p ws ivie gery ivie rom the rm s soon s soun heling h ourre, t out 3 weeks. wo weeks lter, the new nose ws trimme to the esire shpe, the nostrils eing splinte y pks ippe in egg white inserte into their vities. Te nl shping o the nose ws rrie out y inserting tues into the nostrils. Although gliozzi eme mous euse
ws erete or him ininBologn; ppropritely he hols n rtiil nose his hn. Te possiility o trnsplnttion o skin s ree gr without the nee to mintin its loo supply ws mjor vne. Giuseppi Bronio in 1804 showe tht vrious sizes n shpes o piees o skin oul e remove rom one re o the sheep’s k n gre suessully into nother skin eet in the sme niml; the experiment ile i the skin ws tken rom one niml n gre to nother (Figure ( Figure 15.3). 15.3). Felix Guyon (1831–1920) o Pris showe in 1869 tht smll piees o skin oul e gre into
o his work, opertion n wsttempt onsiere y the Churh to ehis srilegious, to improve upon Go’s hnir. Aer his eth, his oy
woun woul hel.oTe sme gve yer, Jques Reverinn (1842–1929) Genev more rene esription o the sme proeure n
Kidney transplantation 239
Figure 15.3 Baroni’s experiment on skin autograting in the sheep. (From Calne RY: Renal Transplantation.. London, Arnold, 1963.) Transplantation
showe tht ompletely ethe piee o skin oul ontinue to live n grow on rw reipient re i kept rmly in ontt. He showe tht est results were otine when numer o smll grs were use, n so-lle ‘pinh grs’ re still use y this tehnique to this y y.. Only omprtively smll res n e thus gre, gre , n the onor sites sites hel with rther ugly ug ly srs. An importnt vne ws me y Crl Tiersh (1822–1895), who ws suessively proessor o surgery t Erlngen n Leipzig. In 1874, he pulishe pper esriing his tehnique o skin gring using wer-thin lm o epiermis n sliver o unerlying ermis. Lrge eets n e thus gre, n n the gret vntge is tht the onor re o skin regenertes n n e use gin i neessry – eture o gret vlue when extensive skin urns, perhps involving more
or exmple, ws rise, stithe into tue n tthe to the eet in the t he ptient’s ptient’s e. It erive its loo supply rom the onor site, ut new loo vessels woul grow into it rom the reipient re. One this new loo supply ws estlishe, the se o the peile oul e ivie n the skin gr spre out to reonstrut the eet. Oviously, this ws lengthy multi-stge proeure, ut its results were revolutionry. Inee, the t he peile p remine in generl use until reent yers. Now, using the mirosope to nstomose loo vessels, the plsti surgeon n tke p o skin with its unerlying so tissues, musle n even one n trnsplnt this t one stge to repir mssive eet. Inee, using this tehnique, severe ngers n even lims n e sewn k with very high suess rte.
KIDNEY TRANSPLANTATION O the soli orgns, the kiney ws the rst to e use in experimentl n then in humn trnsplnttion. Inee, it remins toy y r the most ommon orgn to e trnsplnte. Over the lst entury, numer o vitlly importnt prolems were suessully overome: rst, the tehnil etils o the trnsplnttion opertion; seon, the mens o improving the onition o the ptient ying o renl ilure to rener him t or surgery; surgery; thir, t hir, n most iult, the t he immunologil rrier to the trnserene o tissues rom one sujet to nother. Emerih Ullmnn (1861–1937), Hungrin
thnTiersh 50% o gr the oy gring. Te is thesure, stnrrequire proeure use toy, now employing speilly onstrute lrge rzors to ut the gr whih n just the epth o the gr to the surgeon’s requirements (the ermtome). Te First Worl Wr o 1914–1918 rete vst numers o sulties with horrile eets o the e whih, up until then, t hen, woul hve ee repir. Hrol Gillies (1882–1995), young New Zeln er, nose n throt surgeon in the Royl Army Meil Corps (RAMC), ws esignte to set up eite tem to el with these ses n
surgeon Vienn, kineyto othe og into working its nek,injoining thegre renl vessels roti rtery n jugulr vein y mens o tues o mgnesium, mgnesium, n letting urine rin r in through the ureter onto the skin o the nek. Te gr lste or 5 ys. He showe tht gring kiney rom one og to nother or rom og to got rpily ile. Erly linil ttempts were ilures: Mthieu Jouly (1860–1913), o Lyon, gre pig’s kiney to the elow o ptient in renl ilure n use got’s kiney in nother se. Both kineys ile to serete urine n were remove. In 1910, Ernst Ungr (1875–1938) o Berlin trns-
new tehniques o skin replement werews rpily evolve. Te most importnt o these the tue peile p. A p o skin, rom the rm,
plnte the ying kineys o ilure; monkeytheinto the groin o oth womn o renl ptient ie 2 ys lter n post-mortem o the gre
240 Organ transplantation
orgns showe pthy nerosis. Another ttempt, using monkey kiney, y Shonstt in 1930 lso ile. Te rst humn kiney llogr ws perorme y Yu Voronoy (1895–1961) in Kiev in 1933. Te kiney o mn who ie o he injury n ws loo group B ws tken 6 hours er eth n gre to the thigh o womn o 26, loo group O, suering rom ute renl ilure s result o suiie ttempt y meruril poisoning. Te gr ile to untion, n she ie 2 ys lter. By 1949, Voronoy h perorme six suh grs with no sustntil renl untion u ntion in ny o them. It ws the work o remrkle n ontroversil mn, Alexis Crrel (1873–1944) (Figure 15.4), tht provie the mjor vne in the tehnique o orgn trnsplnttion, espeilly tht o suturing smll loo vessels together. He qulie in meiine in the University o Lyon in 1893 n stuie uner Jouly, pioneer in the suture o lerte rteries n who, s we hve lrey mentione, perorme the rst ttempts t trnsplnt to humn ptients. In June 1894, the murer o the Presient o the Frenh Repuli, Si Crnet, in Lyon onsierly impresse the young Dr Crrel. Deth ws ue to the trnsetion o the portl vein o this unortunte mn y the knie o his ssilnt. Crrel insiste tht his lie l ie oul hve een sve i surgeons lerne to suture loo vessels eetively. Inee, in the lst ee o the 19th entury, severl surgeons in Europe n Ameri experimente with the suture o ivie rteries, n the rst suessul repir o gunshot woun o the emo-
Figure 15.4 Anne Marie de la Meyrie and Alexis Carrel just jus t beore their marriage, marri age, Paris, 1913. 1913. (From Edwards WS: Alexis Carrel, Visionary Surgeon.. Springeld, Surgeon Spring eld, Thomas, 19 197 74.)
rl rtery wsinperorme in Chigo JB 14.24). Murphy (1857–1916) 1897 (see Figures 14.23y 14.23 n n Crrel, s young intern, experimente on the suturing o loo vessels, oth rteries n veins, using ne neeles n thre, whih he otine rom Lyonnise le workers. In 1904, he move to the University o Chigo, where he ollorte with the 25-yer-ol Chrles Guthrie. ogether, they estlishe speil septi niml lortory tht olishe the inetions tht h ogge previous vsulr experiments. Tey evelope the tringultion tehnique or the nstomosis o ne loo vessels: the two ens were pproximte y
Figure 15.5 Carrel’s triangulation technique or end-to-end vascular suture. (From Carrel A: La
three stithes ne roun silk or humn hir, pleseprte one-thir o theowy the irumerene (Figure 15.5). Retrtion on eh hel the
technique opératoire des anastomoses vasculaires et la transplantation des viscères. Lyon Médical 1902; 1902; 98, 859–864.)
Kidney transplantation 24 241 1
vessel ens together to llow insert insertion ion o ontinuous stith n voie the possiility o thing the k wll o the rtery. In ition, this metho voie piking up the eges o the vessel with oreps, whih proue ruising n swelling o the wll, interere with heling n ilitte thromosis. Crrel n Guthrie evelope gring o segments o vein into rtery, esrie pth vein grs, whih enlrge the imeter o the rtery n showe tht the vein wll thikene to ommote high rteril pressure. Tey preite tht the veins oul e use or rteril reonstrution, ut it is surprising tht the vein gr n vein pth metho ws not use in linil prtie until the 1950s. Crrel n Guthrie lso emonstrte tht lim oul e re-tthe er irultion iru ltion ws interrupte or over n hour, proeure tht ws not rrie out in humn su jets, until unti l in 1962, oy o 12 h his severe rm replnte t the Msshusetts Hospitl, Boston. Crrel h previously gre kiney to the nek o og in Lyon in 1892. With Guthrie, he now set out to perorm numerous renl trnsplnts tr nsplnts to the nek in ogs. ogether, they evelope the Crrel pth – utton o ort ontining the mouth o the renl rtery tht oul e suture into the exise similr eet in the reipient rtery (Figure 15.6). Tis enle tiny vessels to e gre suessully n is tehnique use to this y. Other experiments inlue trnsplnttion o the ovry n the thyroi n even the hert o smll og to the nek o lrge one; the gre hert her t survive or 2 hours. hours. Crrel ws soon
Figure 15.6 The Carrel patch. A patch o aortic wall (3) containing the renal artery with its orice (2) is removed. The arterial anastomosis (5) is placed at a distance rom the small renal artery so that blood fow through the renal artery is not obstructed by anastomotic blood clot. The aorta is demonstrated by numbers 1 and 4. (From Carrel A: La technique opératoire des anastomoses vasculaires et la transplantation des viscères. Lyon Médical 1902; 1902; 98, 859–864.)
out y wht mens to prevent the retion o the
le to emonstrte tht lthough og’s inee, kiney trnsplnte to its own nek oul survive, oul llow the niml to live in helth even when the opposite kiney ws remove, trnsplnt o kiney rom one niml to nother nother woul woul il er ew ys. Crrel ws lerly wre tht lthough he oul overome tehnil surgil prolems o trnsplnttion, he ws eete y its iology. In letter to Teoor Koher, the gret Swiss surgeon, in 1914, he wrote ‘onerning homoplsti trnsplnttion (rom one niml into nother) o orgns suh s the kiney, I hve never oun positive results to ontinue er ew months, wheres
orgnism ginst new orgn’. Tis, .in t, ws to tke lmost hl entury to hieve. hieve Beore leving this remrkle mn, we must just list some o Crrel Crrel’s ’s other hievements. He ws ppointe to the Rokeeller Institute or Meil Reserh in New York in 1906, with its mgnient reserh ilities. Here he ontinue his trnsplnt work, ut in other experiments showe tht he oul use gr o the og’s ort or inerior ven v kept in ie-ol sline or week to reple the ort o t. It ws not until mny yers lter tht this ws use linilly; rozen gr is ‘e-nture’ n oes not set up
in utoplsti trnsplnttion ws lwys positive. Te iologil sie othe theresult question hs to e investigte very muh more, n we must n
n He experimente withimmunologil lung resetion retion. n enotrhel nesthesi, rrie out iret hert surgery in the og n
242 Organ transplantation
oretol tht it woul e possile to operte on isese hert vlves, n rrie out unmentl experiments on tissue ulture n orgn ulture (in ollortion with Chrles Linergh). During the First Worl Wr, he perorme extensive linil stuies on woun heling n n inetion in speilly estlishe militry hospitls immeitely ehin the ront line on the Western Front (see Figure 9.28). He 9.28). He ws wre the Noel Prize or Physiology n Meiine in 1912.
Te kineys untion s n ultr-lter: wter n smll moleules (slts n wste prouts suh s ure) re exrete, wheres lrge moleules re retine or resore. o proue n ‘rtiil kiney’ tht will lter out wste prouts rom the loo, ilysing memrne is require. One suh memrne is the ptient’s own peritoneum. In 1923, G Gnter use peritonel ilysis to lower the loo ure o nimls in renl ilure, n in 1927, H Heusser n H Werer rst ttempte to relieve uremi ptients y this mens. By 1948, over 100 ptients o renl ilure trete y this tehnique were reviewe. Te results were poor; there were tehnil prolems with the theters use, the omposition o ui n inetion, whih le o ourse to peritonitis. However, there were one or two enourging suesses; or exmple, in 1946, se ws reporte o ure o ptient suering rom omplete suppression o urine use y the preipittion o sulphthizole rystls in
up o series o tues o elloiin, through whih the loo ws irulte, immerse in ilysis solution in ottle. Tis pprtus llowe toxins to pss through the memrne into the th while keeping loo orpusles n plsm within the irulting loo. Te rst eient rtiil kiney ws onstrute y Willem Kol, n its evelopment is sinting story. Kol ws orn in Leyen, Holln, in 1911, the son o physiin. He qulie in meiine in Leyen in 1938 n joine the university eprtment epr tment o meiine uner Proessor Polk Dniels s n intern. With his hie, he isusse the possiility o lering the loo o toxins in ptients ying o renl ilure. When Holln ws overrun y the inving Germn rmy in My 1940, Polk Dniels n his wie, oth Jews, ommitte suiie. Unwilling to work uner the Nzi physiin ppointe to reple his ol hie, Kol move to work in the hospitl o the smll town o Kmpen. Here, with the help o n engineering ollegue, Kol uilt his rst ilysis mhine in 1943. He relise tht the smll moleules o ure n other toxi hemils oul ross semi-permele memrne, ellophne, n, in ition, tht exess o wter oul e remove rom the ptient i more onentrte solution ws ple in the ilysis th. In wrtime Holln, everything neee to uil the mhine ws in short supply or ws even unotinle. Te prototype mhine mhi ne ws uilt out o ellophne tuing mounte on wooen rums tht were ple in lunry tus ull o the ily-
theTe urine y mens peritonel ilysis. moern er o ommene in 1959 with the evelopment o intermittent ilysis with single isposle theter ple in the peritonel vity n with ommerilly prepre ilysis solutions. In 1968, the rst permnent in-welling peritonel theter ws evelope n this le to the metho o ontinuous multory peritonel ilysis tht n e rrie r rie out in the ptient’s home. home. Nowys, some hunre thousn ptients worlwie re eing trete y this tehnique, tehn ique, ounting or perhps one in ve o the worl’s ilysis popultion. Te term ‘rtiil kiney’ ws rst use y JJ
sis solution. Plsti ws gin. unville; tues were use overtuing n over Neelesruer were re-shrpene n use repetely. Te rst ptient ws 29-yer-ol emle in renl ilure – nemi, rethless n hrly le to see. Aer her rst ilysis, she eme lui n her rething n vision improve. Aer 12 tretments, ll her suitle loo vessels were thromose, n she ie. Autopsy revele shrunken n srre kineys. In ll, 17 ptients were ilyse in Kmpen, with two survivls. In 1950, the wr over, news o Kol’s mhine rehe eyon Holln. He ws invite to the
Ael, LG Rowntree n removl BB urner in 1913, when they reporte suessul o sliylte rom the loo o rits y mens mens o n pprtus pprt us me
Cleveln in the Unite Sttes, here, with more Clini sophistite equipment, then moern ilysis mhine ws evelope (Figure (Figure 15.7). 15.7).
ARTIFICIAL ARTIFIC IAL KIDNEYS
The immunological basis basis o transplantation 243
Figure 15.7 Renal dialysis using the ‘articial kidney’. Patient o the author at Westminster Hospital, 19 1964. 64.
In the Koren Wr, ilysis ws use to tret woune soliers in ute renl ilure; the mortlity roppe rom 95% to 35%, n the vlue o renl ilysis ws rmly estlishe. Te pprtus use toy, now miniturise n provie with isposle ilysis oils, is se on Kol’s originl mhine (Figure 15.7). Kol then stye on t Cleveln to help evelop the hert–lung pump, whih me se open ri surgery possile (see Figure 14.15) 14.15) n, in 1961, evise the intr-orti lloon or ri ssist in ses o ute myoril ilure – evie tht is now in wiespre use. In 1990, he ws nme y Lie Magazine s one o the 100 most importnt Amerins (he ws y now nturlise) in theUnite 20th entury. Kol97ie in 2009 in Pennsylvni, Sttes, ge yers.
reeive series o grs rom her rother’s thigh to the urne res, n 15 ys lter seon set o gr ws pplie. Mewr note rpi egenertion ertio n o the seon set o skin grs n relise tht this emonstrte quire immunity y the reipient to the grs; the so-lle ‘seon set phenomenon’. Tis le to n extensive series o niml experiments. Te ‘seon set rejetion’ ws more rpi lso i the host h rst een injete with white ells rom the onor. Tese eviently ontine ntigens tht interere with the trnsplnt. In 1951, working with Rupert Billinghm, it ws shown tht skin grs rom one rit to nother oul e prolonge y ily injetions o ortisone. Mewr’s work together with Sir Frnk Mrlne Burnet (1899–1985) o Austrli le to their eing wre the Noel Prize or Meiine in 1960. Menwhile, surgeons in numer o entres ontinue to experiment with renl trnsplnttion in ptients ying o vne kiney ilure. Between 1951 n 1953, Dvi Hume (1917–1973) n his tem in Boston trnsplnte kineys to the thigh in 15 ptients, ringing the ureter out to rin onto the sie o the leg. Tose grs tht untione ontinue to o so or rom 37 to 180 ys, the ptients eing trete with low-ose sterois or immunosuppression. In 1951, t the Neker Hospitl in Pris, René Kuss (1913–2006) ws onronte with young rpenter ge 16, who h llen rom soling n rupture his right kiney. Te kiney ws remove, ut er the opertion, it ws isovere tht he h
Te puzzling oservtions o Crrel, in the erly yers o the 20th entury, o suess when n utogr ws perorme rom one prt o the niml to nother site, n ilure when grs gr s were ttempte rom one niml to nother (heterogrs) were solve y the lssil stuies o Peter Mewr (1915– (1 915–1987) 1987) n his ollegues. olle gues. Working in Oxor
ongenitl sene the other Te oy’s mother plee thtoshe shoulkiney. e llowe to onte one o her kineys to her son, n it ws oun tht the two shre the sme mjor n minor loo groups. Te opertion ws perorme on Christms night o tht yer; the gre kiney immeitely untione, n the oy’s generl onition improve onsierly, ut, s we now woul onently preit, rejetion set in er 3 weeks. In 1954, there ws mjor step orwr in the story o humn orgn trnsplnttion – the suessul trnsplnt o kiney rom one ienti-
uring the SeonheWorl Wr on prolemswomn in skin trnsplnttion, stuie 22-yer-ol who h severe urns on her hest n rm. She
l to nother. Its suess rrier proveoul tht, e i onlytwin the iult immunologil overome y some mens or nother, then orgn
THE IMMUNOLOGICAL BASIS OF TRANSPLANTATION
244 Organ transplantation
trnsplnttion in mn oul e esile proposition. Te opertion took ple on 23 Deemer 1954, t the Peter Bent Brighm Hospitl in i n Boston. Te ptient ws 24-yer-ol mn mitte uner the re o John Merrill in severe kiney ilure. Sine the ptient h twin rother, the possiility o trnsplnt ws onsiere. Te ptient ws ilyse on the rtiil kiney, whih improve his onition so tht urther investigtions oul e rrie out. Te twins’ loo ws oun to e ientil or ll the eight loo group systems tht were then known. Te hospitl reor o their irth showe tht there ws ommon plent, n urthermore, oth twins h the reltively rre Drwin’s tuerle o the ers, not possesse y their two silings. Te twins h ientil eye olours tht, gin, were mrkely ierent rom those o their silings. A skin gr gr ws exhnge etween the twins: peret tke ws otine n survive surv ive s norml skin or month. month. It ws eie to go he with the opertion. Proeures were perorme simultneously on the onor n the reipient in jent operting rooms. A norml le kiney ws remove rom the helthy twin y Hrtwell Hrrison n gre g re into the right lower
omen o the ptient y Joe Murry. Te renl vessels were nstomose n stomose to the ili i li vessels o the ptient, n the ureter implnte into the ler – tehnique tht hs eome the stnr prtie in ll renl trnsplnts (Figure 15.8). Te operting time ws 3½ hours. When the lmps were relese rom the loo vessels, the entire kiney eme pink n ler urine owe opiously rom the onor kiney. Te post-opertive ourse ws smooth or oth the ptients. A yer er the trnsplnttion, the ptient ws well n rrie on unlimite tivity. X-rys showe tht the gr kiney ws untioning well (Figure 15.9). Surely, i ny opertion is to reeive tht muhworn ole ‘ mjor rekthrough’, this ws it. By 1961, ouple o ozen more renl trnsplnttions h tken ple etween humn ientil twins, o whih 17 were perorme y the Boston tem. Tree o their ptients ie, ut o the remining ptients, ptients, the longe longest st survivor surv ivor ws live 7 yers er surgery. Joseph Murry (191 1919–2012 9–2012)) reeive the Noel Prize or Meiine in 1990. Tere still remine, o ourse, the tremenous prolems o the immunologil rrier to trnsplnttion. Tese suesses stimulte worlwie
Figure 15.8 Details o the technique o renal transplantation in man as perormed by Dr Joseph Murray. (From Merrill JP et al.:
Figure 15.9 The rst successul renal transplant between identical twins, 23 December 1954. Front row: Richard Herrick, the recipient, on the let, Ronald, the donor, on the right. Back
Successul homotransplantation o the human kidney between identical twins. Journal of the American Medical Association 1956; Association 1956; 160, 277.)
row, let to right: Joseph Murray, surgeon, John Merrill, nephrologist, and Hartwell Harrison, urologist. Courtesy o Dr Joseph Murray.
Liver 245
reserh to mke orgn trnsplnttion ville or ptients other thn twins. It h lrey een shown in 1952 y Frnk Dixon n his o-workers tht the immune retion oul e suppresse in rits y using X-ry irrition. In 1959, John Merrill perorme kiney gr etween nonientil twins er irriting the reipient, n similr proeure ws rrie out y the surgil tem t the Neker Hospitl, Pris, using olt irrition or immune suppression. Aprt rom n osionl suess (the Pris tem, or exmple, hieve the rst suessul long survivor o non-twin trnsplnttion), the numerous serious omplitions o whole-oy irrition le to the eventul nonment o this metho. In 1959, R Shwrtz n W Dmeshek, working t u’s Meil Shool, Boston, showe tht the tretment o rits with 6-merptopurine or 14 ys proue long-lsting immunologil tolerne to humn serum lumin. Aer seeing this report, young English surgil registrr, Roy Clne (ontemp.), eie to investigte the eet o this rug on renl homogr homogr in ogs. His emonstrtion emons trtion tht the experimentl niml nim l oul ept ompletely unmthe kiney gr rom nother onor using this purine nlogue pro vie the sis on whih susequent trn trnsplntsplnttion o onor orgns hs epene (Figure 15.10). Tis ws helpe onsierly y the evelopment o more eetive rugs, prtiulrly zthioprine in 1961 n ylosporin in 1976. Clne went on to eome proessor o surgery in Cmrige, where his unit eme Me to surgeons n reserh workers in this el. He lter pioneere
liver, pnres n smll intestine trnsplnttion in this ountry. He hs not only een knighte ut is one o the ew surgeons to hve een elete Fellow o the Royl Soiety.
TRANSPLANTATION OF OTHER ORGANS Te kiney is the ovious orgn or trnsplnttion. It is ilterl, so tht, in ition to using ver orgn, lose reltive living onors n volunteer kiney. In ition, thn thnks ks to eetive ilysis, the reipient n hve his or her generl onition improve remrkly n n e mintine or months or yers in resonle helth until suitle gr eomes ville. I kiney gr shoul il, the ptient n e mintine on ilysis n susequent re-gring n e perorme. With other orgns, ilure n only e resue y n emergeny removl o the onor orgn n re-gr. Other rom orgns the prolems o eing single (prt thepresent lungs) n, to te, long-term support mhines hve not prove eetive in spite o millions o pouns hving een spent on experimentl liver ilysis n on the evelopment o implntle or extrorporel hert ssist mhines.
LIVER Liver trnsplnttion represents ormile tehnil prolem. Te ptient is espertely ill rom vne mlignnt isese, irrhosis, liver poisoning or some other mjor illness n is eeply
Figure 15.10 (a) Roy Calne, in white coat, with a long-term dog renal grat survivor. (b) Close-up o the rst dog to survive 6 months ater renal transplantation. (Courtesy o Sir Roy Calne.)
246 Organ transplantation
Figu re 15.11 Figure 15.11 The technique o liver transplantation.
junie. Tere is, t present, no meil mens o mrkely improving the ptient’s onition eore surgery. Moreover, the tehnil prolems o gring the vsulr n iliry systems o the onor liver into i nto the reipient re omplex (Figure (Figu re 15.11) 15.11).. C Sturt Welh (1909–1980), in New York in 1955, experimente with uxiliry trnsplnttion o liver in the og, leving the originl liver in ple. Aer extensive niml experiments, Toms Strzl (1926–2017) o Denver perorme the rst humn liver trnsplnttion in 1963. Te ptient ws 3-yer-ol hil with ongenitl
Te oronry rteries o the onor were peruse through the reipient’s roti rtery, n venous return rom the hert ws eete y the pulmonry rtery r tery o the gr eing nstomose nstomose into the jugulrr vein o the host. jugul In the 1950s, numer o groups in the USA n USSR were experimenting experimenting with w ith hert trnsplnttion er removl o the reipient hert n using hypothermi. Host survivl ws otine or only ew hours. However, the tehnil iulties o linking up the t he pulmonry n systemi irultion irultion were onsierle. Te vent o the pump oxygentor t this time to tke over the host’s irultion llowe more time or this omplex proeure. An enormous tehnil vne ws me y Normn Shumwy (1923–2006) n his group t Stnor University in 1961. Tis rpily eme, n inee remins, the stnr stn r proeure. proeure. Tis moition onsiste o iviing the ort n the pulmonry rtery n oth the tri trns versely in oth the onor n the reipient. In this th is wy, the entrne o the superior n the inerior ven v into the right trium n o the our pulmonry veins into the le trium remin unisture, the le n right tril wlls eing suture to the onor hert t point nterior to these veins (Figure 15.12). Tis sustntilly shortens the time require or the reipient to e on hert ypss,
iliry tresi; opertion suess ws notthe hieve untilile. 1967. Strzl’s Tis wsrst n 18-month-ol hil with primry ner o the liver who survive or over yer ollowing trnsplnttion eore ying o metstti isese rom the originl tumour. Te rst liver trnsplnt in Europe ws perorme y Roy Clne in Cmrige in 1968. Further experiene, n the introution o ylosporin, hs gretly improve results, n survivls o 20 yers or more re not unusul.
THE HEART Crrel n Guthrie, in their lssil trnsplnt experiments in the erly yers o the 20th entury, ple smll onor hert into the nek o og.
Figure 15.12 The technique o heart transplantation.
Multiple organ transplantation 24 247 7
n Shumwy’s group hieve long-term survi vors using immunosuppressive rugs. r ugs. Te rst hert trnsplnt tr nsplnt in mn ws perorme y Jmes Hry n his tem t the University o Mississippi in 1964. Te ptient h terminl hert isese n ws given himpnzee hert, whih only supporte the ptient or pproximtely n hour eore ilure ourre. In 1967, Christin Brnr (1922–2001) in Cpe own suessully trnsplnte the hert o humn onor who h ie o rin injury into 54-yer-ol entist in hroni hert ilure. Te ptient ie o inetion on the 17th post-opertive pos t-opertive y, ut seon ptient gre ew weeks lter survive or over yer. Te hert hs lwys een n orgn tht engeners gret emotion in the puli, n this opertion eme perhps the most puliise in the history o surgery, oth the ptient n his surgeon eoming wht mounte to pop strs with worlwie mei overge. Isolte lung trnsplnttion in humn ws rst reporte in 1963, gin y Jmes Hry, n omine hert–lung trnsplnttion in 1969 y Denton Cooley in Houston, exs. oy, these proeures hve psse into the stnr rmmentrium o trnsplnt surgery.
inlue implnttion o the ut o the pnres into the ler or the intestine. Attempts t extrting the islet o Lngerhns ells (the ells tht proue insulin) rom the pnres n using these s gr hve een sujet to intense n expensive reserh with, t present, only megre linil pplition.
INTESTINE Ptients who hve lost mjor prt o their smll intestine ue to injury or isese n e mintine minti ne y hroni intrvenous eeing – grim existene. rnsplnttion o smll intestine hs een rrie out suessully in smll group o ptients.
MULTIPLE ORGAN MULTIPLE O RGAN TRANSPLANTATION Multiple orgn trnsplnts trnspl nts re now perorme. Roy
Severe ietes my e omplite y renl ilure, n so the possiility o pnres trnsplnttion t the time o renl gring in suh ptients is n ttrtive proposition. Suh gr
Clne, or exmple, hs 10-yer survivl i n ly in who reeive hert–lung–liver trnsplnttion or severe lung n liver isese. Another ptient with non-mlignnt mssive intr-ominl tumour unerwent six-orgn trnsplnt o stomh, uoenum, smll owel, liver, pnres n kiney n ws well 2½ yers er his opertion. Te mjor prolem t present with orgn trnsplnttion is severe lk o onors. Tis hs ouse ttention on the possiility o xenotrnsplnttion – the use o other speies. Muh work is eing one on moiying onor speies y geneti engineering, ut the prolems
ws University rst reporte y RihrCurrent Lillihei tehniques in 1966 t the o Minnesot.
o rejetion o novel ross-speies inetions ren still the to erisks overome.
PANCREAS
16 Envoi: Today and tomorrow Our tour o A History of Surgery provides a perspective on the ingenuity and sometimes bizarre developments o man to tackle disease. Te development o o tools, anaesthesia and aseptic ase ptic techniques permanently changed the landscape o surgery while modern advances in technology continue to revolutionise surgical practice worldwide. We now live in an era where an array o imaging modalities and minimally invasive techniques techniques are available to assist in the diagnosis and management o disease. Not only can we see active internal bleeding through a series o X-rays taken aer the injection o dye into a vessel (angiography) (angiog raphy) but also we can arrest it using coils inserted into the eeding blood vessel through a catheter no more than a ew millimetres wide. A blocked artery can be opened up with a balloon passed under X-ray control, with or without the placement o a stent to maintain patency, leaving nothing more than a needle mark on the skin. Te repair o abdominal aortic aneurysms is now routinely perormed in specialist units by passing stent gras via the emoral arteries through small groin incisions (endovascular aortic repair (EVAR) (Figure (Figure 16.1a,b). 16.1a,b). What was previously very major abdominal surgery can now be perormed through small incisions with better outcomes and patients can now be discharged rom hospital aer a ew days. In other elds, a pelvic abscess can be drained with needles inserted transcutaneously under image guidance and the whole colon can be removed laparoscopically. Internal organs can be visualised through natural orices to exam-
(cystoscopy) and the colon (colonoscopy), to name a ew examples. A major milestone in the design o the endoscope was made by the physicist Harold Hopkins (1918–1994) who was the pioneer o bre optics. His research in nuclear and optical physics led to his invention o the zoom lens that was rst used in televising a sporting event in 1948. Tis was soon ollowed by the ‘brescope’, where light shining through a bundle o fexible glass bres no more than 0.025 mm was used to produce an image. At a meeting with a gastroenterologist, Hopkins became aware o the risks posed by the rigidity o the endoscopes. ogether with Karl Storz (1911–1996), a German instrument maker, the two developed a fexible endoscope that utilised bre optic science to illuminate the gastrointestinal tract. Te fexible endoscope provided images o high resolution and could negotiate acute angles in the gastrointestinal tracts with a much lower risk o peroration. Flexible instruments that could be inserted through endoscopes, cystoscopes and bronchoscopes were developed to take samples o cells or tissue or analysis, deal with bleeding and remove cancerous growths. Minimally invasive techniques in surgery that expedite recovery and minimise morbidity are one o the major milestones in modern surgery. Perhaps the most noteworthy example o this is indeed laparoscopic surgery. My early teaching on appendicectomies was through laparoscopy, which I now perorm routinely, and I have removed more gallbladders laparoscopically than t hrough open surgery surgery ! Figure 16.2 is 16.2 is a
ine thegastrointestinal trachea and bronchi (bronchoscopy), the upper tract (oesophagogastroduodenoscopy) the lower urinary tract and bladder
photograph some o the common laparoscopic instrumentso and Figure 16.3 16.3 is is o a laparoscopic appendicectomy operation. 249
250 Envoi: Today and tomorrow
Figure 16.1 (a) Various types o endovascular stent grats used in EVAR as a minimally invasive approach
o treating aortic aneurysms. The grats consist o a fexible wire rame onto which a special type o abric is woven. The metal spikes enable grat xation onto the vessel wall (Photograph provided by Mr Jason Constantinou, MD, FRCS, at the Royal Free Hospital, London). (b) An operating theatre or EVAR with specialist imaging equipment and a portable fuoroscopic unit (C-arm). (Photograph provided by Jason Constantinou, MD, FRCS, at the Royal Free Hospital, London.)
Lprosopi ‘keyhole’ surgery ws introue t the eginning o the 20th entury y Dimitri Ott n Germn surgeon George Kelling who were the rst to use it to evlute the eets o pneumoperitoneum on ogs in 1901, n in 1910, pulishe similr experimentl work on humn
who lso experimente on humns n nimls. Te rst orwr-viewing sope o 135° view ws pioneere y the Germn gstroenterologist, Heinz Klk, in 1929. In 1938, Jnos Verres evelope neele or the experimentl retion o pneumothorx tht
sujets. Tis tehnique ws ws known s ‘eliosopy’ n the term ‘lprosopy’ in t oine y the Sweish surgeon, Hns Christin Joeus,
ws soonor opte or the retion o pneumoperitoneum lprosopy. It onsiste o n outer nnul with spring-loe oturtor tht oul
Envoi: Today Today and tomorrow 251
Figure 16.2 Common laparoscopic graspers which include, rom top to bottom, Johan, Babcock, Curved Maryland grasper and Big grasper. (Photo provided by Sala Abdalla MRCS at Queen Elizabeth Hospital, London.)
Figure 16.3 Laparoscopic appendicectomy.
plement uner iret vision. Ironilly, toy this tehnique is routine or generl surgeons ut not so populr with gyneologists g yneologists! In the 1980s, new vnes enle imges rom lprosopy to e mgnie n isplye onto V sreens, n soon er me the rst lprosopi holeystetomy opertion in Septemer 1985 in Germny y Erih Muhe. Te rst to e rrie out in Engln ws y Dvi Rosin t St Mry’s Hospitl, Lonon in 1989. It ws soon estlishe tht this th is tehnique resulte in less postopertive pin, ewer post-opertive inetions n tht ptients were ishrge erlier rom hospitl y omprison to those tht unerwent open holeystetomy through n olique or vertil inision in the ominl wll. By 1992, lprosopi holeystetomy eme the epte gol stnr. Within 5 yers, gstri unoplition, gstretomy, oletomy, renletomy ren letomy,, splenetomy splenetomy,, nephretomy, ritri (weight-loss) opertions n herni repirs were ll suessully ttempte ttempte lprosopilly n re nowys routinely perorme lprosopilly. Te lprosopi tehnique ontinue to evolve through the introution o single inision lprosopi surgery (SILS), where single inision oul e use to introue multiple instruments to rry out n opertion. Tis tehnique ws rst use in lprosopi holeystetomy n ppenietomy in the lte 1990s, n sine then it hs een pplie to urologil, gyneologil n other generl surgil opertions, inluing oloretl n ritri proeures. While some trils hve emonstrte
e inserte linly into the thori or peritonel vity. Moreover, throughout the 1930s, the lprosope ws trille in gstrointestinl n gyneologil surgery, n y the 1970s, lpros-
vntges vntge s o SILS over onventionl lprosopy in terms o post-opertive pin n relte moriity, the longer opertive time, higher overll osts n prtil hllenges my explin why this tehnique hs not eome wiely opte. Further vnes in minimlly invsive surgery rought out NOES, ‘Nturl Orie rnsluminl Enosopi Surgery’, soon er the turn o the new millennium. Tis ‘srless’ tehnique uses the nturl ories, the mouth, vgin n nus, s ess points, p oints, ollowing whih enosopi n lprosopi tehniques my e omine to rry out proeures.
opy ws useHrrith wiely in gyneology. In 1971, the gyneologist Hsson evelope the open mini lprotomy ‘Hsson’ tehnique o se tror
NOES ws y gstrointestinl enosopists s rst theypioneere gine more skills in enosopi prtie in the 1980s. Te proeures in
The surgeon and her assistant, holding the laparoscope, stand on the let side o the patient and the monitor and screen are on the right. Classically, three incisions are made on the abdominal wall through which trocars and instruments are inserted. (Photo provided by Sala Abdalla MRCS at Queen Elizabeth Hospital, London.)
252 Envoi: Today and tomorrow
NOES my e tegorize in terms o orie use, trget viser or whether hyri (omining lprosopy n enosopy) or pure enosopi. Diret-trget NOES o not reh viserl wll to reh nother orgn, n exmples o these inlue the enosopi removl o nerous growths in the olon or newer tehniques in the tretment o hlsi, where instruments inserte through the gstrosope re use to ivie the musle o the lower oesophgel sphinter (Perorl Enosopi Myotomy). Distnt-trget NOES require ut to e me in the wll wl l o n orgn in in orer to reh the trget orgn. Exmples o these re trnsvginl ppenietomies, rst reporte s series in 1949 y Bueno, trnsvginl holeystetomy, esrie in 2003, n the trnsgstri holeystetomy tht ws rst rrie out y Mresux in 2007. NOES hs not een wiely opte euse o its numerous prtil hllenges n omplexity with no emonstrle eviene o vntges over other minimlly invsive tehniques. Te emergene o new tehnologies esigne to ompete or entre stge with lprosopi surgery hve pushe innovtions in this el even urther. High enition two- n three-imensionl (3D) mers, motorize enosope positioners, vne isseting n seling evies suh s the Ligsure n Hrmoni slpel, n mgneti mg neti trtion systems re some o the vne lprosopi tools tht re irete towrs improving the proieny o lprosopi surgery. While minimlly miniml ly invsive invsive surgery hs rilly
the rst rooti pltorm to e pplie in surgery ws the ‘PUMA 200’, use in 1985 in the USA to onut n imge-guie imge-gu ie rin iopsy. In 1988, 1988, the ‘PROBO’, n ultrsoun-guie rooti system ws use in urology to perorm prostte surgery, n in 1992, the ‘ROBODOC’ system ws use or perorming hip rthroplsty. Rooti surgery hs sine expne to other speilties inluing gyneology, riothori, peitri surgery, he n nek surgery, oloretl surgery n in upper gstrointestinl n heptopnretioiliry surgery, where it is use in lengthy, omplex proeures suh s oesophgetomies n liver n pnreti resetions. ypilly, the surgeon is sete wy rom the opertive el n is in hrge o the ontrols o the rooti rms, whih re ontine in sterile el roun the ptient. Surgery is ilitte through smll inisions with high-resolution mgnie vision. Perhps, the most well-known surgil root is the D Vini, rst introue in 2003, omprising 3D high-resolution vision n instruments tht n turn in ll iretions with 90 ° o rtiultion n whih re psse through 1–22 m inisions (Figure 16.4). It is le to replite 1– humn hn movements using EnoWrist tehnology nolo gy n reeive Feerl Drug Aministrtion (FDA) pprovl in generl surgery in 2000 n in urology or ril prosttetomy in 2001. Ril
hnge therelte surgil lnspe, it ion hsn inherent limitt limittions ions to ner mnipult mnipultion preision tht n mke opertions with intrite steps or in iult ntomil lotions rther hllenging. Rootis hve rought new innovtions tht ugment the surgeon’ su rgeon’ss eye n hn h n to hieve optiml views n ury uring omplex surgery n in essene overome the limittions o lprosopy. Roots re evies tht omine mehnis, eletronis n inormtis systems to rry out tions uner iret mnipultion or in n utomte shion. Tey hve n ege over the humn
Figure 16.4 The Da Vinci robot. The surgeons are seated away rom the operative eld at the
hn tht repetitive they re not fite tremor or tigueinrom tsks. Whileyroots hve een wiely use or ees in other inustries,
control console, where they manipulate the robotic arms in the sterile eld. (Photo provided by Intuitive Surgical, Surgi cal, Inc 2016.)
Envoi: Today and tomorrow 253
prosttetomy, or rinom o the prostte, is the proeure in whih rooti ssistne hs shown ler vntges over oth open n stnr minimlly invsive tehniques with ewer omplition, shorter hospitl sty n n inrese rte o ompleteness o resetions. However, in holeystetomy, it is hs not emonstrte signint linil enet over lprosopi surgery to merit its routine use. By 2012, the numer o opertions worlwie using the D Vini root h rehe 500,000. Te limittions o the root inlue its lrge size, lk o ttile eek, lg time, prolonge set-up time n high ost. However, improvements in tehnology n engineering my one y yiel roots tht re smller (Figure 16.5), quik to set up in the operting room n heper to proue, whih is nlogous to progresses in some o our most prize items suh s moile telephones. While the surgil root hs een impressive in its perormne n outomes, it is still evie tht is remotely ontrolle y the surgeon’s hn n rin. Te next lep orwr in tehnology rests on the evelopment o rtiil intelligene (AI) systems tht re ple o perorming tsks tht normlly require humn intelligene suh s resoning, eision mking n pttern reognition.
AI is sophistite omputer system tht is ple o perorming suh tsks tht woul normlly require humn intelligene. Tis is me possile through network o ene lgorithms in omputer progrming tht untion like neurons in the humn rin. Tese rtiil neurl networks or lgorithms utonomously proue omplex tsk tht is not iretly inuene y humn rin or hn. One o the erliest pioneers o this tehnology ws the British mthemtiin Aln uring in the 1940s when he introue the ie o igitl omputing n omputer progrmming tht helpe rek the Germn Enigm Coe in the Seon Worl Wr. Te pst ee hs seen huge expnsion in AI in the el o meiine n surgery. In Ophthlmi surgery, n AI system ws proue y Google’s DeepMin in prtnership with the Moorel’s Eye Hospitl in Lonon to help help ignose retinl isese. Other AI systems tht re eing evelope whih my one y e le to interpret vrious types o sns to ignose ierent ners n improve eieny in the operting thetre thet re n in outptient linis. It is more likely tht these systems will enhne our uture elivery o helth rther thn mke the t he surgeon o the 21st entury osolete. Other emerging tehnologies tht hve risen rom the rpi expnsion o AI systems re Augmente Augmen te Relity (AR) n Virtul Relity (VR). AR systems superimpose rtiil inormtion generte y omputer to one or more o the senses to enhne its perormne. Exmples o this inlue the AuVein (Figure (Figure 16.6), 16.6), evie
Figure 16.5 The versius system by UK group, Cambridge medical robotics (CMR) surgical, demonstrated by Luke Hares, technology director and co-ounder o CMR Surgical. This is the next generation o surgical robotic systems that
tht projets the ntomy o veinspunture. onto the skin sure, ssisting with venous Te Google Glss is nother evie tht omes in mounte heset n emonstrtes ertin ntomil or untionl etils on rel-time imges. Te Hololens is rn o smrt glsses ville toy tht isplys omputer-generte hologrms onto rel ojets. Current pplitions o AR in the t he operting room inlue its use or optiml port plement in lprosopi surgery n in omintion with ner inr-re spetrosopy to provie visull gui visu guine ne in lymph noe isse issetion tion in ner surgery.
are smaller with highly portable robotic arms designed to be more lightweight, fexible and versatile. (Photo provided by CMR Surgical.)
In VR the imge n the ment re tehnology, oth omputer-simulte to environemulte relity. Te term ‘virtul’ mens ner or in-eet,
254 Envoi: Today and tomorrow
Figure 16.6 AccuVein vein visualisation technology. This is a type o AR technology where superimposed images are projected on real lie objects. It enables the execution o routine tasks in a quick and ecient manner. (Photo provided by AccuVein. AccuVein.))
n thereore, VR tehnology is omputergenerte simultion o relity. VR simultors in meiine n help in the quisition n improvement o skills in ontrolle environments with simulte ptients n re thereore powerul tools in trining. VR is urrently wiely use in trin-
n guie se in thetre using sreen-projete mrkings tht the lol surgeons n use to perorm the surgery. Tis les to more eient use o resoures in n er where reul resoure mngement is prmount. Tese tools re sustntil in eution n meil imging to support
ing in enosopi lprosopi surgery, time n stuies hve shownn reution in opertive n ury when VR trining is employe or new trinees with no prior experiene o lprosopi trining. In vsulr surgery, VR n generte enoluminl views tht n e use in the pre-opertive plnning o mjor surgery n similr enets my e gine in the visulistion v isulistion n nlysis o omplex rtures in orthopeis. AI systems like AR n VR n enle liniins in one hospitl to ollorte with nother in the sme ountry or ierent ountry ltogether. Cliniins n, through VR, trnsport themselves
linil mking. Longeision n omplex opertions require lot o plnning. Te expnsive rry o meil imging molities tht re ville toy provie very useul ntomil etil to prepre or surgery. However, new type o vne imging tehnology tht n ssist with preprtion or mjor opertions is 3D printing, lso known s rpi prototyping. Tis enles the retion o omplex ojets y eeing series o igitl imges rom ompute tomogrphy or mgneti resonne imging sns into speilise 3D printer. Te printer then retes lyer-y-lyer 3D moel
to nyproviing linil re setting to support theentre elivery o re, rom speilist to one in rurl or remote setting. Te remote surgeon
o the imges, using vrious o mterils inluing plsti, liqui resin types n gypsum. Te linil pplition o this hs le to the esign o
Envoi: Today Today and tomorrow 255
ptient-spei orgn moels tht provie plple inormtion on the ntomil strutures. For exmple, in ri surgery, 3D printing hs een use to rete moels o herts with ongenitl eets tht n e use in preopertive plnning. In 2016, this tehnology ws use in i n Chin to uil ull-size moel o neonte’s hert who ws orn with ongenitl eet. It ws use or plnning o the omplex surgery, whih ws then rrie out suessully. In the Unite Ar Emirtes in the sme yer, 3D printing tehnology ws use to remove nerous tumour tu mour rom womn’s kiney. Te tem t Guy’s n St Toms’ n Evelin Chilren’s n Gret Ormon Street Hospitls, Lonon, Unite Kingom hve evelope the worl’s rst use o 3D printing in omplex peitri renl trnsplnt surgery in onjuntion with meil physis (Figure 16.7). Te min hllenges in peitri renl trnsplnttion inlue trying to ple n ult-size kiney into the very smll omen o hil who my lso hve omplex vsulr vsu lr ntomy. In this respet, ptient-spei
3D printing hs een use to enhne n support preopertive plnning in those ses where esiility o implnttion ws unertin. Aitionl urrent pplitions o 3D printing inlue the evelopment o implnts, prostheses n surgil evies n in the retion o spei moels or meil eution. More reent vnes hve use 3D printing tehnology in the el o tissue regenertion to proue untionl living tissues rom ioomptile mterils. Tis emerging el is reerre to s ‘ioprinting’. It is r more omplex proess tht involves the use o DNA, ells n tissue growth tors s hoie o iologil mteril to onstrut ioomptile tissues tht n e use or ptient-irete therpy. It hs lrey een use to generte severl types o tissue, whih inlue vsulr vsul r gr grs, s, skin, r rtil tilge, ge, one n hert tissue n promises to e the uture or the evelopment o untionl orgns tht n e use or trnsplnttion. While tissue engineering using 3D printing tehnology is reltively new tehnology, the priniple tehniques o tissue engineering hve een employe sine the 1980s. issue engineering relies on the pity o iniviul ells seee in mtries to prolierte in the presene o growthinuing tors n evelop into tissues. Tese tissues n then e trnsplnte into reipients (the originl onors o the ells) s utologous mteril tht thereore requires no immunosuppression er trnsplnttion. Perhps one o the most mous exmples o this tehnology ws
Figure 16.7 Three-dimensional printing. This is a patient-specic 3D model print o a child’s abdomen (3 years years old, 10 kg child) and his ather’s adult-sized kidney used or planning or a living donor renal transplantation. (Photo provided by Stratasys and Pankaj Chandak, transplant
the grown imge o with the humn er onitslortory oy thtmouse eme heline news roun the worl in 1997. Tis rtilginous er ws orme rom ioegrle moul on whih rtilge ells rom ow were seee. Tis le to mny similr experiments over the next two ees, ut the nl onstrut ile er the ioegrle moul mteril ws resore. Other tissue types tht hve een engineere in-vitro n trnsplnte inlue ornes, loo vessels n trhel tissue. While orne repirs hve prove to e suessul, vsulr n n trhel engineere tissues hve not, n this highlights the omplex-
registrar and research ellow and Nick Byrne, Department o Medical Physics, St Thomas’ Hospital.)
ity o in vivo tissue evelopment, untionlity regenertion. One o the key tors ientien s ontriuting to the ilure o engineere tissue
256 Envoi: Today and tomorrow
implnttion is the integrtion o the reipient’s loo vessels into the implnte tissue, n urrent reserh is looking to ress this hllenge. No isussion out regenertive meiine is omplete without ressing stem ell tehnology. Stem ells re unierentite ells tht hve the potentil to renew n ierentite into ny ell type n re roly tegorize into emryoni n ult sutypes. Tey orm the si uiling loks n, while in emryoni lie they speilise into spei lines, in the ult, stem ells ilitte repir n regenertion n re present in smll mounts in every tissue type. Ault stem ells hve, or ees, een use in one mrrow trnsplnttion n or treting loo, utoimmune n mlignnt onitions. However, emryoni stem ells re not urrently use in meil therpies, lthough reserh is ongoing into their potentil or use in tissue replement ollowing spinl or injury or in the restortion o vision in retinl isese. While ells n e use to regenerte new tissue, the geneti mteril in ells n e moie in suh wy tht iretly ets ellulr ellul r untion n evelopment. Te growth in unerstning the moleulr spets o isese is set to hnge meil n surgil prtie o the uture. Gene therpy is n evolving el in meiine n most o the work in this re is irete towrs the tretment o ner, with tive trils running ross severl ontinents. Strtegies or gene therpy in ner inlue immunotherapy ; where ells re genetilly mnipulte to stimulte the
immune system to estroy ner ells, oncolytic virotherapy ; where virl prtiles replite insie n estroy ner ells, n gene transer, whih introues new genes into ner ells tht le to their estrution or slow evelopment. Gene therpy is still in its inny, in ny, ut ut it promises inno vtions tht n e use in ise isese-preventt se-preventtive ive strtegies suh s the evelopment o ner viness or or erly ig vine ignosis nosis n tretment o ner. Our surgil lnspe is hnging t tremenous pe. We re more inorme n interonnete thn ever with the internet n soil mei, n there re more emle surgeons thn there hs ever een eore. Surroune y rpily evolving tehnologies, we n ourselves living longer ut uner the thret o ementi n oesity. Our popultion is inresing t isproportionte pe with regr to ville resoures. Our helth system is struggling to support the extr lo n my require restruturing. Ten there is ntiioti resistne, whih is proly the iggest urrent thret to glol helth. However, in n er o inrese regultion, ethis n litigtion, oul our uture evelopments hiner our progress? Wht will e the impt o these on provision o re or ptients n the trining o surgeon o the uture? Te uture will e ene y not only our new tehnologil vnes ut y how we ress our new hllenges while trining uture genertions o surgeons n keeping ptient welre t the hert o the ete.
Index
Note: Page numbers in italics reer to gures and tables. A
Abbe, Robert, 95 abdomen, penetrating wounds o, 140– 140 –1 abdominal injuries, 11 1100, 139, 139, 140 Abdominal Operations Ope rations (Moynihan), 108 108,, 11 1133 Abel, J. J., 242 Abernethy, John, 59 abortion, 18 abscesses, 7, 10 10,, 29, 29, 41 41,, 105 105,, 106 106,, 117, 135 117, 135,, 148 148,, 160 160,, 217 AccuVein vein visualisation technology, 253 253,, 254 acupuncture, 12 12,, 12 acute abdominal pain, 105 acutely infamed appendix, 112 adhesions, 11 1122 Aetiology, Aetiolog y,of Concept andFever P revention Prevention Puerperal , 85 Aetius o Amida, 22 22– –3 AI systems, see see articial articial intelligence (AI) systems Albee, Frederick, 16 1611 Albee gra, 16 1611 Albinus, Bernhard, 51 Albright, Fuller, Ful ler, 21 2100 Albucasis, 24 24,, 24 Alexander the Great, 18 ambulance, 131 , , 13 1311–3, 135 135,, 136 136,, 137, 139 137, 139,, 21 2100 America, 63 63– –4 American Civil Civi l War, 135 135– –6
Ammonius o Alexandria, 18 1811 amputation, 28 28,, 29 29,, 36 36,, 42 42– –3, 43 , , 48,, 49 48 49,, 54 54 , , 57 57,, 64 64,, 72 72,, 73 73,, 78,, 79 78 79,, 86 86,, 89 89,, 98 98,, 104 104,, 1100, 128 11 128,, 128 , , 130 130– –5, 5, 143– 143 – 6, 149 149,, 153 153,, 159, 159, 165 165,,
anus, 17 17,, 29 29,, 30 30,, 102 102,, 104 104,, 182 182,, 185 185,, 251 aorta, 69 69,, 70 , , 71 71,, 72 , , 21 2188–22 22,, 219, 219, 227,, 228 227 228,, 230 230,, 231 231,, 235 235,, 236 , , 241, 241, 241 , , 246 aortic aneurysm surgery, 234 234– –6
169 Amussat, Jean, 11 1144 Amyand, Claudius, 105 anaesthesia, 5, 35 35,, 49, 49, 64 64,, 75 75– –83, 83, 96 96,, 1022, 104 10 104,, 105, 105, 11 1144, 122 122,, 129,, 13 129 1333–5, 142 142,, 146 146,, 159, 159, 171, 17 171, 1733, 17 1755, 187, 187, 190 190,, 199,, 21 199 2166, 221, 221, 241 241,, 249 Anathomia,, 25 , , 27 Anathomia anatomical illustration, 51 anatomy and surgery, 42 Te Anatomy Te Anatomy of the Human Body , 56
Apologie and an d reatise reatise Containing C ontaining the rips Made in Divers Places,, 36 Places appendicectomy, 156 appendicitis, 105 105– –7 AR, see see Augmented Augmented Reality (AR) Arabian medicine, 23 23– –4 Archives of Surgery Surge ry , 109 Arderne, John, 29 , , 29 29– –30 Aristotle, 18 Armamentarium Armament arium Chirurgicum Chir urgicum,, 165,, 166 165 Armamentum Armament um Chirurgicum Chirur gicum,, 43 43,, 43
Ancient Egypt, 2 , 7–10 10,, 10 , , 93 93,, 191 191,, 2111 21 Ancient Greece, 15 15– –19, 19, 18 1811 Ancient Rome, 19 19– –20 20,, 20 Anderson, Tomas, 87 André, Nicholas, 151 aneurisma, 41 aneurysm, 22 22– –3, 41 41,, 49 49,, 61 61,, 64 64,, 69 69,, 70,, 89, 70 89, 11 1199, 230 230,, 231, 231, 231 , , 233– 233 – 6, 236 Anglo-Saxon medical writing, 152 Annals of Surgery Su rgery (Matas), (Matas), 230 antiseptic surgery, 84 84– –92 92,, 102 102,, 122,, 153 122 153,, 173 173,, 17 1744, 221 Antommarchi, Dominique, 195
arterial surgery, 230 230– – 4, 234 234 , , 235 articial heart valves, 227, 227, 227 articial arti cial intelligence (AI) systems, 253 articial kidney transplantation, 242– 242 –3, 3, 243 Aselli, Gaspare, 44 44,, 45 asepsis, 190 aseptic surgery, 90 90,, 91 91– –2 Askanazy, Max, 209 Attachment Attachme nt of the Placenta Place nta to the Uterus (Shippen), Uterus (Shippen), 63 Augmented Reality (AR), 253 253– –4 Australian Aborigines, 151 257
258
Index
Avicenna, 23 23– –4 axillary lymph nodes, 171 B
Babylon, 7, 8, 10 Bailey, Charles, 225 225,, 229 229,, 230 Bailey’s English Dictionary , 81 Ballance, Charles Alred, 110 , , 1100 –11 11 bandaging technique, 49 49– –50 50,, 50 Bannister, John, 38 barber-surgeons, 35 35– –7, 38 38 , , 39 39,, 42 42,, 49,, 51 49 51,, 55 55,, 56 56,, 127, 127, 129 129,, 189 Barnard, Christian, 247 Baronio, Giuseppi, 238 Baroni’s experiment, on skin autograing, 239 Basedow, Karl von, 206 Basedow’ss disease, 206 Basedow’ Battle, William, 11 1122 beating heart surgery, 221 221– –5 Beatson, George, 179 Beaulieu, Jacques, 184 Beck, Claude, 228 Beleld, William, 11 1144 Bell, Benjamin, 61 61,, 171 Bell, Charles, 129 Bell, John, 65 Bell, Joseph, 61 Bichat, Xavier, 50 Bidloo, Govert, 58 Bigelow, Henry,77 76, 81 Bigelow, Jacob, 77, Bigelow, W. W. G., 225 Billingham, Rupert, 243 Billroth, Teodor Teodor,, 95 95– –8, 96 , , 102 102,, 199,, 201 199 201,, 221 Biondi, Domenico, 21 2166 Bjork,, Viking, Bjork Vik ing, 227 bladder irrigator, 192 1811 , , bladder stone, cutting or, 18 1811, 18 194 perineal lithotomy, 18 1811–8 suprapubic lithotomy, 188 188– –90 transurethral lithotrity, 19 1911–5 Blalock, Alred, 220 220,, 221 Block, M. H., 215 215– –16
blood circulation, 44 1744 Bloodgood, Joseph, 17 blood transusion, transu sion, 144 , , 144 144– –5 blood vessels, 13 13,, 21 21,, 23 23,, 27 27,, 32 32,, 36 36,, 54,, 63 54 63,, 72 72,, 87 87,, 89 89,, 96 96,, 11 1166, 125,, 128 125 128,, 135 135– –7, 143 143,, 187, 187, 207, 225 207, 225,, 232 232,, 239 239,, 240 240,, 242,, 244 242 244,, 249 249,, 256 bloody fux, 100 Blundell, James, 121 121– –2, 143 143– – 4, 144 Bobbs, John Stough, 49 49,, 93 93,, 94 94,, 94 Boerhaave, Herman, 51 51,, 194 Boer War, 136 Böhler, Lorenz, 157 Bologna, 25 25,, 26 Bonaparte, Napoleon, 195 bone ragments, 153 Boott, Francis, 79 brain, wounds on, 130 breast cancer, radical surgery or, 64 breast tumours, 165 165– –73 73,, 167 case study, 167 167– –70 70,, 169 radical operation, 17 1744 –9 treatment, 179 A Brief and Necessary reatise, A reatise, ouching the Cure of the Disease Now Usually Called Lues Venera Venera (Clowes), 40 Britain, 55 55– – 63 British Journal of Surgery , 108 British Medical Journal (Lister), (Lister), 95,, 136 95 136,, 154 154,, 204 Brock, G. S., 222 Brock, Russell, 220 220,, 224 224,, 224 , , 241 Brooke, Bryan, 101, 101, 101 Brown, John Young, 10 1011 Brunton, Tomas Lauder, 222 Bryant, Tomas, 112 Bülau, Gotthard von, 213 Burnet, Frank Macarlane, 243 Byrne, Charles, 60 Byzantium, 22 22– –3 C
Caesarian operation, 121 Caesarian section, 11 1199–23 23,, 122 , , 122– 122 –3, 123
Cairns, Hugh, 11 1188–19 Calne, Roy, 245 245,, 245 Calvin, John, 34 Cambridge medical robotics (CMR), 253 cancer o colon, 102 102– –3 large bowel, 10 1011–2 o rectum, 103 103– –5 Cancer of the Breast and Its Operative reatment (Handley), 17 1766 Cannon, Walter B., 11 1133 Te Canon Te Canon,, 23 capital operation operation,, 80 80,, 80 carbolic spray, 91 cardiac surgery, 21 2188, 220 220,, 222 222,, 226 226,, 226 , , 228 228,, 236 236,, 243 243,, 255 Carlisle, Anthony, 59 Caroline o Ansbach, 61 , , 61 61– –2 Carpue, Joseph Joseph,, 14 , , 14 14– –15 Carrel, Alexis, 222 222,, 229 229,, 232 232,, 233 heart transplantation, tr ansplantation, 246 kidney transplantation, t ransplantation, 239– 239 – 42 42,, 240 , , 241 Carrel–Dakin technique, 143 143,, 144 Cases of lithotrity (Heurteloup), (Heurteloup), 192 Casualty Clearing Stations (CCS), 138 , , 138 138– – 40 cataract, couching or, or, 13 13– –14 14,, 14 Caulk, John, 11 1166 cauterisation o wound, 126 , , 126 126– –8 celioscopy, 250 Celsus, Aulus 19, , 165 165, , , 168,, Cornelius, 168 1811–2 , 197 18 197,,19 198, 198 , 213 213, 230 Cérenvelle, Edouard de, 215 Certaine Workes of Chirurgerie, Chirurgerie , 129 Charles, Prince, 100 100– –1 Charnley, John, 91 91,, 162 162– –3, 163 Chauliac,Guy de, de, 21 2111 Cheselden, William, 42 42,, 55 , , 55 55– – 6, 57,, 186 57 186– –7, 189 189– –90 90,, 190 chest-wall chestwall deect, 177 Cheyne–Stokes respiration, 18 China, 10 10– –13 Chinese acupuncture, 12 12,, 12 Chinese physi physicians, cians, 11 11,, 12
Index 259
Chirurgerie, 41 Chirurgerie, Chirurgia, 25 25,, 25 Chirurgia Magna, Magna, 27 27,, 29, 29, 29 Chirurgie,, 28 Chirurgie chloroorm, 82 , , 82 82– –3 cholecystostomy, 49, 49, 94 94,, 112 Chopart, François, 49 chronic varicose ulcer, 37 circumcision, 2– 4 Civiale, Jean, 64 64,, 191 191,, 191 Clark, imothy, 45 Classifcation o Roots and Herbs, Herbs, 12 clavicle, ractures o, 49 49– –50 ‘clean’ wounds, 136 Cline, Henry, 68 Clowes, William, 40 40,, 40 cocaine, 83 code o King Hammurabi, 7–8, 8 collateral channels, 69 69,, 70 Te Collection Te Collection,, 24 colon cancer, 102 102– –3 Company o Barber-surgeons, 37 37,, 38 , , 39 38 39,, 42 42,, 129 129,, 189 Company o Surgeons, 14 14,, 37 37,, 39, 39, 56,, 62 56 62,, 63 A Compendious Practice o the Art A o Surgery (Vigo), (Vigo), 126 compound racture, 88 88 , , 88 88– –9 compound injury, 153 compound skull injuries, 141 constrictive pericarditis, 218 Cooper, Astley, 59 59,, 68 68 , , 68 68– –73 73,, 72 , , 158,, 171 158 171,, 191 191,, 197, 197, 230 Cooper,, William, Cooper Wil liam, 68 Copernicus, Nicholas, 30 copper plates, 52 52,, 54 coronary artery disease surgery su rgery,, 228– 228 –30 30,, 229 corticosteroids, 101 couching or cataract, 13 13– –14 14,, 14 Cowper, William, 42 42,, 42 Craoord, Clarence, 219 Craword, Jane odd, 65 65,, 65 , , 66 66,, 68,, 68 68 cretinism, 202 202,, 202 Crile, George, 206 206,, 206
Cushing, Har vey vey,, 61 61,, 11 1188 , , 118 118– –19 19,, 141– 141 –3, 142 , , 17 1744 , , 175 175– –6 Cutler,, Elliott, Cutler El liott, 222 cyclopropane, 83 cystosarcoma phyllodes, 166 166,, 167 Czerny, Vincenz, 98 98,, 102 102,, 104 104,, 107
Crimean War, 133 133– – 4, 134 , , 135 Cruveilhier, Jean, 100 Curling, Tomas Blizzard, 202
(Moynihan), 108 dislocations, 5, 10 10,, 16 16,, 19, 19, 58 58,, 59 , , 151– 151 –8
D
Dahl-Iverson, Erling, 176 Dahl-Iverson, Dameshek, W., 245 Dandy, Walter, 119, 119, 11 1199 Daniels, Polak, 242 Danville, 65 Dark Ages, 21, 21, 22 22,, 24 Davies, Morriston, 217 Davies, Tomas, 213 da Vinci, Leonardo, Leonardo, 31, 31, 32 Da Vinci robot, 252 252,, 252 Davy, Humphrey, 75 Dawson, Lord, 223 DeBakey, Michael, 229 de Chauliac, Guy, 28 28 , , 28 28– –9 deormity o knee, 161 161– –2 , 162 De Humani Corpora Fabrica Fabrica (Te Structure o the Human Body),, 32 Body) 32– –4 de La Peyronie, François, 48 delayed primary suture, 138 De L’Orthomorphie (Delpech), L’Orthomorphie (Delpech), 159 Delpech, Jacques-M Jacques-Mathieu, athieu, 159 De Medicina, Medicina, 165 de Mondeville, Henri, 28 De Motu Cordis (Te Motion o the Heart), , 30 Heart) 30,, 44 Denys, Jean Baptiste, 143 De Re Medicina, Medicina, 19 Desault, Pierre-Jo Pierre-Joseph, seph, 49 , , 49 49– –50 50,, 50 , , 198 De Wall-Lillehei bubble oxygenator, 227, 227, 227 dialysis, 242 242– –3, 243 , , 245 diarrhoea, 101 diathermy, 11 1188 Dionis, Pierre, 43 Diseases o the Stomach Stomach
dissection, 12 12,, 19 19,, 20 20– –2 , 24 24– –7, 7, 25 , , 32,, 34 32 34,, 37 37,, 43 43,, 48 48,, 49 49,, 56 56,, 57,, 64 57 64,, 69 69,, 71 71– –3, 104 104,, 173 173,, 175,, 177, 175 177, 185 185,, 186 186,, 190 , , 201,, 206 201 206,, 209 209,, 217, 217, 218 218,, 253 Dixon, Frank, 245 doctor–patient relationship, 18 Donally, Mary, 120 120 Dos Santos, Joao Sid, 233 Dos Santos, Reynaldo, 233 Douglas, James, 188 188– –9 Dublin Medical Press, Press , 64 Dubost, Charles, 221 221,, 229, 229, 234 234– – 6, 235 , , 236 dung, 2 Dupuytren, Baron Guillaume, 198 Duval, Pierre, 223 E
East India Company, 42 Ebers papyrus, 9 , , 9–10 Eclectic Repertory and Analytical Review (McDowell), Review (McDowell), 66 Edinburgh Medical and Surgical Journal (Syme), (Syme), 73 Edinburgh Medical Journal , 64 64,, 120 Edwards, Lowell, 227 Edwin Smith papyrus, 9, 9 elective orthopaedics, 158 158– – 63 Elliot-Smith, Grafon, 152 embryology, 44 Empedocles, 15 Empyema,, 212 Empyema Encyclopaedia o Medicine, Medicine, 22 endovascular aortic repair (EVAR), 249,, 250 249 endovascular surgery, 236 EndoWrist technology, 252 Enantement Caesareinne, Caesareinne, 120 England, 37 ‘the English Paré’, 129 Enlargement o the Tyroid Gland in Connection with Enlargement or Palpitation o the Heart (Parry), 205 enteric ever, 136
260
Index
epidemic dysentery, 101 Te Epidemics Te Epidemics,, 16 Erasistratus, 19, 19, 26 erysipelas, 137 ether, 75 75– –83 83,, 135 Ether Dome, 77, 77, 78 ether inhaler model, 77, 77, 77 Euphrates fows, 7 euthanasia, 18 see endovascular aortic EVAR, see aortic repair (EVAR) Excellent reatise of Wounds made with Gunshot (Gale), (Gale), 39 extracardiac surgery su rgery,, 218 F
Fabrica of Vesalius, Vesalius, 27 Fallot, Etienne-Louis, 220 220 , , 220 220– –1, 226 Federal Drug Administration (FDA), 252 Félix, Charles François, 43 43– –4 Felkin, Robert, 120 120,, 121 emoral artery, arter y, 49, 49, 61 61,, 72 72,, 81 81,, 89 89,, 107, 230 107, 230,, 231 231,, 232 , , 233 233,, 233 , , 234 234,, 234 234 , , 236 236,, 240 240,, 249 erments, 86 Ferne, James, 55 bromyxoma, 11 1166 Fine, Pierre, 102 Finney, J. M. ., 17 1744 First W29 War, ar,–137 137– 46 stulaWorld in ano, 29– 30,–30 Fitz, Reginald, 106 106,, 106 fying ambulances, 131 131,, 13 1311 Fogarty, Tomas, 233 orearm bones racture, 2 , 3 Forlanini, Carlos, 215 Fox, Edward Lawrence, 204 ractured olecranon, wiring wiri ng o, 153– 153 –4, 154 ractures bandaging technique, 49 49– –50 50,, 50 bone ragments, 153 o clavicle, 49 49– –50
compound, 88 88 , , 88 88– –9 and dislocations, 151 151– –8 mischie in, 42 42– –3 nail xation o, 157, 157, 157 neck, 158 Potts, 58 58,, 59 stainless steel plates or, or, 155 155– – 6, 156 France, 48 48– –50 Franco, Pierre, 36 36– –7, 188 Franco-Prussian War, 136 Franklin, Benjamin, 194 194– –5 Fraser, William, 82 Fredet, Pierre, 99 French Academy o Medicine, 198 French Revolution, 49 French School o Surgery, 43 French surgery, 28 Freyer, Peter, 11 1144–15 15,, 115 ‘the Freyer prostatectomy’, 11 1144, 115 , , 116 rolics, 75 Frost, Eben, 76 Fuller, Eugene, 11 1144 G
Galen, 19 19– –20 20,, 20 , , 22 22,, 23 23,, 25 25,, 27, 27, 32,, 34 32 Gale, Tomas, 39 , , 39 39– – 40 40,, 129 Galileo’s design, 30 gall bladder surgery, surgery, 93 93– –5 gallstone surgery su rgery,, 93 93– –5 Ganter, G., 242137 gas gangrene, Gask, George, 212 gastric surgery, su rgery, 95 95– –9 Gedroitz, Vera, 136 136– –7 Geminus, Tomas, 37 General System of Surgery (Heister), 51 51,, 198 198,, 213 gene therapy, 256 George II, King, 37 German Enigma Code, 253 Germany, 51 51– –5 Gibbon, John, 225 225– –6 Gilord, Hastings, 107 Gillies, Harold, 37
Glasgow, 41 Glasgow Medical Journal , 64 Gley, Eugène, 209 Gluck, Temistokles, 162 162,, 216 goitre, surgical treatment o, 198– 198 –202 202,, 200 200– –2 Google Glass, 253 Gordon, Alexander, 84 Gowers, William, 116 Graham, Evarts, 214 214,, 21 2144 , , 217, 225 217, Graves, Robert, 205 205,, 206 Great Doctors of the Nineteenth Century (Hale-White), (Hale-White), 203 ‘Te Great War’, 137 Groenvelt, Jan, 188 Gross, Robert, 219 219,, 220 220,, 225 Gross, Samuel, 11 1144, 198 Gruntzig, Andreas, 236 Guedel, Arthur, Art hur, 216 Gull, William, 202 202,, 203 gunpowder, 126 126– –30 gunshot wounds, 29 29,, 39, 39, 40 40,, 127 127,, 129,, 131 129 131,, 133 133,, 136 136,, 140 140,, 230,, 232 , , 233 , , 240 230 Gunshot Wounds (Guthrie), Wounds (Guthrie), 133 Gussenbauer, Carl, 98 Guthrie, Charles, 233 233,, 240 240,, 241 Guthrie, Douglas, 89 89– –90 Guthrie, George James, 133 133,, 133 , , 212 Guyon, Felix, 238 Guy’s Hospital, 68 68,, 68 gynaecologists, 163 H
Habershon, Samuel, 100 haemorrhage, 24 24,, 27, 27, 36 36,, 58 58,, 61,, 69 61 69– –73 73,, 89 89,, 98 98,, 109,, 11 109 1111, 112 112,, 121, 121, 122,, 125 122 125,, 137 137,, 144 144,, 156,, 169 156 169,, 182 182,, 183 183,, 199,, 201 199 201,, 211 211,, 212 212,, 218,, 222 218 222,, 230 haemorrhoids, 17 On Haemorrhoids On Haemorrhoids,, 17
Index 261
Hale-White, William, 203 halothane, 83 Halsted, William Stewart, 83 83,, 83 , , 92,, 11 92 1188, 173 , , 17 1744 , , 17 1744 –5, 175 , , 201 Hancock, Henry, 105 Handley, Sampson, 17 1766, 176 Hardy, James, 247 Harken, Dwight, 224 Harrison, Hartwell, 244 Hartmann, Henri, 223 Harvard Medical School, 81 Harvey, William, 30 30,, 44 44,, 44 44 , , 194 Hasson, Harrith, 251 Hawes, William, 47 Hayward, George, 79 heart transplantation, tr ansplantation, 246 , , 246– 246 –7 Heidenhain, Lothar, 17 1744 Heineke, Walter, 103 Heister, Lorenz, 51 51– –5, 52 , , 105 105,, 166 166,, 167, 169, 167, 169, 169 , , 170 170,, 213 Henry VIII o England, 37 37,, 38 , , 39 hernia, 19 19,, 23 23,, 29 29,, 35 35– –7, 48 48,, 51,, 52 51 52,, 58 58,, 62 62,, 69 69,, 93,, 100 93 100,, 105 105,, 120 120,, 175,, 186 175 186,, 251 Herophilos, 19 19,, 26 Heurteloup, Charles Louis Stanislas, 19 1911–2, 193 Heusner, Ludwig, 107 Heusser, H., 242 Hibbs, Russell, 16 1611
Home, Everard, 59 59– – 60 60,, 61 Homo sapiens, sapiens, 1 Hopkins, Harold, 249 Hopkins, Johns, 11 1199 Horsley, Victor, 11 1166 –18 18,, 11 1188 , , 204 Hunagel, Charles, 227 Huggins, Charles, 179 Hugh o Lucca, 25 Humane Society, 47 Hume, David, 243 Humphry, Murray, 190 Hunterian Museum, 60 60,, 61 Hunter, John, 57 57– – 61 61,, 59 , , 63 63– – 4, 129, 129, 230,, 238 230 Hunters canal, 61 Hutchinson, Jonathan, 108 108– –9, 9, 109 hyperthyroidism, 205 , , 205 205– –8 hypothermia, 225 hypothyroidism, 202 202– –5 202– –4 , , 202
K
I
thyroidectomy technique, 201 Koch, Robert, 215 Kolesov, Vasilii, 229, 229, 230 Kol, Willem, 242 242,, 243 Koller, Carl, 83 Kraske, Paul, 104 Kunlin, Jean, 234 Küntscher, Gerhard, 157, 157, 157 Kuss, René, 243 kyphosis, 11 11,, 11
Highmore, Nathaniel, Hilden, Wilhelm Fabry32von, 165 Hilton, John, 160 Hindu surgery, 13 hip racture, 158 158,, 158 Hippocrates, 15 , , 15 15– –16 Hippocratic Facies, 16 Hippocratic method, 16 16– –17 17,, 17 Hippocratic physicians, 18 Hippocratic writings, 16 Hirschsprung, Harald, 99 Holbein, Hans, 37 Holland, Eardley Ea rdley,, 123
irradiation, 179,, 179 179 irrigation fuids, 1011 10 Italian surgery, 27 27,, 28 Italy, 50 50– –1
Jaboulay, Mathieu, 239 Jacques, Frère, 184 184– – 6, 185 James IV o Scotland, 39 Jeerson, Georey, 233 Jeghers, Harold, 11 1100 Jenner, Edward, 58
lacerated bullet wound, 139 139,, 139 Lambotte, Albin, 155 155,, 157 laminectomy, 11 1166 Te Lancet (journal), (journal), 5, 99 99,, 152 152,, 221,, 222 221 Landsteiner, Karl, 144 144– –5 Lane, William Arbuthnot, 11 1100, 155– 155 –7, 156 , , 213 213,, 222 Lanranc, 27 27,, 27 Langenbuch,, Carl Langenbuch Ca rl Johann, 94 94,, 94 laparoscopic appendicectomy operation, 249 249,, 251
Hollier, Tomas, 194 Holmes, Oliver Wendell, 81 81,, 84
Johansson, Sven, 158 Jones, Robert, 138 138,, 153
laparoscopic cholecystectomy, 251 laparoscopic keyhole surgery, 250
ileostomy, 10 1011 Illness, 21 imaging modalities, 249 Imhotep, 8, 9, 9 immobilisation, 160 immunotherapy, 256 India, 2, 13 13– –14 14,, 18 18,, 23 injuries, 2 intestine transplantation tr ansplantation,, 247 Intravenous Intraven ous anaesthetic drugs, 83 intussusception, 108 108– –10
J
Kalk, Heinz, 250 Keen, William Williams, 94 Keith, Arthur Art hur,, 100 Kelling, George, 250 Kendall, Edward, 205 Kentucky State Medical Society, 67 Kerr, John Munro, 123 key-hole surgery, 64 Keynes, Georey, G eorey, 178 178,, 178 , , 179 kidney transplantation, t ransplantation, 239 239– – 42 42,, 240 , , 241 kidney tumour tu mour,, 94 94– –5 Kirklin, Kirkli n, John, 227 knee deormity, 16 1611–2, 162 Kocher, Teodor, 94 94,, 95 95,, 104 104,, 198– 198 –201, 201, 199 , , 200 200 , , 203 203,, 209, 241 209, goitre patient o, 202 operative myxoedema, 204 204,, 204
L
262
Index
large bowel cancer, 101 101––2 large intestine surgery, 99 99––101 Larrey, Baron, 212 Larrey, Dominique Jean, 130 , 130––3, 132 130 Larrey, Jean, 152 L’École de Chirurgie (the School o Surgery), 48 Lectures on Surgical Pathology (Paget), 172
Lower, Richard, 143 Lower, 143,, 218 Ludwig’ss angina, Ludwig’ angi na, 28 lung resection, 215 215––17 17,, 21 216 6 , 217 lung surgery, surger y, 211 211––14 14,, 213 lymphatics, 44 44––5 lymph nodes, 171
Miscellanea Miscell anea Curiosa Cur iosa MedicoPhysica (Clark), 45 45–– 6 M
Macbeth , 119
Long, Craword, 75 75–– 6
Macewen, William, 91 91,, 116 116,, 161 161,, 161, 216 Mackenzie, Hector, 204 McBurney,, Charles, 107 McBurney McCormack, William, 136 McDowell, McDo well, Ephraim, Ephra im, 65 , 65 65––8, 67 McGill, Fergusson, 11 1144 McKee, George, 162 McWhirter, Mc Whirter, Robert, 177, 177 177––8 Magill, Ivan, 216 malaria, 17 17,, 84 Malpighi, Marcello, 31 31,, 44 Mandl, Felix, 210 Mandragora ofcinarum ofcinar um , 75 Marcus Aurelius, 19 Mareschal, Georges, 48 Margottini, Mario, 177 Marian operation, 183 Massachusetts Medical Society, Societ y, 79 Matas, Rudolph, 71 71,, 216 216,, 230 230,, 230 , 231,, 231 231 Mathijsen, Antonius, 152 Mayo, Charles, 206 206,, 207 207,, 207 Mayo, William Worrall, 207, 207––8 207 Medawar, Peter, 243 Medical and Physical Physic al Journal Journa l , 102 Membership o the Royal College o Surgeons (MRCS), 133,, 153 133 Memoirs o Military Surgery S urgery (Larrey), 131 Merrill, John, 244 Mesmer, Anton, 75 mesmerism, 75 Mesopotamia, 7–8
Louis France,48 43 Louis XIV XV ooFrance, Lowe, Peter, 40 , 40 40––1
Te Method o reating Wounds Method Made by Firearms Firear ms , 36 Meyer, Willy, 17 1744, 17 1744
Lectures on the Principles and Practice o Surgery
(Cooper), 171 Le Dran, Henri, 170 170––1 Le Gros Clark, Wilred, 100 Lett, Hugh, 179 lex Caesarea, 119 ligation o blood vessels, 128 ligature, 30 lignocaine, 83 Lillehei, Walto Walton, n, 226 Lillihei, Richard, 247 limb amputatio a mputation, n, 42 42––3, 43 Lind, James, 42 Lisranc, Jacques, 103 103–– 4 Lister, Joseph, 73 73,, 86 , 86 86––91 91,, 91 , 108 108,, 136,, 153 136 153––5, 154 , 159, 159, 173 Liston, Robert, 72 72––3, 79 79––81, 81, 171 171––2 Lithotomia Lithoto mia Douglassiana (Douglas), 188 lithotomists lithotomis ts cruel instruments, 183 lithotomy history o, 184 184––5 perineal, 181 181––8 position, 182 182,, 182 , 184 184,, 184 , 186 suprapubic, 188 188––90 lithotrite, 115 115,, 192 192,, 193 lithotrity, transurethral, 191 191––5 Little’s disease, 159 Little, William John, 159 Littré, Alexis, 48 liver transplantation, 245 245–– 6, 246 Lockhart-Mummery, J. P., 104 London Medical and Chirurgical Review (McDowell), 67
Mikulicz-Radecki, Johannes von, 92,, 98 92 98,, 103 Miles, Ernest, 104 104,, 104 Millin, Milli n, erence, erence, 116 minimally invasive techniques, 249, 252 249,
Mondeville, Henri de, 165 165,, 211 Mondino de Luzzi (Italian physician), 26 Moniz, Antonio, 233 Monroe, John, 218 Monro Secundus, Alexander, A lexander, 65 Morgagni, Giovanni, 50 50––1, 93 93,, 218 Morgan, John, 59 59,, 63 Morison, James Rutherord, 100 Morse, Tomas Herbert, 107 Morton’s model, 77, 77, 77 Morton, Tomas, 106 Morton, William, 75 75––82 82,, 76 , 135 Moxon, Walter, 101 Moynihan, Berkeley Berkeley,, 95 95,, 105 105,, 107––8, 108 , 113 107 113,, 11 1144, 223 Muhe, Erich, 251 multiple organ transplantation, 247 Mundinus, 25 , 25 25––7 Murphy, J. B., 107 107,, 215 215,, 230 230––2 , 231– 231 –3 , 240 Murray,, George Redmayne, 204 Murray Murray, Joe, 244 Murray, Joseph, 244 N
nail fxation, 157, 157, 157 Napoleonic Wars, 130 130––3 Natural Orifce ransluminal Endoscopicc Surgery Endoscopi (NOES), 251 251––2 neck, ractures o, 158 nephrectomy, 11 1144 neurosurgery, 116 116––19 new blood, 20 New Health Society, Societ y, 157 Nightingale, 133–– 4, 134 nitrous oxide,Florence, 75,, 83 133 75 Nitze, Max, 11 1166, 11 117 7
Index 263
non-contagious diarrhoea, 100 non-contagious 100– –1 nose, reconstruction o, 14 14,, 14 see Natural Orice NOES, see Orice ransluminal ransluminal Endoscopic Surgery (NOES) Nourse, William, 57 William, 57 O
Observations on Extraction of Diseased Ovaria, Ovaria, 67 olecranon, racture o, 153 153– –5, 154 On a Cretinoid State Supervening Super vening in Adult Life in Women Women (Gull), 202 oncolytic virotherapy, 256 On the Contagiousness of Puerperal Fever , 84 On the Sites and Causes of Diseases Diseases (Morgagni), 50 On Wounds and Injuries of the Chest (Guthrie), (Guthrie), 212 open-heart surgery, 225 225– –7, 226 , , 227 operative myxoedema, 204 Te Operative Story of Goitre Te Goitre (Halsted), 201 Operative Surgery (Kocher), (Kocher), 200 200,, 200 Te Operative Surgery of the Eye Te Eye (Guthrie), 133 orbito-rontal orbit o-rontal perorating wound, 141, 141 141,
ractures and dislocations, 151– 151 –8 L’Orthopédie (André), L’Orthopédie 1511 (André), 151 151,, 15 O’Shaugnessy, Lawrence, 228 228,, 228 Osler,, William, Osler Wil liam, 101 osteosynthesis, 157 osteotomy, 161 Ott, Dimitri, 250 Owen, Richard, 209 P
Paget, James, 172 172,, 172 , , 173 Paget’s disease o bone, 173 Paget’s disease o the nipple, 173 Paget’ss disease o the penis, 173 Paget’ Paget, Stephen, 221 Palpitation of the Heart with Enlargement of the Tyroid Gland (Stokes), (Stokes), 205 Pancoast, Joseph, 171, 171, 171 Pancoast’ss mastectomy technique, Pancoast’ 171,, 172 171 pancreas tra nsplantatio nsplantation, n, 247 parathyroid glands, 208 208 , , 208 208– –10 10,, 209 Paré, Ambroise, 35 35– – 6, 36 , , 39 39,, 120 120,, 127, 127 127, 127– –30 30,, 184 184,, 211 211,, 213,, 230 213 Paris, 39 39,, 48 Parkes-Weber, Frederick, 109– 109–110 Parry, Caleb Hillier, Hill ier, 205
Ord, Mi ller, 203 Miller, 237, 237 organWilliam tra nsplantation nsplantation, , 237, 237– –8 articial kidneys, 242 242– –3, 243 heart, 246 , , 246 246– –7 immunological basis o, 243 243– –5, 244 , , 245 244 intestine, 247 kidney transplantation, t ransplantation, 239– 239 – 42 42,, 240 , , 241 liver, 245 245– – 6, 246 multiple organ, 247 pancreas, 247 skin grafing, 238 238– –9, 239
Parry, John, 111185 , , 85 11 Pasteur, Louis, 85– –7, 86 patella, racture o, 153 153– – 4, 154 Patey, David, 178 Pathological Anatomy , 101 pathology, 51 ‘the pathology o the living’, liv ing’, 105 patients condence, 18 Paul, Frank Tomas, 103 Paul–Mikulicz operation, 103 Paul o Aegina, 23 Pauls tube, 103 103,, 103 Péan, Jules, 95 , , 95 95– – 6, 98
Oribasius o Pergamum, 22 orthopaedic surgery, 151, 151, 151 , , 163 elective, 158 158– – 63
Pecquet, Jean, 44 44– –5 Pepys, Samuel, 194 perce-pierre, 191
Percy, Pierre François, 130 perorated peptic ulcer, 107 107– –8 perineal lithotomy, 181 181– –8 Persian Avicenna, 23 persistent ductus arteriosus, 218– 218 –19, 19, 219 Petersen, Marius Smith, 162 Petit, Jean-Louis, 48 48 , , 48 48– –9, 9, 93 93,, 171 Peutz, John, 110 Philip II o Spain, 39 Physick, Philip Syng, 59, 59, 63 63– – 4, 64 Pinel, Phillipe, 47 Pirogo, Nikolai, 134 Plaster o Paris, 152 Platter,, Felix, 202 Platter Plummer, Henry, 207 poliomyelitis, 10 10,, 10 Porro, Eduardo, 122 post-operative post-op erative adhesions, 112 57,, 57 Pott, Percivall, 57 57– –9, 153 153,, 160 Pott’ss disease, Pott’ disea se, 58 58,, 58 Pott’ss racture, Pott’ rac ture, 58 58,, 59 , , 153 Potts, Willis, 221 prehistoric period, 1–2 circumcision, 2– 4 skull, trephination o, 4 –5 preliminary laparotom laparotomy, y, 104 Te Principles and Practice of Te Medicine,, 101 Medicine Pring, Daniel, 102 Pringle, James Hogarth, 233 233,, 234 PROBO system, 252 prostatectomy, 11 1144–16 prosthesis, 162 prosthetic replacemen replacements ts,, 158 158,, 158 A Proved Practice for All Young A Chirurgions, Concerning Burnings with Gunpowder and Wounds Made with Gunshot Gu nshot etc. etc . (Clowes), 40 Pugh, William Russ, 82 pulse rate, 44 pyaemia, 137 R
radiation therapy, 178 radical operation, 17 1744–9
264
Index
radical prostatectomy, 252 252– –3 radical surgery, su rgery, 64 radium implantation, 178 178,, 178 , , 179 rag and bottle method, 82 82,, 82 see Royal RAMC, see Royal Army Medical Corps (RAMC) Ramstedt, Conrad, 99 99,, 99 Te Ranby Cup, 63 63,, 63 Ranby, John, 37 37,, 56 56,, 62 62– –3 see 3D printing rapid prototyping, see Rau, Johannes, 51 Recklinghausen, Friedrich von, 209 rectum ca ncer ncer,, 103 103– –5 Regimen sanitatis Salernitanum, 22 Regius Proessor o Surgery, 161 Rehn, Ludwig, 206 206,, 218 218,, 221 221– –2 Renaissance o surgery, 24 24– –31 anatomy, 32 32– –4 Reverdin, Auguste, 203 Reverdin, Jacques-Louis, 203 203,, 203 , , 238– 238 –9 On the the Revolutions of the Celestial Spheres (Copernicus), Spheres (Copernicus), 30 Reybard, Jean Francis, 102 Rhazes, 23 23– –4 Richards, Owen, 140 rickets, 161 161– –2 , 162 Riegner, Oskar, 110 Rienho, William, 217 ROBODOC system, 252 Robotic surgery, 252 252,, 252 Robson, Arthur Mayo, 95 Rockeeller Institute or Medical Research, 241 Roentgen, Roentge n, Wilhelm, 113 113,, 155 155,, 155 Romanis, Franciscus de, 183 Roman surgery, 19 Rome, 19 19– –20 Rosin, David, 251 Ross, Donald, 227 Rovsing, Torkild, 113 Rowbotham, Stanley, Sta nley, 216 Rowntree, L. G., 242 Royal Academy o Surgery, 48 48,, 49 Royal Army Medical Corps
Te Royal Inrmary, Inrmar y, 87 87,, 87 Royal National Orthopaedic Ort hopaedic Hospital, 159 Royal Westminster Ophthalmic Hospital, 133 rubber-cued endotracheal tube, 217 Rudbeck, Ola, 45 ruptured ectopic pregnancy, 1111–12 11 ruptured spleen, 110 110– –11 Ruptures,, 58 Ruptures Russo-Japanese war, 136 136– –7 Ruysch, Frederik, 51 51,, 206 Rydigier, Ludwig, 95 95,, 96 , , 98
Schmieden, Vi ktor, 218 Viktor, School o medicine, 19,, 24 19 Schultes, Johannes, 43 Schwartz, R, 245 scirrhous tumour tu mour,, 102 Scotland, 61 Scott, William, 82 Scultetus, 43 43,, 165 Second World War, 147 147– –9, 9, 157 Sellors, Tomas Holmes, 224 Semmelweiss, Ignaz, 84 84 , , 84 84– –5 Semon, Felix, 204 Servetus, Michael, 34
avulsion, 56 , , 56 56– –7 Hippocratic method, 16 16– –17 17,, 17 Larrey’s method o amputation, 132 , , 132 132– –3 Shumway, Norman, 246 246– –7 sigmoid colon, 100 100,, 100 SILS, see see single single incision laparoscopicc surgery laparoscopi (SILS) silver bistoury, 43 Simmler, Josias, 202 Simpson, James Young, 82 82,, 82 , , 112 Sims, Marion, 94 single incision laparoscopic surgery (SILS), 251 skeleton o Obrian, 60 60,, 60 skull, trephination o, 4 , , 4 –5, 16– 16 –17 small intestine, wounds, o 139, 139, 139 , , 140 Smellie, William, 120 120– –1, 121 Smith, A. G., 67 Smith, Elliot, 181 Smith, Nathan, 67 Smith-Petersen, Smith-P etersen, Marius, 158 Smith, Richard, 129 Smithy, Horace, 224 Society or the Recovery o Drowned Persons, 47 sof clay, 2 Soranus o Ephesus, 19 Southern Italy, 21 21– –2 Souttar, Henry Sessions, 223 223,, 223 , , 225 mitral valvotomy valvotomy,, 223 , , 224 Spanish Civil War, 146 146– –7 ‘Spanish sickness’ sickness’,, 41 spleen bullet wound o, 139 139,, 139 ruptured, 11 1100–11 splenectomy, 110 splint, 138 138,, 151 151– –3, 3, 160 Splints o bark, 2 Stage III tumours, 173 173,, 173 stainless steel plates, 155 155– – 6, 156 Starling, Ernest, 206
(RAMC), 137, 137, 228 228,, 239 Royal College o Surgeons, 56 56,, 59, 59, 160
Several Chirurgical Treatises, Treatises , 130 Shippen, William, 59, 59, 63 shoulder
Starr, Albert, 227 Starzl, Tomas, 246 stem cell technology, 256
S
Sabiston, David, 229 sacculitis, 100 sae modern surgery, 103 Salernum (Salerno), 22 Sanctorius, 44 Sanctus, Marianus, 183 Sandström, Yvar, 209 Sanger, Max, 122 122,, 122 Santorio (Sanctorius), Santorio, 30,, 44 30 Sauerbruch,, Ferdinand, 216 Sauerbruch 216,, 216 Scarpa, Antonio Antonio,, 50 , , 50 50– –1 Schi, Morritz, 203 203,, 204 Schimmelbusch, Kurt, 91 Schlatter, Carl, 99
Index 265
reatise on the Teory and Practice o Midwiery (Smellie), (Smellie), 120 reatises o Fistula in Ano, Haemorrhoids and Clysters,, 29 Clysters rendelenburg, Friedrich, 110 trephination o skull, 4 , , 4–5, 16 16– –17 reves, Frederick, 107, 107, 107 richina spiralis, spiralis, 173 rousseau, ro usseau, Armand, 206 trypanon,, 4 trypanon ubbs, Oswald, 219 tuberculosis, 160 160,, 160 , , 161 161,, 214 214– –15 15,, 215 tuberculous disease, 159 ufer, Teodore, Teodore , 216 uring, Alan, 253 urner, B. B., 242 typhoid ever, 136
abulae anatomicae Sex (Vesalius), (Vesalius), 32 agliacozzi, Gaspare, 37 ait, Robert Lawson, 90 90,, 94 94,, 95 95,, 106,, 111, 106 111, 11 1111–12 12,, 122 aussig, Helen, 220 220,, 221 aylor,, Gordon, 140 aylor 140,, 140 elling, Maxwell, 100 100,, 100 tendon, division o, 159 extbook o Surgery (Paré), (Paré), 120 ‘the apostle o tenotomy’, 159 Tiersch, Carl, 239
Tomas splint, 138 138,, 138 , , 152 152,, 153 Tomas, . G., 123 Tompson, Henry, 186 , , 188 , , 193 3D printing, 254 254,, 255 Tudichum, John, 93 thyroidectomy, 198 198,, 206 thyroid gland, 197 goitre, surgical treatment t reatment o, 197– 197 –202 202,, 198 , , 200 200– –2 hyperthyroidism, 205 , , 205 205– –8 hypothyroidism, 202 202– –4 , , 202– 202 –5 tibia, racture o, 157, 157, 157 igris ows, 7 toenail, 54 54– –5 ‘ommy’s’ helmet, 141 141,, 141 raité des Maladies Chirurgicales et les Opérations qui leur Conviennent (Chopart), (Chopart), 49 rajans column, 20 20,, 20 ransactions o the Zoological Society o London London (Owen), 209 transurethral lithotrity, 191 191– –5 transverse racture, 153 153– – 4, 154 traumatic surgery, 19 A reasure or the Englishman A Containing the Anatomie o Man’s Body (Vicary), (Vicar y), 37 reatise o the Diseases o Bones Bones (Petit), 48 A reatise o the Inhalation o the A Vapour o Ether , 79 A reatise o the Scurvy (Lind), A (Lind), 42 reatise on Dislocations and Fractures (Cooper), Fractures (Cooper), 158 reatise on Gunshot Wounds Wounds (Guthrie), 133 reatise on Hernias, Hernias, 36 Areatise A reatise on the Disea ses o the Breast and Mammary Region ( Region (V Velpeau), 170 reatise on the Excision o Diseased Joints (Syme), Joints (Syme), 159
van Leeuwenhoek, Le euwenhoek, Anton, A nton, 84 Varco,, Richard, 226 Varco Vascular surgery, 64 Velpeau, Al red, 170 Verres, Janos, 250 Vesalius, Andreas, 32 , , 32 32– –5, 33 Vicary, Tomas, 37 37,, 39, 39, 129 Vienna Accident Hospital, 157 Vigo, Giovanni da, 126 Vineberg, Arthur, Art hur, 228 Virchow, Rudolph, 209 Virtual Reality (VR), 253 253– –4
Tomas, Evan, 153 Tomas, Hugh Owen, 138 138,, 152 , , 152– 152 –3, 153 , , 160 160,, 160
reatise on the High Operation or the Stone (Cheselden), Stone (Cheselden), 189
visc eroptosis, 112 visceroptosis, 112– –13 vitamin vita min C discovery, di scovery, 42 Volkmann, Richard von, 17 1744
Stephen, John, 32 32,, 33 stimulation, 12 Stokes, William, 205 stomach or cancer, 98 98– –9 Storz, Karl, 249 Stromeyer, George Friedrich, 159 Te Structure o the Human Body , 35 Te Stump, Johannes, 202 sulphasalazine, 101 Sumerian civilisation, 8 Suppuration and the Formation o Pus (Morgan), Pus (Morgan), 63 suprapubic lithotomy, 188 188– –90 Surgeon-anatomist 16th century, 35 35– – 41 17th century, 41 41– –6 18th century, 47 47– –8 19th century, centur y, 64 64– –71 Te Surgeon’s Mate (Woodall), Te Mate (Woodall), 42 surgery, 1 On the the Surgery o Mutilations by Grafing , 37 surgical incompeten incompetence, ce, 24 surgical instruments, 43 Susruta (Hindu surgeon), 13 13,, 14 14,, 182 Sydenham, Tomas, 100 100,, 194 Syme, James, 72 72– –3, 73 , , 86 86,, 159 Symon, Gustav, 113 113– –14 System o Surgery (Bell), (Bell), 61 System o Surgery (Gross), (Gross), 198 T
U
ulcerative colitis, 100 100,, 101 Ullmann, Emerich, 239 Ungar, Ernst, 239 University College Hospital (UCH), 79 79– –81 Urban, Jerry, 177 urological surgery, 113 113– –14 urologists, 163 V
266
Index
von Bergman, Bergma n, Ernst, 91 von Eiselberg, Eiselberg , Anton, 98 Von Langenbeck, Bernard, 97 97– –8 von Neuber, Gustav, 91 Voronoy, Yu, 240 VR, see Virtual Reality, (VR)
W
Wakley, Tomas, 64 Waksman, Selman, 161 Wall, Richard de, 227 Walters, Ralph, 216 Wangensteen, Owen, 177 warare, surgery o, 125 125– –6 American Civil Civi l War, 135 135– –6 Boer War 136 Crimean War, 133 133– – 4, 134 , 135 First World War, War, 137 137– –46 Franco-Prussian War, 136
gunpowder, 126 126– –30 Napoleonic Wars, 130 130– –3 Russo-Japanese war, 136 136– –7 Second World War, 147 147– –9 Spanish Civil War, 146 146– –7 Warren, John Collins, 64 64,, 76 , 76– 76 –9 Weber, Wilhelm, 99 Weir, Robert, 101 Welch, C. Stuart, Stuar t, 246 Wells, Horace, 75 Wells, Tomas Spencer, 112 Werder,, H., 242 Werder Westminster Hospi Hospital, tal, 47 47,, 47 Wharton, Tomas, 197 White, Charles, 84 Wiles, Philip, 162 Wilks, Samuel, 101 William o Salacet, 26 Wiseman, Richard, 129 , 129 129– –30
Wölfer, Anton, 96 , 96 96– –7, 7, 98 Woodall, John, 42 Worshipul Company o Barbers, 37 wound, 2 cauterisation o, 126 , 126 126– –8 ‘wound man’, 125 125,, 126 Wren, Christopher, 143 Wright, Wrigh t, Almroth, 136 X
xenotransplantation, 247 X-rays, 155 discovery o, 11 1166 Y
Yonge, James, 42 Young, Yo ung, Hugh, Hug h, 11 1166
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