History of Hand Surgery1

While it is true that hand surgery evolved as a separate field only in the twentieth century, its seeds were sown a long time ago in the checkered past of medicine. Susruta, the great Indian surgeon is credited with describing the first pedicled flap in history. His treatise (5th century AD), describes the use of a pedicled forehead flap for reconstruction of the nose. He is also known to have described more than 120 surgical instruments, including scalpels, saws, scissors, needles, hooks, probes, directors, sounds, forceps, trocars, etc. The first writing on tendon repair comes from Avicenna, an Arabian surgeon of the tenth century who advocated that cut or ruptured tendons should be sewn together. However, this was rarely followed in Europe because of the strong influence of Galen who taught that tendons and nerves had the same characteristics and repair of either would result in gangrene and convulsions. The misconceptions of ancient medicine often stemmed from a poor and often fanciful understanding of anatomy. The works of Leonardo da Vinci (1452–1519) and Andreas Vesalius (1514–1564) were among the earliest attempts at a methodical understanding of the internal structure of the human body. Their exhaustive and amazingly accurate treatises on anatomy paved the way for modern scientific surgery. Ambroise Pare (1510–1590) can justifiably be called the father of modern surgery. Having become an army surgeon in 1536, Pare's surgical knowledge and skill were garnered and honed in the battlefields of France. He is the first person to have described wound debridement as a means of reducing infection. He is also known to have reintroduced the use of a ligature, which had fallen into disuse since the time of Celsus, thus making it possible for safe amputations and disarticulations. Pare is also known to have developed prosthetic limbs for rehabilitation of amputees. The invention of the microscope by Leeüvenhoek (1632–1723) laid the foundation for its future use in surgery. The 19th and 20th centuries saw an explosion of scientific discovery that had tremendous impact on the development of medicine. Of particular significance were: the discovery of anaesthesia by Morton (1819–1868), sterilization by Pasteur (1822–1895), bacteria by Koch (1843–1910), asepsis by Lister (1827–1912), X-rays by Roentgen (1845–1922), radium by the Curies (1898), therapeutic application of radium in malignancy by Danysz (1903) and penicillin by Fleming (1929).2

Coverage of wounds, which had been a major source of concern, received a new fillip with the description of a tubed abdominal flap based on the superficial inferior epigastric artery by Shaw and Payne (1946). A number of random pattern flaps were subsequently described but were limited in their application by the strict geometric confines imposed by their uncertain blood supply. The development of the groin flap based on the superficial circumflex iliac artery by McGregor, Jackson and Lister in 1972 broke the shackles of rigid geometry and permitted large flaps to be raised. Soon, there were a profusion of flaps described, each based on an identifiable vessel running through its axis. Quickly enough, tiny flaps based on digital vessels were also described, enabling sensate coverage of the fingertip. Significant among these was Venkataswami's oblique triangular flap, reported in 1980, which permitted a cosmetic as well as sensate reconstruction of oblique amputations of the fingertip.

Surgical treatment of vascular injuries can be traced to Murphy (1857–1916), who successfully repaired a femoral artery severed by a gunshot wound in 1896. This was preceded by his phenomenal work on the anastomosis of other hollow visceral structures like the gall-bladder, stomach and intestines. Abbe (1851–1928) attempted prosthetic union of blood vessels by means of a fine glass tube in 1894. Halstead began experiments on replantation in 1887, which were subsequently reported in 1922. Alexis Carrel between 1900 and 1907 reported a succession of landmark surgical procedures that included a successful canine limb replant as well as techniques for vascular repair including the triangulation technique and the use of arterial and vein grafts to restore circulation. The invention of the operating microscope by Carl Zeiss marked another breakthrough in the development of surgery. Nylen and Holmgren used the microscope for the first time in 1921 for ear surgery. Jacobsen and Suarez in 1960 coined the word “micro-surgery” and demonstrated the feasibility of repair of vessels less than 1mm in diameter. This was followed by the first successful revascularization of a digit by Kleinert and Kasdan in 1962. Malt and McKhann in 1962 successfully replanted an arm in a 12-year-old boy, which was followed by a forearm replantation by Horn in the same year. Komatsu and Tamai reported the first successful replantation of a completely amputated thumb in 1965. Though unknown at that time, Chinese surgeons, led principally by Chen Chun Wei, had already been actively involved in the development of microvascular anastomosis. Much of their work came to light following the American Replantation Mission to China in 1973. It was to this mission that Chen Chun Wei declared about replantation that “Survival without restoration of function is not success”. Much of the success of microsurgery can also be attributed to the development of excellent microinstruments and fine atraumatic microsutures through the continued efforts of Acland and Buncke. In 1966, Buncke performed a toe-to-hand transfer in a rhesus monkey, the first ever in man or beast. This was followed by the first human toe-to-thumb transfer by Cobbett in 1969. In 1972, McLean and Buncke reported a successful transplantation of composite free tissue, a vascularised omental transplant for a severe scalp avulsion in a young lady followed by Daniel and Taylor with a free skin flap transfer in 1973. This was soon followed by many other reports of free tissue transfer, notable of which was the functional transfer of expendable muscles in Japan in the mid 1970s by independent teams led by Harii and Kubo. The description of free fibular transplant by Taylor in 1975 marked another milestone in the field of microsurgical reconstruction, permitting free bone transfers. Recent understanding of cutaneous and muscular blood supply has led to the mapping of angiosomes, depicting areas of skin supplied by identifiable blood vessels, while Mathes and Nahai have developed an excellent classification of muscles based on their vascular pattern. The profusion of flaps available to the reconstructive surgeon today, accompanied by the fact that microanastomosis has become a standard and routine procedure all over the world seems ironic in light of the comment made to Julius Jacobson, the founder of microsurgery, who was told by a renowned surgeon of the time that “…bringing the microscope into the operating theatre will never amount to anything!” In a similar repeat of history, Harold Kleinert in 1962, who while operating on the world's first successful digital revascularisation was criticised in no uncertain terms that he was “…wasting valuable operating room time by trying to stitch back those tiny vessels!”

The fields of muscle and tendon repair have also witnessed tremendous changes. As alluded to earlier, though Avicenna advocated tendon repair in the tenth century, European physicians did not do so for a long time as they were influenced by the teachings of Galen. This reluctance to repair tendons continued till the 19th century when Albrecht von Haller refuted the Galenian concepts and obtained approval of the French Academy of Science. Heuck reported the first successful free tendon graft in 1882 when he sutured back an accidentally excised segment of thumb extensor. Codavilla towards the end of the 19th century wrote on 3tendon transfers and indicated the need for continuous motion to prevent adhesions. The next significant contribution in the development of tendon surgery came in the early part of the twentieth century from Mayer, who emphasised the need for a detailed knowledge of anatomy, atraumatic handling of the tendon, proper tension, and preservation of the tendon sheath. This set the stage for Sterling Bunnel (1882–1957) who added to the above, concepts such as asepsis, proper incisions, bloodless field, preservation of pulleys and timing of motion and therapy. Bunnel also developed a simple suture technique for tendons that was less bulky and permitted repair within the confines of the digital sheath. However, Bunnel was strongly convinced that delayed tendon grafts were preferable to primary repair in Zone II tendon injuries, and coined the term “no man's land” for this area. Verdan did try to promote the concept of primary repair in Zone II injuries and conducted experimental studies to prove his case. However, the teachings of Bunnel were so strong that his opinion held sway till the late 1960s, when Kleinert and Kutz from Louisville reported good results following primary repair in Zone II injuries. So strong was the influence of Bunnel's teachings that the American Society for Hand Surgery appointed a committee of distinguished surgeons to visit Louisville and validate their claims. Nonetheless, the committee soon reported that primary flexor repair in Zone II was indeed safe thus removing all constraints on hand surgeons. Once it was established that primary repairs were possible in all zones of tendon injury, interest shifted to the methods of mobilising them following repair. Currently, there are three basic regimens in practice. The regimen recommended by Kleinert's group from Louisville is one of passive flexions provided by rubber band traction followed by active extension. Duran and Houser promote passive flexion as well as passive extension while Snow's group from Belfast recommed active assisted flexion followed by active extension. These different methods with many subtle variations of the same theme are all in current use over the world. No one method has been shown to be better or worse than the other. The field of tendon transfer saw tremendous leaps being made in the middle of the 20th century. Moberg from Sweden developed and promoted several transfers for restoration of upper limb function in tetraplegics. Paul Brand served with missionary zeal in the southern part of India principally operating on people suffering from leprosy. He is responsible for describing many procedures for restoration of hand function, especially that of the intrinsics, and has also provided a scientific basis for determining the best possible donor muscles for transfer. Zancolli from Argentina, while developing many muscle transfers, especially for the treatment of spastic deformities, also provided a stunningly detailed analysis of the extensor muscles of the hand, a subject that had been largely relegated to the back because of the overwhelming interest that flexor surgery generated among hand surgeons.

Nerve repair saw tremendous improvements in the latter half of the 20th century. The current understanding of the pathoanatomy of nerve injuries derives primarily from the pioneering works of Sunderland on the internal topography of nerves and Seddon, who established standards for modern day nerve suture and grafting. Earlier to this, nerve injuries were indeed well known but poorly understood. Panas (1878) localised ulnar nerve compression to the elbow but it was only in 1887 that the cubital tunnel was identified as the pathologic area by Foux, who then went on to describe anterior transposition of the nerve for relief. Though Guyon described the tunnel that bears his name in 1861, it was Hunter in 1908 who described ulnar nerve compression in this location, until which time, the problem was attributed to “occupational causes”. Strangely enough, carpal tunnel release, which seems to be the bread and butter surgery of today's hand surgeon, was first reported only in 1933 by Larmonth, though the symptomatology of median nerve compression at the wrist had been described in 1880 by Putnam and decompression of the tunnel had been suggested by Marie and Fox in 1913. Obstetric palsy had long been known to modern medicine through the works of Smellie (1764), who first described the condition and Duchenne (1872) who coined the term “obstetric palsy”. Danayau in 1851 performed an autopsy on a newborn with palsy and found the brachial plexus to be infiltrated with blood, though not disrupted. Erb in 1874 presented a classical description of an upper plexus lesion that now bears his name. Klumpke, who is distinguished for being the first ever woman medical resident in French history, described her eponymous lower plexus palsy with Horner's syndrome in 1875. Surgery of the brachial plexus has made significant advances in the last few decades of the last century. A large proportion of this has been due to the introduction of microsurgical techniques in plexus reconstruction by Millesi in 1964 and Narakas in 1966. Alain Gilbert from France has contributed significantly to the reconstruction and salvage of pediatric brachial plexus injuries. Currently, many microsurgeons the world over are dedicating their services almost exclusively to the reconstruction of the brachial plexus, thus heralding the birth of a new subspeciality of hand surgery.4

No chronicle of the history of hand surgery can be complete without a mention of Buck-Gramcko and his contribution to the reconstruction of the congenitally deformed hand. His revolutionary concept of pollicization of the index finger in 1959 opened an entire new chapter in reconstructive surgery of the hand, paving the way for many digital transposition procedures. The other one that needs to be touched upon is the development of orthotics and prosthetics. Centres all over the world have contributed to the progress that has been made in these fields. However, particular mention has to be made of BB Joshi from India who, constrained by cost concerns, developed an amazing array of splints using inexpensive household materials. His chapter on these simple homemade splints in Robb and Smith's textbook of surgery stands unique. The field of prosthetic devices in the hand owes its growth largely to James Hunter who intrduced the use of silicone and subsequently to Swanson who developed silicone prostheses for almost all upper limb joints.

All through the ages, hand surgery has been practiced by orthopaedic, plastic and general surgeons alike and remains so even to this day. Interest in the hand as a separate entity can be traced to the pioneering works of Kanavel in the early part of the twentieth century, who wrote extensively on the anatomy of the hand, highlighting its intricacy and beauty. The development of hand surgery as a separate speciality began with Kanavel's students Koch, Mason and Allen in Chicago as well as with Sterling Bunnel in San Francisco. Bunnel was a general surgeon but was quickly drawn to the repair and reconstruction of hand problems. His monumental experience gleaned during World War II led to the publication of his magnum opus in 1944 titled Surgery of the Hand. This book remained a bible for all aspiring hand surgeons for several decades. Bunnel has credited the Surgeon General of the United States of the time as being principally responsible for directing him to organise specialised hand care centres, which he did in various military hospitals after World War II. Another towering personality was Eric Moberg of Sweden, who almost single handedly took hand surgery to the level of a new and separate speciality in Europe.

The early part of the 20th century saw hand surgery swiftly developing as a new speciality. This raised the need for a common platform where hand surgeons could share their experiences and views. Once again, it was Sterling Bunnel who provided the solution. His foresight, combined with the organisational skills of Joseph Boyes led to the birth of the world's first hand surgical society, the American Society for Surgery of the Hand in 1946. Bunnel was its first president and in his presidential address in 1947, Bunnel stated “I am sure the day will come when there will be in various nations many reciprocating societies for surgery of the hand”. Truly enough the next few decades saw the birth of hand societies all over the world and finally the International Federation of Societies for Surgery of the Hand was established in 1966. Throughout the early part of the 20th century, hand societies sprang up in a number of European countries, notably, the UK, France, Germany and Sweden to name a few. An encouraging trend has been the birth of several hand societies in the Far East during the second half of the 20th century. One of the earliest was the Japanese Society, which was formed in 1957. The Australian Society took birth in 1972 while the Thai Society was formed in 1978. It is heartening to note that today the International Federation of Societies for Surgery of the Hand (IFSSH), has more than forty member hand societies representing in excess of 5,000 physicians worldwide. The society has been established with the mutual objectives of promoting free and full exchange of information throughout the world, to preserve historic and scientific resources for current and future generations, and to coordinate activities between member societies.

The birth of Hand Surgery as a speciality was soon followed by the need for a specialised training in hand surgery. Fellowship programmes arose all over the world, notably in the United States, United Kingdom, Sweden and Australia. In 1973, the American Board for Medical Specialities recognised a certification in Hand Surgery as an added qualification to basic training in General, Orthopaedic or Plastic Surgery. Currently, Sweden and Singapore have recognised Hand Surgery as an entirely independent speciality. The rapid pace at which knowledge in hand surgery has grown has prompted the need for sharing and disbursement of information. Today, there are many periodicals dedicated to the field of Hand Surgery. The American and European editions of the Journal of Hand Surgery, Hand Clinics and Hand Surgery from the Asia Pacific Societies are among the better known ones to be published in the English language. This raises the specter of an inevitable though somewhat unfortunate fallout of the wonderful diversity of human society that much knowledge is often lost because of linguistic barriers. It is a matter of concern that a lot of excellent clinical work goes unnoticed because of it being published in languages that are not widely spoken in the world. This is an issue that needs to be seriously addressed in the future. Fortunately, some excellent 5textbooks written originally in other languages have been translated into English, notable of which is Raoul Tubiana's “The Hand”. Hand Surgery is increasingly being recognised as a distinct speciality the world over and centres of excellence have developed in every continent. Referring to the development of hand surgical training all over the world, Paul R Manske in his editorial in the American Journal of Hand Surgery wrote, “Teaching learning and a structured education are seamless, contiguously joined like the curves of a circle. Each is a specific entity, but the lines that delineate them are indistinct. They complement and potentiate each other in the ongoing cycle of information gathering and concept development. All are essential to the educational whole. They are integral to our pursuit of knowledge as students of hand surgery”.

The future of hand surgery is bright. The absolute explosion of scientific development in the last century has blurred the lines between scientific fact and fiction. Advances in immunosuppressive therapy have made hand transplantation a reality and it should not be long before this surgery becomes as routine as other well established allograft tissue transfers. Suzanne Ildstad at the University of Louisville has successfully induced mixed chimerism in experimental animals, thereby making them tolerant of allografts. There is promise of being able to induce the same in humans. This would enable composite tissue transplants that will not require the use of potentially harmful immunosuppressive drugs. Genetic engineering has made it possible for us to dream of synthesising all kinds of tissues and who knows, maybe even a biological prosthesis! The advent of telecommunication has seen national borders disappear overnight. Computers have made accurate documentation and instant recall possible. Programmes for language translations are now available and their use in scientific documentation should soon lead to an unshackling of information and knowledge from the bonds of language. Hand surgery, being a relatively new child of the field of medicine is poised for a glorious and exciting future. It is at this juncture that we should pause and recollect the pioneering contributions of those giants who made this field possible and on whose broad and generous shoulders we now stand.

Writing on the history of any subject is a task that can never be complete. The above few passages trace the significant milestones in the birth and development of Hand Surgery. The chapter is deliberately brief, for, to quote Virchow, “Brevity in writing is the best insurance for its perusal”.