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In prehistoric times, sharpened flints and other sharp-edged devices were used to perform various surgical operations. Circumcision and other ritualistic operations were later performed with similar instruments. There are indications that in Neolithic times saws of stone and bone were used to perform amputations. Nearly all major operations were performed by the ancient Hindus nearly a thousand years before the advent of Greek medicine. Knowledge of the use of soporific potions to alleviate the pain caused by surgery can be traced to remote antiquity.
The early Greeks and Romans practiced surgery with great skill and with such cleanliness that infection of surgical and other wounds was relatively uncommon. Their cleanliness and their use of boiled water or wine for irrigating wounds was probably suggested by Hippocrates, a competent surgeon and diagnostician of that time. Other notable early surgeons were Erasistratus and Herophilus of the medical school at Alexandria, and Galen, whose numerous treatises were long influential.
The surgical and sanitary techniques employed by the Greeks and Romans were lost with the decline of their civilizations. During the Middle Ages in Europe there was a marked regression in surgical knowledge, and postoperative infection was common. Surgical practice soon fell into the hands of the unskilled and uneducated: the barber-surgeon, who performed the usual functions of a barber as well as surgical operations, became a common figure, especially in England and France. It was not until the 18th cent. that surgery began to reach a professional level. There were, nevertheless, notable figures in early surgery, among them Guy de Chauliac in the 14th cent., and in the 16th cent. Ambroise Paré, who developed sutures and ligatures to stop bleeding and sew up wounds.
The Birth of Modern Surgery
With the introduction of antiseptic methods, surgery entered its modern phase. Louis Pasteur established the fact that microbes are responsible for infection and disease. Using this knowledge, Dr. Ignaz Semmelweis reduced postpartum infections (puerperal sepsis) in the wards of Vienna's lying-in hospitals by urging doctors to wash their hands between patients. In the 1860s Joseph Lister introduced the use of carbolic acid as a cleansing and disinfecting agent, and his results in reducing infection were dramatic. It was found later that the carbolic acid spray that Lister used to cleanse the air about the patient was unnecessary, but the antiseptic treatment of instruments and other articles in contact with the patient continued until antisepsis was gradually replaced by the aseptic methods employed in modern hospitals. Before the discovery of antisepsis by Lister, about 80% of surgical patients contracted gangrene.
Ernst von Bergmann is credited with introducing steam sterilization under pressure for treating instruments and all other medical equipment used for a surgical patient. William Stewart Halsted, the famous surgeon at Johns Hopkins Hospital, introduced sterile rubber gloves when the hands of his fiancée became irritated from constant washings and antiseptics. The development of methods of anesthesia, especially the discovery in the 1840s of the value of ether, has also been of immeasurable value.
Surgery in the Twentieth and Twenty-first Centuries
In the 20th and 21st cent., surgery has benefited from an improved understanding of the causes of shock and its treatment; knowledge of blood group typing and transfusion techniques; understanding of blood clotting and the use of anticoagulants; and the development of antibiotics to control infection and analgesics to control pain. Surgical instruments have developed along with modern technology and are now sophisticated, meticulously designed devices. Electrically powered surgical instruments are invaluable for cautery and for separating hard tissues such as bone with minimal damage. Surgical stapling instruments, first developed in the Soviet Union, can join blood vessels or other tissues in less than half the time required by hand stitching. New medical glues, surgical tapes, and even zippers now enable surgeons to close some wounds effectively without stitches. With the development of X-ray techniques and fluoroscopy and, later, CAT scans and magnetic resonance imaging (MRI), surgery gained valuable diagnostic instruments. Some operations are now being conducted inside specially adapted MRI devices, allowing the surgeon to have live images for guidance during operations. Holograms can be created using data from MRI and other diagnostic instruments and are beginning to be used in the operating room to give surgeons a three-dimensional image of the area to be operated upon, and models created using 3D printers may be used in preparing for complex surgeries.
Cryogenic, or supercooled, probe beams have been used to precisely remove tissues and abnormal growths. Ultrasound techniques, using very-high-frequency sound waves, are used to break up kidney stones and are employed in brain and inner-ear operations, which require great precision and control. They are also used to scan the pregnant uterus, a process that, unlike X-ray scanning, does not endanger the fetus. Medical lasers, which produce amplified monochromatic light waves in a very narrowly focused beam, have become useful tools in various forms of surgery, notably that of the eye, and are now commonly used to remove or “spot-weld” tissues.
The heart-lung machine made open-heart surgery possible by taking over the blood-pumping and breathing functions of these organs during operations. Hypothermia, or cold surgery, by which the body is cooled to lower the rate of metabolism, thus reducing the need for oxygen, has made long operations, especially those involving transplantation, possible. Other recent transplantation advances include procedures involving the liver, lungs, pancreas, bone marrow, and the kidney. The first human heart transplant was performed in 1967 by South African surgeon Christiaan Barnard. The usefulness of transplantation is currently limited by the fact that drugs must be used constantly to halt the body's rejection of foreign tissue.
New techniques in orthopedic surgery (see also orthopedics) have also been introduced, including the use of cementing substances to unite bones destroyed by tumor and the replacement of joints with metal or plastic devices. Plastic surgery and reconstructive surgery have made enormous strides, and microsurgery is making severed or injured limbs usable.
A trend toward less invasive surgery and shorter hospital stays began in the 1980s. By 1995 more than 56% of all surgical procedures in the United States were done on an outpatient basis, without an overnight stay in a hospital. Endoscopic surgery, using small incisions and tiny instruments attached to fiber-optic viewing devices (see endoscope), has been used in place of more traditional procedures for gall-bladder surgery, and it has been used on the fetus in the womb to correct life-threatening birth defects before birth. Angioplasty is frequently used to circumvent or postpone the need for coronary artery bypass.
See O. H. and S. D. Wangensteen, The Rise of Surgery (1979); R. Selzer, Confessions of a Knife (1979); A. S. Earle, Surgery in America (1965, rev. ed. 1983); R. M. Youngson, The Surgery Book (1993); N. L. Tilney, Invasion of the Body (2011).
the branch of medicine that studies diseases treated mainly by operative intervention and devises operating methods and techniques. Along with internal medicine, modern surgery developed into a major clinical discipline, growing out of “hand treatment” in the narrowly practical sense. What is required of the surgeon is not only a mastery of operative technique but also the general biological and medical knowledge on which treatment methods are founded.
The “surgical diseases” do not constitute a clear-cut group of pathological processes; the concept itself changes in scope with the growth of scientific knowledge. Until the end of the 19th century, for example, the surgical treatment of appendicitis was unknown, and the disease was regarded as falling within the scope of internal medicine; today, acute appendicitis is considered a surgical disease and is treated by operative intervention only. The study and treatment of heart diseases were the exclusive province of internists until the mid-20th century—that is, until the development of cardiovascular surgery, which entails the study and surgical treatment of heart defects, aneurysms, angina pectoris, and myocardial infarction. The achievements of modern surgery are linked to the progress of the natural sciences and technology and to advances in anesthesiology, reanimatology, and the science of blood transfusion. All these advances made it possible to use surgical methods in treating diseases of hitherto inaccessible vital organs such as the heart, lungs, major blood vessels, brain, and spinal cord.
History. Along with internal medicine and obstetrics, surgery is among the oldest medical specialties. Archaeological finds and ancient manuscripts attest that surgical treatment was attempted as early as the Stone Age. Bloodletting, bonesetting, cesarean section, and the removal of stones from the bladder were practiced in Egypt in the second or third millennium B.C. In ancient India, nasal defects were repaired by grafts of skin from the forehead. Greek medical writings from the time of Hippocrates describe such operations as trepanation of the skull, puncture of cavities, and treatment of fractures, as well as a great number of surgical instruments. Celsus describes an amputation in which hemorrhaging was arrested with ligation of the large blood vessels. The second-century Greek physician Antyllus performed an operation for aneurysm of the blood vessels and wrote about the treatment of fistulas and the crushing of a calculus in the bladder.
Medieval medicine, in keeping with religious dogma, forbade the spilling of blood and the use of corpses for anatomical study. This led to the opposition between medicine, which was practiced by “scholarly” physicians, and surgery, which passed into the hands of barbers and bathhouse attendants and became a craft. The advances in anatomy associated with the work of Vesalius, Fallopio, and Eustachio during the Renaissance laid the scientific foundations for the development of surgery. The use of firearms also played a part, as it caused huge numbers of casualties and a greater need for the treatment of wounds. Paré, one of the founders of scientific surgery, worked out the technique of amputation and contributed to the science of dressings and treatment of gunshot wounds. The French surgeon P. Franco, who was Paré’s contemporary, perfected the techniques of inguinal herniotomy and lithotomy.
Others who made notable contributions to surgery were B. Maggi (Italy), and F. Würtz (Switzerland) in the 16th century and H. Fabricius (Italy), J. Hunter (Great Britain), and A. Scarpa (Italy) in the 17th and 18th centuries. An academy of surgery was founded in Paris in 1731, and in 1743 it was granted the same rights as the medical faculty of the University of Paris. Surgery was now formally established as a medical profession.
In Russia, the earliest surgeons were quacks and “bonesetters.” Foreign surgeons appeared at the court of the grand duke of Moscow in the 15th and 16th centuries. In the 17th century, army troops had their regimental physicians, barbers, and “blood-throwers”—that is, individuals who performed bloodletting and applied dressings. In 1707, by order of Peter I, the Moscow general hospital established a hospital school where surgery was taught in conjunction with anatomy. Similar schools were established in St. Petersburg and Kronstadt in 1733. The first Russian surgical clinic opened in St. Petersburg in 1806; it was named after I. F. Bush, who wrote a handbook of surgery in Russian. I. V. Buial’skii and other well-known surgeons were followers of Bush’s school of surgery.
The introduction of anesthesia and asepsis in the 19th century disposed of the two major problems—pain and postoperative suppuration of the wound—that had hindered the progress of surgery in spite of the fairly high level of operating techniques. This was accomplished within a mere two decades. Narcosis by the use of ether was proposed by W. Morton in 1846; a year later, J. Simpson substituted chloroform for ether as an anesthetic. In 1867, J. Lister suggested that the microorganisms contaminating a wound could be controlled by means of carbolic acid and thus laid the foundations of antisepsis. In the late 19th century this was replaced by asepsis, which aimed at the preoperative destruction of microorganisms and their spores by physical means—for example, by boiling linens and instruments in water or sterilization by steam.
The discovery of X rays enabled 20th-century physicians to examine deep-lying organs and tissues, thus significantly improving the quality of surgical diagnosis. Another contributing factor was the development of endoscopy, which made it possible to examine such organs as the urinary tract, the rectum, and the esophagus.
In France, advances in 19th-century surgery are associated with the names of D. Larrey, G. Dupuytren, and J. Lisfranc (1790–1847). The seroserous suture proposed by A. Lembert in 1826 remains the basis of gastrointestinal surgery. Various techniques for the ligation of major arterial trunks, herniotomy, and bone and joint operations were worked out by British surgeons, such as A. Cooper (1768–1841) and J. Paget (1814–1899). Leadership in the development of surgery passed to Germany and Austria in the last quarter of the 19th century. B. Langenbeck, after whom many operations were named, and T. Billroth, a pioneer in gastric surgery, were the founders of scientific surgery in Germany. Their students and followers included the Swiss surgeon T. Kocher and the German surgeons F. von Esmarch (1823–1908), E. von Bergmann (1836–1907), F. Trendelenburg (1844–1924), J. von Mikulicz-Radecki (1850–1905), and A. Bier (1861–1949).
Among the significant achievements of the mid-19th century was the work of the Russian surgeon and anatomist N. I. Pirogov, founder of topographic anatomy (the basis of rational surgery) and modern military field surgery, a pioneer in the broad use of anesthesia and antisepsis in Russia, and a prominent supporter of the anatomical-physiological approach in surgery. Other Russians who contributed to advances in surgery were N. V. Sklifosovskii, A. A. Bobrov, P. I. D’iakonov, and N. A. Vel’iaminov.
The late 19th and the early 20th century were also marked by rapid advances in surgery in the United States—associated with the excellent equipment available in such large-scale surgical centers as the Mayo Clinic in Rochester. American surgeons whose work earned world renown include H. W. Cushing and G. Crile (1864–1943).
Modern developments. Major changes in surgery accompanied the evolution of contemporary medicine, with its division into increasingly narrow disciplines and simultaneous integration of allied fields of different disciplines to form complex branches, dealing with the pathology, diagnosis, treatment, and prevention of diseases of specific organs and systems—for example, cardiology. As early as the mid-19th century, surgery began to separate into branches that became independent medical disciplines (ophthalmology, otorhinolaryngology, urology, orthopedics, and traumatology). Oncology became a separate branch in the 20th century. Further differentiation and specialization, resulting from the specialized methods of examination and treatment developed in mid-century, led to the establishment of proctology as an independent scientific branch; the same may be said of pulmonary and vascular surgery.
Since the turn of the century, surgery has sought not only to remove diseased organs but also to restore them; this is reflected in the extensive use of plastic surgery to correct congenital and acquired abnormalities. Further progress in surgery is largely dependent on advances with respect to blood transfusion, shock prevention methods, and the use of antibiotics.
In the USSR, the first signs of rapid progress in surgery can be seen in the decade after the October Socialist Revolution of 1917. S. P. Fedorov founded a surgical school and did pioneering studies in surgery of the biliary and urinary tracts; P. A. Gertsen and N. N. Petrov laid the foundations of oncology in the USSR; I. I. Grekov, I. I. Dzhanelidze, V. S. Levit, A. V. Martynov, A. G. Savinykh, S. I. Spasokukotskii, V. N. Shamov, and S. S. Iudin made important contributions in connection with abdominal and emergency surgery; N. N. Burdenko and V. A. Oppel’ were instrumental in the development of Soviet neurosurgery, surgical endocrinology, and military field surgery; and A. V. Vishnevskii contributed to the science of local anesthesia.
The notable progress of cardiac surgery in the second half of the 20th century is based on the advances of modern anesthesiology as well as the successful use of heart-lung machines and of devices inducing hypothermia (that is, reducing the temperature of the body). Important work in this field was done by R. Brock and H. C. Suttar (Great Britain), C. Bailey, M. DeBakey. A. Blalock, D. Cooley, and D. Harken (United States), P. Valdoni and A. Dogliotti (Italy), C. Crafoord (Sweden), and N. M. Amosov, A. N. Bakulev, V. I. Burakovskii, A. A. Vishnevskii, P. A. Kupriianov, E. N. Meshalkin, and B. V. Petrovskii (USSR).
Advances in physiology and immunology enabled surgeons in the 1960’s and 1970’s to effect successful transplants of the kidneys (for example, by B. V. Petrovskii in the USSR) as well as of the heart and liver, thus laying the foundations of transplant science. The first successful human heart transplant was performed in 1967 by C. Barnard (Republic of South Africa). Some promising American-Soviet joint experiments have recently been made with the goal of creating an artificial heart.
Surgery is taught in the surgical departments of medical institutes and schools; in the USSR, instruction is also offered in the departments of topographic anatomy and operative surgery. Additional surgical training and specialization are provided in surgical clinics (including, in the USSR, the institutes of advanced medical training) and the various departments of large hospitals. Scientific research in surgery is centered in the major surgical clinics and specialized surgical institutes. In the USSR such research centers include the Institute of Clinical and Experimental Surgery and the A. V. Vishnevskii Institute of Surgery in Moscow, the institutes of emergency medical care in Moscow and Leningrad, the Institute of Clinical and Experimental Surgery in Kiev, and the Institute of General and Emergency Surgery in Kharkov.
The first Russian society of surgeons was founded in 1873 in Moscow. Surgical problems were discussed at the Pirogov Congresses from 1885 to 1899. The first congress of Russian surgeons was held in 1900; starting with the 22nd, held in 1932, these were called all-Union congresses. The 29th was held in 1974 in Kiev. Since 1953, the All-Union Society of Surgeons has been part of the International Society of Surgery (founded 1902), which holds congresses every two years; the 24th was held in 1971 in Moscow.
The following journals of general surgery are published in the USSR: Khirurgiia (since 1925), Vestnik khirurgii im. I. I. Grekova (Leningrad, since 1855), and Klinicheskaia khirurgiia (Kiev, since 1921). Foreign surgical journals include Acta Chirurgica Scandinavica (Stockholm, since 1869), Zentralblatt für Chirurgie (Leipzig, since 1874), American Journal of Surgery (New York, since 1890), British Journal of Surgery (Bristol, since 1913), and Archives of Surgery (Chicago, since 1920).
REFERENCESOppel’, V. A. Istoriia russkoi khirurgii. Vologda, 1923.
Meyer-Steineg, T., and K. Sudhoff. Istoriia meditsiny. Moscow-Leningrad, 1925. (Translated from German.)
Razumovskii, V. I. “Istoricheskii ocherk razvitiia russkoi khirurgii.” In Rukovodstvo prakticheskoi khirurgii, vol. 1. Leningrad-Moscow, 1936.
Zabludovskii, A. M. “Sostoianie khirurgii na Zapade v pervuiu polovinu XIX veka.” Vestnik khirurgii im. Grekova, 1937, vol. 50, books 133–134; vol. 51, book 135.
Kolesov, V. I. Stranitsy iz istorii otechestvennoi khirurgii. Moscow, 1953.
Mnogotomnoe rukovodstvo po khirurgii, vols. 1–12. Edited by B. V. Petrovskii. Moscow, 1959–68.
Geselevich, A. M., and E. I. Smirnov. Nikolai Ivanovich Pirogov: Nauchno-biograficheskii ocherk. Moscow, 1960.
Zabludovskii, P. E. Istoriia otechestvennoi meditsiny, parts 1–2. Moscow, 1960–71.
Iudin, S. S. Razmyshleniia khirurga. Moscow, 1968.
Struchkov, V. I. Obshchaia khirurgiia, 3rd ed. Moscow, 1972.
Bankoff, G. The Story of Surgery. London, 1947.
Traité de technique chirurgicale, 2nd ed., vols. 1–8. Paris, 1952–61.
Marcus, E., and L. M. Zimmerman. Princples of Surgical Practice. New York, 1960.
Schmitt, W. Fundamentals of Surgery. Leipzig, 1962.
Chirurgische Operationslehre, 8th ed., vols. 1–6. Leipzig, 1969–76.
M. A. Mal’tsev, L. S. Sapozhnikov, B. M. Olivkov, and I. D. Medvedev made significant contributions to veterinary surgery in the USSR. Soviet veterinary surgeons developed and introduced new methods of performing economically worthwhile operations on farm animais. Ongoing studies are concerned with anesthesiology, the properties of wounds in various animal species, and operations on the extremities, the reproductive organs, and the digestive and other systems. The principal research centers are the respective departments of the institutions of veterinary education; such research work is coordinated by the veterinary department of the V. I. Lenin All-Union Academy of Agricultural Sciences. Veterinary surgery is taught in the institutions of veterinary education and in technicums.
I. I. MAGDA
What does it mean when you dream about surgery?
If someone has experienced surgery, a dream about surgery could be putting one back in touch with the emotions one felt around the operation. Alternatively, a dream about surgery could represent a more general concern about one’s health. Metaphorically, a dream surgery could reflect a feeling that we are “operating” on our emotions, such as removing our heart (a symbol of affection).