Surgery

I

Introduction

Surgery, treatment of disease and correction of deformity or defect by manual and operative procedures, with or without the use of drugs. This branch of medicine is subdivided according to the nature of the procedure employed, including: general surgery, which deals with all manner of cases; orthopaedic surgery, which pertains to the correction of deformity; and plastic surgery, which involves the building up of tissues and the restoration of lost parts, principally by the transfer of tissue. Surgery is also subdivided according to the region involved, as: intracranial (brain) surgery; aural (ear) surgery; cardiovascular (heart and blood-vessel) surgery; and abdominal surgery. Many elements have contributed to the development of surgery, such as the gradual accumulation of knowledge concerning anatomy and physiology, the discovery of the circulation of the blood, the perfection of the microscope, the discovery of X-rays, and the invention of better instruments and apparatus, including laser and ultrasonic devices. The discovery of anaesthesia and antisepsis has broadened the scope of surgery so that patients formerly treated with plasters and medicines are now subjected to surgical intervention. For further information, see separate articles on most of the doctors and organs and diseases mentioned in this article.

II

Early History

Elementary general surgical procedures were known in many diverse societies since ancient times, but more scientific surgical techniques were not practised until the 3rd century bc.

A

Ancient

The ancient Egyptians are said to have performed operations such as castration, lithotomy (removal of stones from the bladder), amputations, and various eye operations. In India, the Hindus were familiar with surgical practices such as the treatment of fractures, the removal of bladder stones, and operations for fistula, and they are credited with having originated plastic surgery on the ears, nose, and cheeks. The surgery of the early Greeks, largely practised on the battlefield, seems to have been derived from that of the ancient Egyptians, as was their medicine. In Rome, sacerdotal or guild medicine and surgery prevailed until the time of the Greek physician Hippocrates, whose studies, practice, and writings embraced surgery as well as medicine. The Hippocratic corpus includes references to sound knives, curettes, trephines, forceps, and specula, which indicates the range of surgical operations undertaken in this period. Little definite progress was marked until the rise of the Alexandrian School (233-230 bc), when surgery was based on diagnostic precision and operative daring through the study of human anatomy. The Greek anatomist and surgeon Herophilus was the founder of this study.

B

Medieval

Medieval surgery was practised from the decline of the Alexandrian School to the beginning of the 16th century. The Roman physician Aulus Cornelius Celsus, the Greek physician and philosopher Galen, and Paul of Aegna, a Greek surgeon of the late-7th century, virtually shaped the course of surgery throughout the Middle Ages. Thereafter, as much scientific learning was centred in the Muslim world, Byzantine and Arabian medicine helped to foster surgery. Al-Razi, or Rhazes, recorded the use of leeches, cupping, bleeding, and sutures made of animal gut. Qanun (Canon of Medicine) by Avicenna reinforced the notion that surgery was a distinct branch of medicine, undertaken by a second class of practitioners, an idea perpetuated for many centuries. In 1215, Pope Innocent III regarded the shedding of blood to be especially detestable and relegated those whose work involved this to the lowest social ranks. This view was reinforced by the Council of Tours (1163), which restricted the surgical work of monks.

This notwithstanding, during the latter part of this period, European countries, especially Italy, produced many distinguished surgeons. Outside of Italy, the distinctions of medicine and surgery were formalized. In France, in about the middle of the 13th century, a new order of surgeons arose, called surgeons of the long robe, as distinguished from the barber-surgeons, who were known as surgeons of the short robe. The 14th-century surgeon, Guido Lanfranchi, or Lanfranc, reacted against the inadequacy of the idea that surgeons were mere technicians. Instead, he encouraged surgeons to think of themselves as physicians who practised surgery. Meanwhile, a sense of professional identity among surgeons slowly emerged. Corporations, or guilds, reinforcing the notion of surgery as craft, taught by apprenticeship rather than a discipline of higher learning, were formed in several countries. In England, the Company of Barbers and the Guild of Surgeons (recognized since 1368) joined forces to form the City of London’s Company of Barber-Surgeons, receiving their charter and lawful access to four bodies a year from King Henry VIII in 1540. No doubt, there was a certain strength in numbers, but later the surgeons would seek to throw off their earlier allegiance with the trade of lowly barbers as they recast their own self-image. London provided a dynamic environment for surgical practice, but the company had no power to enforce its rules beyond the city’s boundaries, indicating the largely unregulated nature of surgical practice as a whole.