Holistic medicine

History of surgery


Surgeons and Executioners - The History of Surgical Treatment
Not just the Homo Sapiens, but the Neanderthals already knew the art of surgery. The skeleton of one of our relatives with an amputated arm testifies to this, and this patient is 50,000 years old. The following article describes the development of surgical treatment, from the first cranial openings several thousand years ago to complex modern interventions.

Surgery tasks

The Greek word "Cheir urgia" means "do it by hand". Indian doctors cut stones and used nasal prostheses during the Vedas, presumably because cutting the nose was a regular punishment. Surgery has been used since the Stone Age to stop blood flow, treat broken bones, remove ulcers and stones, and cut purulent wounds.

Preoperative cranial operations

"First comes the word, then the medicine and then the knife" (Christian Albert Theodor Billroth (1829-1894), German surgeon).

3,500 BC BC, the ancestors of the Incas practiced trepanation, so they opened the skull, and seven out of ten suffered the intervention - far more than in the 19th century. Such trepanated skulls can be found even in earlier cultures, even in a gray one Premature 12,000 years ago. The bones clearly show that the interventions have healed.

The doctors of the pharaohs in Egypt trepaned frequently and the wounds healed regularly. In the Corpus Hippocraticum 300 BC This operation is mentioned for the first time in writing.

In the 19th century, the scientist Broca proved that skull operations with the instruments of the Stone Age were easily possible: He used it to cut freshly deceased bone slices from the top of the skull.

Archaeologists today assume that these operations did not serve cultic but medical purposes, for example to remove bone fragments or end headaches.

Egyptian surgeons?

Egypt was considered a haven of medical knowledge in ancient times. Having learned his craft here led to a reputation among Greek doctors like studying in Harvard today.

Nevertheless, Egyptologists found little evidence of surgery. Herodotus (around 490-425 BC) wrote with admiration: "Every doctor treats only one illness ... there are ophthalmologists, ear doctors, dentists, gastric doctors and doctors for certain internal diseases." But there was no question of surgeons.

The papyri, the original Egyptian sources, also give little information about surgery. However, some texts at least suggest that Egyptian doctors performed surgical interventions.

The Ebers papyrus, for example, recommends cutting open “swellings” with the hemen, the doctor's knife. What do you mean with that? Abscesses, blisters or tumors? If they were tumors, then these were surgical interventions in the body and not just on the surface.

In any case, the Egyptians circumcised the foreskin of boys during puberty. A relief in the Sakkara necropolis from around 2200 BC. Chr shows a boy. A man clasped his raised hands in front of him, another man crouched, rubbing his limb with an object. Below is: "Rub hard to make it work." A second picture shows the same man attaching a knife to the child's foreskin.

Mummies show that almost all adults were circumcised. As with Muslims and Jews, this probably served religious purposes - the Jews may even have adopted the custom from Egypt.

In a lower jaw from Saqqara around 1500 BC Chr, two parallel holes were found over a root infection. These may have been intentionally drilled into it, but it may also be a natural defect. Because thousands of jaws from other mummies did not have these holes.

In 1914, Hermann Junker found gold wire on two molars made of a saccara sakara and another find in 1952 strengthened the thesis that Egyptian dentists closed gaps in their teeth.

Munich mummy expert Andreas Nerlich found out - with colleagues and in close cooperation with the Egyptological Institute at Heidelberg University, the German Archaeological Institute in Cairo and the Egyptian Supreme Council of Antiquities - that there is tangible evidence of surgical interventions in ancient Egypt.

To do this, they examined the skull of a male mummy. The man probably died between 1080 and 714 BC. The scientists inserted an endoscope into the skull, through the middle ears, the nasal cavity and an opening in the roof of the nasal cavity.

Computed tomography showed that there was a defect in the bone under the intact skin and tissue above the left parietal bone above the left ear. The cause was probably a blow. A crack ran into the skull cap and the bones had re-formed. Pieces of bone were missing in the damaged and healed region. However, the meninges and outer skin were intact. So a doctor had removed the bone fragments and treated the wound.

Early amputations and wooden prostheses

A mummified foot from the Ramessid period (1305-1080 BC), which the scientists examined, proved to be partially amputated. The entire forefoot had been removed and the wound had healed since the skin and soft tissues covered the cut. Not even a scar could be seen.

A woman's mummy contained a wooden prosthesis for the big toe. The stump of the toe was covered with intact skin, apparently there had been no complications. The prosthesis also showed strong signs of wear, which shows that the woman had lived for years after the procedure. The experts discovered calcification of the aorta and the small arteries in the affected foot - the woman therefore suffered from arteriosclerosis.

This disease slows down healing processes: the successful operation and the precise fitting of the prosthesis testify to the skills of the doctors involved.

If the Egyptian doctors operated on a larger scale, they knew far better methods of relieving the pain than their descendants in the Middle Ages. They used incense, which they imported in large quantities from the country of Punt (presumably Yemen and / or Eritrea), used it to smoke in the sick camps, and the chemical substances were found in the lungs of mummies. The tetrahydrocannabinol contained in the incense causes euphoria and reduces pain.

The Egyptians also put poppies in graves, but we don't know if they used opiates as a pain reliever.

The Papyrus Smith testifies that the Egyptians understood wound healing: “If you examine a man with a gash on his chin that extends to the bone, then you should feel his wound. If you find his bone healthy, then you should say that someone with a gash on his chin that extends to the bone has an illness that I will treat. Then you shall put two bandages on those gaps; you should combine it with fresh meat on the first day, then treat it with fat, honey, fibers every day so that it feels better. ”Nerlich emphasizes that such procedures are also useful for surgical wounds.

In 2002, the scientists came to the conclusion that doctors in ancient Egypt were perfectly capable of performing surgical operations. There is little direct evidence of this, but according to Nerlich, this is probably due to the fact that the mummies have not been adequately paleopathologically examined. Well healed wounds in particular were difficult to identify.

"Where there is pus must be opened"

This sentence by the Greek doctor Hippocrates, the founder of rational medicine, shows that the ancient Greeks practiced surgery because it formulated one of their basic laws.

Doctors in ancient Sparta and Athens removed hemorrhoids and bladder stones, and the knowledge of the ancient Greeks entered the Roman Empire, the methods of which in turn formed the basis for medieval medicine - even if much of their knowledge was lost.

Gladiators under the knife

The first known Greek doctor in Rome was in the third century BC. Chr Archagathus, and he worked as a surgeon, because his practice was called "cutting and burning", which earned him the name Carnifex, executioner. Archagathus did such a good job, however, that he was 220 BC. Chr received Roman civil rights.

The ancient Romans knew very well about surgery. They adopted the Greek word cheirourgos and latinized it to surgeon. In the time of Tiberius, it referred to a specialist in surgery, namely the Greek Ptolemy.

In the Roman Empire there were specialized healers, stone cutters, star engravers and tooth pullers. A good surgeon should be young, have a steady hand and strong nerves. Doctors should generally have surgical knowledge.

Roman doctors used sophisticated devices in surgery, including an entire set of scalpels. They knew about retractors, needles and sutures to close wounds, and they had special tweezers and pliers to remove foreign bodies from injuries.

Simple rural doctors already had spatulas, probes, scalpels, spoons and bone lifters. Specialists had star needles to prick the eye lens, trepane to open the skull, instruments to remove bladder stones, artery forceps and birth forceps.

The scalpels enabled precise cuts, nightshade plants and opium reduced pain, and the clamps stopped bleeding. However, the Romans knew neither hypodermic syringes nor knew about sterile surgical techniques. Although they suspected that diseases were transmitted from person to person, they had no clue about viruses and bacteria.

The patricians and gladiators in particular enjoyed complicated operations. The training of gladiators took years, and their masters had invested too much to simply let arena survivors die there.

Surgeons operated on the injured fighters in a hospital specially built for them. They separated the treatment room and the sick room, which shows that they knew about the spread of diseases. The operating rooms faced the sun in order to use daylight as long as possible.

The anatomical knowledge of Roman doctors was far better than that of academic medical doctors from the Middle Ages. They dissected the bodies of executed and killed gladiators.

Although doctors understood surgery, sterile instruments and inflammation caused by germs, they did not understand anything. The majority of those injured who died from their wounds are caused by these viruses, bacteria and wound lesions.

Even the blood loss could only be stopped with the tweezers and clamps if the bleeding was minor. An intestinal perforation was almost always fatal, and we only learn from Galenos from a single gladiator who survived an abdominal wound - because his intestine was not damaged.

The emperor, who points his thumb down and thus surrenders the defeated gladiator to death, is now considered the symbol of arbitrary Roman cruelty. However, this death blow could also be a mercy to save the sufferer from an agonizing death from suppurated wounds.

Galenos from Pergamon

Galenus of Pergamon lived in Rome and died in 200 AD. Although he referred to Hippocrates' theory of juices, he transformed them into the teaching of temperaments and thus built the framework of European medicine up to modern times.

Among other things, the doctor treated gladiators and thus gained his experience of human anatomy. So he found out that wounds on the back of the head could blind those affected and that the brain moved rhythmically when a skull was split.

Arabs and Persians

The Arabs and Persians inherited the legacy of Greco-Roman antiquity as well as the knowledge of the ancient Egyptians, because Egypt became part of the Persian empire before Christ and after the triumphal march of the Muslims a country of the Islamic empire.

Abu I-Qasim Chalaf ibn al-Abbas az Zahrawi Abulcasis was a famous operator. The Arab was born near Córdoba in 936 and died there in 1013 as court physician to Caliph al-Hakam II.

Abulcasis continued to develop all of medicine, but his focus was on surgery. He wrote: "If you want to exercise it, you must first familiarize yourself with the anatomy, have knowledge of the bones, nerves, muscles."

The scholar recommended sponges soaked in mandrake and opium for anesthesia and developed various instruments himself. His books represented devices for dentistry as well as the binding of blood vessels.

Barbers and executioners - the Middle Ages

Scholarly medicine in the Middle Ages was based on Aristotle's tripartite division into general practitioners, theoretical physicians and medically educated laypersons. The Middle Ages distinguished between the surgeon / surgeon, the physicus or doctor medicinae and the medically educated layperson. The last ones included jugglers such as midwives, tooth breakers and quacks, executioners and even coverers.

Surgeons were trained as craftsmen and often formed their own guild with the bathers and barbers. Bathers and barbers were mostly considered dishonest. In contrast to the physicus, the surgeon had a bad reputation.

In 1163 the Council of Tours even banned all clergymen from performing surgical treatments. The doctor was on an equal footing with the lower nobility and clergy, the surgeon stood on the edge of the “respectable” trade, near tanners and executioners, cutters and stone cutters.

Surgery was not one of the teaching subjects at the university, and anyone who wanted to work as a surgeon could gain knowledge through practical training with another surgeon. For this reason, too, their operations seldom led to success. The discipline was not taught at German universities until the 18th century.

The bathers and barbers not only shaved and cut their hair, they also healed breaks and dislocations, left patients bloody and put on cupping heads; however, they were prohibited from administering medication.

We can easily imagine what it would mean for the sick if the person who was treating their fresh wound was not allowed to use medication. In the 16th century fewer and fewer people went to the bathhouses because of the infectious diseases that are rife there, and what such conditions meant for patients requires no imagination.

Surgeons and war surgeons - the early modern era

Military doctors promoted professional surgical treatment, which later became a subject in universities. From the 16th century, the ecclesiastical ban on dissecting corpses eased, and knowledge of the inside of the body increased. However, the artisan surgeons were not necessarily bunglers; Dr. Eisenbarth, for example, is still considered a very good doctor.

Conrad Holtzendorff (1688-1751) was the first general surgeon. In 1727 he founded the "Collegium medico-chirurgium" to further develop the army scissors. In addition, an army hospital was created under his aegis in Berlin, which later became one of the most famous hospitals in Europe: the Charite.

To put the subject on a professional level like this was long overdue. For soldiers, wounding meant unimaginable suffering. Every third successfully amputee died of debilitation after the operation. Tetanus, infections and blood loss claimed far more deaths than immediately fatal wounds.

Holtzendorff was also unable to contain the deaths sustainably. Until the 19th century, the disinfection of wounds was as unknown as the cause of the inflammation. There were no separate operating rooms, but chairs and tables that the employees carried from one room to the next. The surgeons used cutting knives, stretching instruments, spear clamps, tongs and spoons.

The advent of textbooks

The lack of social recognition by the surgeons hampered their professional development; however, several textbooks by surgeons came out in the early modern period. Johann Schultheiß (1595-1645) published the work "Armamentorium Chirurgicum", 1666 the German edition "Wundarzneyisches Zeug-Hauß" appeared.

Schultheiß presented the surgical instruments and methods of his time, including tools that he had developed himself. The textbook explained therapies for tumors, ulcers, wounds, fractures and dislocations. The doctor showed the instruments on picture boards.

Pierre Donis (died 1718) published "Cours dóperation de Chirurgie" in 1707, in which he explained techniques of surgery in detail in ten chapters. The work was considered a standard work and was widely distributed.

A year later the textbook by Lorenz Heister (1683-1758) came out, entitled "Surgery, in which everything that belongs to the wound artzney, in the newest and best way". It was an encyclopedia that summarized the state of knowledge of (European) surgery at the time, and surgeons used it as a handbook.

Surgeons become doctors

The division between academic doctors and practical surgeons or medical practitioners who served as assistants continued into the 18th century. However, more and more doctors criticized the inadequate training of "barbers" and the, real or perceived, catastrophic results of their lack of specialist knowledge.

The "general medical edict" for Brandenburg-Prussia in 1725 clearly stipulated that only trained doctors were allowed to "curate". Only those who had attended a special school were considered surgeons. Firstly, Bader had to undergo an examination, secondly, they were not allowed to call themselves that, and thirdly, they could not undergo any surgical interventions. However, the surgeons remained auxiliary doctors, but were now officially higher than the Bader.

In 1811, Prussia lifted the guild system of the Middle Ages and thus also released surgery from barbers. In 1818 there was also freedom of establishment for healing professions in Prussia.

The "Provisions on the division and examination of medical and wound care personnel" establish generally applicable examination regulations for all healing professions. The unofficial separation between "practical" country doctors and "academic" city doctors replaced Prussia with the first and second class surgeon.

The first-class surgeons now had to complete a three-year mixture of study and training, perhaps comparable to a university of applied sciences today. Anatomy, surgery and obstetrics became part of the curriculum of some universities and additional teaching material at non-university institutes.

The students learned the anatomy and physiognomy of the human body and passed an extensive test at the end. The surgeon then demonstrated his qualifications during a hike - only then was he allowed to master. The students learned obstetrics from older midwives.

Curricula now included general and specialized surgery, eye diseases, fractures and luxations as well as training on corpses.

Schools closed in the course of the 19th century, because surgery became more and more part of regular medical studies. Graduates generally obtained their doctorate in medicine.

Operation successful, patient dead

Up until the 20th century, surgical interventions were a game of life and death. The danger lay less in the surgical methods, the techniques improved enormously until the 19th - but the knowledge of the causes of infections was missing.

The doctors rarely washed their lab coats, which had blood and germs on them. Sepsis developed and nobody knew why. Ignaz Semmelweis recognized in the 19th century that germ-borne infections were the cause of child bed fever, that many women were getting there at that time, and ordered strict hygiene for doctors and nurses. Success proved him right and the death rate dropped rapidly.

Joseph Lister cleaned hands like tools with carbol, ensuring that little germs could harm the patient during the operation.

Finally, Louis Pasteur and Robert Koch ensured that tools were disinfected and sterilized and that the doctors wore sterile rubber gloves.

Saved limbs

Until modern times, amputation meant mutilation. The doctors on the battlefield amputated as many limbs as possible in the shortest possible time and could hardly take care of plastic surgery. On the one hand, this was due to the lack of anesthetics - they worked quickly to shorten the duration of the pain - and on the other, it was due to the fact that they had few alternatives for amputating.

But the 19th century surgeons were educated in anatomy, pathological anatomy and experimental physiology and found new ways to treat the heaviest wounds. Instead of removing limbs, they also stopped heavy bleeding from the arteries. The goal was to maintain the entire body.

Between 1851 and 1868, experienced surgeons wrote a series of books on surgery that only amputated in extreme emergencies: Esmarch "About resection after gunshot wounds" (1851), Stromeyer "Maximizing the art of war healing" (1855), Pirogow "Basics of general war surgery "(1864) and Bernhard von Langenbeck" About the weft fracture of the joints and their treatment "(1868).

The better training and the new techniques led to unexpected success. In the Prussian-French War of 1870/71, 18.8% of the wounded were released from the hospital in a cured condition.

Modern surgery

Today's surgery creates a picture of the inside of the body and operates by the doctor operating the instruments indirectly in front of the screen - around 1850, doctors would probably have believed this to be pure magic belief.

So-called endoscopes are introduced into the body, started by Johann von Miuklicu (1850-1905) in Vienna.

Successful brain operations are the norm today. Trepanation is one of the oldest surgical practices, but it was surgery on the skull and not on the brain.

Only modern knowledge of the different areas of the brain and their function, a viable anesthetic and comprehensive antisepsis, enabled the surgeons to penetrate the center of our thinking and feeling.

John Rickman Godlee (1849-1925) cut a tumor from a patient's brain in 1884. The victim died shortly afterwards of meningitis. However, as early as 1885, Victor Alexander Horsley (1857-1916) successfully removed a brain tumor.

Brain surgery has been associated with the development of neurosurgery. Ernst von Bergmann (1836–1907) and Anton von Eiselsberg (1860–1939) did pioneering work here. However, Harvey Cushing (1869-1939) became the “star” of this discipline. Cushing cut out more than 2,000 brain tumors, and most patients survived.

The field of surgery is very diverse today, and specialists specialize in one area, i.e. vascular, cardiac, thoracic, pediatric, accident, plastic or visceral surgery.

Other disciplines also require surgical interventions: gynecology, ear, nose and throat medicine, dermatology, neurosurgery, maxillofacial surgery and urology. (Dr. Utz Anhalt)

References

Egypt at the time of the Pharaohs. Everyday life and social life. By Eugen Strouhal. Wasmuth Verlag, Tübingen, Berlin 1994. Awakening the healing arts. Medicine in ancient Egypt. By W. Westendorf. Artemis and Winkler, Zurich 1992.

In the fragile house of the soul. The great odyssey of brain surgery. By Jürgen Thorwald. Droemer-Knaur, Munich 1986.

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