What is a Surgeon?
A surgeon, in the simplest sense, is an individual who performs invasive procedures (surgery) on living organisms. The common usage of the word in our society more specifically indicates a trained physician who operates on humans. The profession is one of great antiquity and increasingly successful outcomes. Neolithic skulls have been found with holes cut through to the interior (Trephining) - possibly to let out the "evil spirits", or reduce intracranial pressure after a head injury. Some of these skulls are fairly extensively healed - indicating at least a few successful surgical procedures. Millennia-old pictograms show surgical procedures being performed. Blood letting, amputations, and circumcision are all surgical procedures that have been carried out over the past several thousand years. (Human sacrifice probably does not count as surgery.)
Surgeons and the practice of surgery in ancient times
Surgeons in Mesopotamia and Babylon, the oldest cultures with written histories, followed the Code of Hammurabi. The code, written about 2250 B.C. and based on the older Sumerian Law, provided specific regulations regarding surgery including rules about eye and bladder surgery and the drainage and treatment of abscesses and infections. It also gave penalties and parameters for malpractice:
"10 shekels of silver for draining an abscess or preserving the sight of a gentleman. If the patient is a slave, then the fee shall be 2 shekels. If opening an abscess shall kill the patient, or result in the loss of the eye, then the physician shall have his hand cut off. If the patient is a slave, the physician must replace the slave with a slave."
(It is entirely possible that this portion of the code of Hammurabi
resulted in the rise of lawyers
, the malpractice litigation
industry, and a relative paucity
Egyptian laws also regulated the practice of surgeons. The Kahun papyrus (authored about 2000 B.C.) described gynecologic and veterinary procedures. The Edwin Smith papyrus dated about 400 years later dealt with diagnosis and treatment and included details regarding specific "manipulations". (Knives were not mentioned in either document.)
Ancient Indian medicine provided wider distinction to the growing specialty of surgery. The Susutra Textbook (not the Kama Susutra) had extensive lists classfying hundreds of diseases. Many procedures were outlined for the budding surgeon including techniques of incision, excision, scraping, puncturing, probing, extraction and suturing. Over one hundred different surgical instruments were described. Wine and hypnotism were commonly used anesthetics at the time.
The presence of Aztec and Mexican surgeons can be derived from the extensive archeological history of those cultures. Over 1,200 drugs were known at the time and surgical techniques were apparently quite sophisticated. Procedures included the use of sutures, the practice of embryotomy, and many other surgical techniques. The explorer Cortez had such confidence in the medical acumen of the natives that he sent a message to Spain that they should not send physicians, as they were not needed.
Chinese surgeons contributed little to the modern practice of surgery. This mainly because of their cultural beliefs that surgery was mutilation, and that mutilation during a person's lifetime would carry over into their death. Their work on acupuncture and acupressure did, however, contribute in some minor ways.
Greek medicine was focused on diet, exercise and climate Thus surgical procedures, although described, were relatively simple. They included cataract and stone removal, abscess drainage, and suturing. Among medical authors, Hippocrates is probably the most well known of that period. He contributed a number of books concerned with the description of disease and its natural history.
Roman surgeons were also minor contributors to the field of surgery. They incorporated Greek influences into their own practices and relied maily on Greek and Arab methods. Galen was the most famous Roman physician. He developed numerous complex compilations of diagnostic and therapeutic modalities but didn't perform surgery, as it was considered manual labor.
The Dark Ages were dark for the field of surgery as well as for the advancement of civilization as a whole. Physicians and surgeons relied upon the often incorrect methods and theories of Galen. Galen believed that illness was caused by an imbalance of four humours: blood, phlegm, black bile and yellow bile. He formulated specific diets to help cleanse the "putrefied juices". He also believed that blood was being made continuously and used up by the tissues. In these times, purging and bloodletting would often be used and were based largely on his ideas. The monks of the time chronicled medical information, but did not create any advances in medical knowledge on their own. Diseased patients were commonly treated by midwives and barbers, and little or no lasting advances were made.
Surgeons in the Renaissance
The Renaissance was a breakthrough period for surgeons as well as the field of medicine as a whole. There was extensive renewed interest in anatomy and the etiology of disease. The field of anatomy, which previously suffered due to the taboos related to dissection of human cadavers, was advanced significantly by several visionaries.
- Andrea Vesalius was a Belgian doctor who was among the first to dissect human corpses in order to learn anatomy. His work proved that much of what was believed at the time about the human body was untrue. He published his findings in a book called The Fabric of the Human Body (The Fabricia), which remained the standard for centuries.
- William Harvey was a doctor at St. Bartholomew's hospital in London, a Fellow of the Royal College of Physicians, and the physician to James I and Charles I. He was appointed Lumleian Lecturer on Anatomy and Surgery to the Royal College of Physicians in 1615 and held that position until 1656. Harvey studied in Italy at the University of Padua where he became interested in the work of Vesalius. He developed the idea of circulation by experimentation on live animals and by dissecting the bodies of executed criminals Harvey was able to reveal that the heart acted as a pump, forcing blood through arteries to the body tissues, and back through the veins to the heart. Harvey realised that valves in the veins stopped the blood from travelling back the wrong way to the heart, thus proving that blood flowed back to the heart from the tissues. The accepted theory of Galen to that point was that the body made new blood as its supplies were used up. Harvey proved this to be wrong, and in 1628 published the details in An Anatomical Disquisition on the Movement of the Heart and Blood. After publishing, Harvey actually lost patients, as his ideas were considered to be eccentric. It was not until after his death that others became convinced that he was right.
Harvey's work actually made little difference to general medical practice at the time. Blood letting remained popular practice, and not until the 1900's did doctors begin checking blood flow by taking a pulse. His work along with that of Paracelcus reveled the errors in the then-accepted teachings of Galen, thus advancing the field and practice of surgery.
- Giovanni Morgagni is considered the father of pathological anatomy. He created a compendium of post-mortem observations and their correlation to clinical disease. He dealt rarely with the esoteric, preferring to work with diseases commonly seen by physicians. After he graduated in 1701, he spent his life atempting to understand disease using the principals of anatomy and dissection. Sixty years after graduation, he published The Seats and Causes of Disease Investigated by Anatomy, the book that formed the foundation of pathological anatomy. The practice of surgery was greatly enhanced, as clinicians could trace diseases to their causes in the internal organs.
- John Hunter was a Scottish born surgeon & anatomist who worked with his older brother William. He was a highly practiced and skillful dissectionist, and used his observations to theorize the causes and treatment of disease. He described the treatment of aneurysms of blood vessels and their treatment by ligation. He also performed experiments looking at the possibility of tissue transfer, the prelude to transplantation procedures.
Advances in printing
technology, including woodcuts
, were also quite important to the advancement of surgery. Mass printing allowed wide dissemination
of medical information in the form of textbooks
. Still, there were very few qualified
doctors, and care was generally provided by midwives, barbers, and lay clergy
. Overall, however, significant advances were made in the understanding of diseases and anatomy along with the function of internal organ
s and structures, and thus to the knowledge of practicing surgeons.
In the early 19th century surgeons operated infrequently. Even in major hospitals, only one or two procedures would be performed on an average day. Pain, infection, bleeding and shock were major obstacles to surgery, and only as these were addressed did surgeons improve their techniques and success rates for surgery.
Anesthesia was a dramatic and important development in medicine. Prior to the discovery of the anesthetic properties of ether, alcohol, mandrake root, opium, and bleeding or reduction of brain blood flow were used to decrease pain and sensations felt by the surgical candidate. The first known use of ether was by surgeon Crawford Long in 1842 for removal of skin tumors. It was first formally reported by surgeon William Morton three years later at the Massachusetts General Hospital.
Wound healing at the time was also quite problematic. Surgeons often operated in street clothes, didn't wear gloves or masks, and occasionally would begin the operation by wiping the scalpel on their boots. The advent of handwashing with antiseptics significantly reduced infections.
Joseph Lister was a surgeon and a member of the staff at the Royal Infirmary in Edinburgh. After Louis Pasteur published his germ theory, Lister began using a solution of steam-sprayed carbolic acid to sterilize instruments, and the skin of the patients and surgeons. Lister had great success, and other surgeons gradually began to accept his methods.
Prior to the 19th century, surgical training was an apprenticeship program, with knowledge passed from teacher to pupil. Bernhard Rudolf Konrad von Langenbeck (1810-1887) was the first to establish formal surgical training which included techniques of surgery, histology and pathology. Langenbeck trained many of the eminent surgeons of the time. He was followed by William Stewart Halsted, who encouraged universities and medical schools to cooperate in the training of surgeons, and formed programs which have developed into the modern residency training programs. He also introduced the use of rubber gloves to surgery, and emphasized care in handling tissues and the use of meticulous hemostasis techniques during surgery.
In modern surgical training programs, surgeons begin training after medical school with a surgical internship for one year. After the intern year they enter a four-year surgical residency program. Each year, the surgical resident is given more responsibility, and participates in training other residents. After the five years of training are complete, the surgeon is considered a trained general surgeon. At this point, surgeons can choose to begin practice, or to enter a fellowship program in their chosen specialty. These fellowships can last from one to several years depending on the difficulty and degree of training necessary. Surgeons, just like all other accredited physicians. must complete a certain number of continuing medical education (CME) each year to maintain their status as board-certified surgeons.
Surgeons are increasingly aided by advances in technology and improved and new procedures. Surgeons today are classified by thirteen basic categories:
For modern surgeons, the future is exciting. Laparoscopic surgery has revolutionized many areas of surgical practice, and robotic surgery is moving from investigational use to standard use in some large medical centers. Surgeons enjoy a field of medicine which is rife with possibilities for both general practice and specialization.