The Muslim empire produced the genius of the Persian, Rhazes, who wrote many texts and actually distinguished between measles and smallpox. He was later followed by another Persian, Avicenna, who wrote the “Canon of Medicine.” But as much as these tomes expounded on diagnosis and medications, there was a surprising paucity of knowledge in the area of surgery.
You may ask “Why?” and the answer is actually quite simple. A good basis for surgery depends on a firm knowledge of accurate human anatomy. Up to this point, dissections were carried out on animals or on parts of human beings; the anatomical knowledge was often based on centuries-old texts, which were often incorrect or flights of fancy of the author. During the late fourteenth and fifteenth centuries new anatomy texts appeared and were much more complete than those we had seen for two thousand years. In 1543 Andreas Vesalius published his “De Humani Corporis Fabrica” (On the Structure of the Human Body), which was based on careful human dissection, and the diagrams are, for the most part, as accurate as anatomical treatises of today. His work was followed by a host of books on anatomy and physiology, and this may well be considered the beginning of modern surgery. Within the next one hundred years there was an explosion of scientific and cultural advancement with the likes of the genius philosopher Rene Descartes (“I think, therefore I am.”), Isaac Newton (Laws of Physics—remember the apple falling on his head?), Galileo (the telescope), Robert Hooke and Anton Leeuwenhoek (the discovery and use of the microscope), and the great discovery and publication of “De Motu Cordis” on the circulation of blood and the function of the heart by William Harvey (1628).
Surgery then took great strides forward when the physician could understand the anatomy and some physiology, and attempt to correct its problems. Likewise, there were advances in the parallel field of medicine, such as Edward Jenner's description of Smallpox inoculation in 1796, Johannes Muller's description of physiology or how things work in the 1830s, and the description of the bacterial cause of disease by Semmelweiss (child bed fever—women dying of infection after being examined by physicians with dirty hands) and Robert Koch (who discovered the organism that causes tuberculosis).
The most famous contribution to surgery and its advancement came with the discovery of anesthesia by several individuals, including Crawford Long, Horace Wells, and William Morton (who first demonstrated a painless operation at the Massachusetts General Hospital in 1846). Nitrous oxide, ether, and chloroform became the drugs of choice and led to the advancement of more complex surgery. In the end of the nineteenth century, Conrad Roentgen's discovery of Xrays led to the opening of new horizons in the field of diagnostics.
With the twentieth century came the development of chemotherapy for syphilis by Paul Ehrlich, followed soon by the discovery of Sulfonamide and the discovery and use of Penicillin by Alexander Fleming in 1928, and its purification and widespread use at Oxford by Howard Florey and Ernest Chain, ten years later.
Liberated from the time-warped problems of pain and infection, and armed with a host of new techniques, surgery came of age in the twentieth century. I won't go into much detail about the advances, but suffice it to say that because of the two World Wars, medicine and surgery were “forced” to make great strides, including immunological advances and a whole host of support technologies including the invention of plastics and inert metals which could be used in surgery. Advances in technique, that started during the last decade of the nineteenth century by such surgical giants as the Viennese Theodor Billroth (abdominal surgery, including ulcer surgery on the stomach) and William Halsted (the radical mastectomy), propelled surgery into the twentieth century and the development of neurosurgery by Harvey Cushing, and thoracic surgery (removal of part or all of a lung) by Harold Brunn, Rudolph Nissen, and Evarts Graham. By 1944, John Garlock in New York City was able to successfully remove an entire esophagus for cancer using part of the colon as an interposition “graft.” In the early 1920s and 30s surgeons began operating on the heart, but successes were rare and true cardiac surgery didn't start until the 1940s with the early development of extracorporeal circulation—first in animals, then in humans—by John Gibbon Jr. Soon it was possible to put the heart completely at rest, stopping the “beating,” and allowing surgeons to remove and replace damaged heart valves and bypass blocked coronary arteries. Alexis Carrel had perfected the suturing of blood vessels back in 1905, and vascular surgery has made great strides since that time. This led to experimentation with organ transplantation, and victories over rejection came with greater understanding of immunology and immunosuppression. In 1967 the world was made aware of the first heart transplant by Christian Barnard in South Africa, a procedure that has now become routine and standard at medical centers throughout the world.
This has been a very brief outline of four thousand years of medical and surgical history, and we should be happy that we live at a time when most of the pain and suffering of surgical intervention has been all but relieved. Let us move on now to understand more about the training that these physicians have in preparation for taking the patient into consultation and the scalpel in hand.
Chapter 3
EDUCATING THE SURGEON
In thirteen hundred and forty two
To become a doctor, there was little to do.
Climb a hill, raise your arms in a humble position
Yell once and dance and...you're a physician.
The training today is much more intense,
The course work is hard and it just makes no sense
To work all those years with no compensation,
And wondering when you will bring home the bacon.
The days are so long and rewards long in coming,
The work is quite hard and the hours are numbing.
The MD degree is just too hard to reach,
I think I'll just go be a bum on the beach.
Now I can imagine that most people don't give two hoots and a holler about the education of a surgeon, but I want to spend a little time on this subject so you know what the surgeon has gone through for the privilege of taking out your gall bladder, repairing your heart or removing your cancer. I have mentioned that the first doctors or “medicine men” were more connected with the “spiritual,” using chants, incantations and “witchcraft,” with folklore passing down from one individual to the next, such as the art of repairing fractures and treating wounds.
The education of the healer was through observation and a type of apprenticeship that lasted for centuries, up until the development of great schools of learning. The first of these appeared in Salerno, Italy in the early 1200's, with the support of Holy Roman Emperor Frederick II. At the Salerno school, the physicians were taught how to fix hernias and fractures and perform amputations. For the most part, they were taught diagnosis for diseases they could do little about. They often prescribed rest, bathing or diet, or gave emetics (drugs to make people vomit), and frequently “bled” patients to remove evil humors. Their knowledge of narcotics allowed them to give opium for pain relief, along with near toxic doses of alcohol.
In the Middle Ages, great hospitals were established throughout Europe, usually affiliated with religious institutions, such as abbeys, convents and monasteries. Most of the physicians were religious personnel, since they usually represented the major portion of the educated populace who could read during that period. Books were all hand written, making them rare and expensive, and information about medicine and surgery, if not passed down from person to person, could only be read by those who understood Latin (in which most books were written). The literate few during this period were the monks and other ecclesiastics, and healing was a combination of physical and spiritual modalities. Throughout this period, childbirth and what we know as obstetrics today was practiced only by the midwives.
With the invention of the printing press and moveable type by Johannes Gutenberg and the first printing