HISTORICAL DEVELOPMENT OF MODERN MEDICINE AND SURGERY
Introduction
Historical background is an important aspect for every discipline. History is the study of the currents of human thoughts and actions as they weave the pattern of our lives. Yesterday is history of today and today is history of tomorrow.
History of Ancient Period
Life among Primitive People
Ancient people led a nomadic life (roaming) from place to place. They used stone as weapons and used to make fire. They were nature worshipers. Their belief is known as animism and the period is as Stone Age.
Beliefs about Sickness
Primitive people believed that sickness comes due to the following reasons:
- Anger of the offended gods, devils or evil spirit
- Supernatural powers of the human enemy
- Displeasure of the dead
- Due to their own sin.
Other Beliefs
Other beliefs are as follows:
Sorcery: A sorcerer had the ability to use magical ritual formulae to compel the supernatural forces to produce injury, disease or even death in another person. This power over another was associated with the ability to cast an evil spell. As a consequence, the fear-ridden body of the victim reflected physiological disorders. In many cultures children were considered to be particularly susceptible.
Magic: They are of two types:
- White: Attract good or helpful spirit.
- Black: To destroy evil spirit or bring harm to one's enemies.People thought that disease was caused either by their failure to please the gods or by their sin. The medicine man was one who paid close attention to signs and symptoms and thus knew what to do in some conditions. He attracted attention by wearing strange costumes, using magic words and queer procedures. As his influence increased, he took up the role of priest, pretending to understand and control the forces of health and diseases. In the role he was known as the priest physician. His word was considered to be the law.
Breaking a taboo: The cultural aspect of this fate was so strong that a person often wasted away for no apparent reason.
Intrusion of a disease object: Illness was believed to be induced by the entrance into the body of some small object. Medicine man sucks out, with his mouth and spits it out, power of suggestion also helps.
Bodily invasion by a spirit: This causes physical and mental distress, disease and even death.
Loss of the soul: The soul could be enticed to leave the body by an evil spirit or a sorcerer. A soul-catching ceremony was required for its return.
Dreams: It was believed that soul leaves the body during the periods of dreaming. Solutions found were submission, sacrifice, supplication.
Submission: It resulted in the attitude of what cannot be cured must be endured.
Sacrifice: It involved animals and human beings.
Supplication: It was expressed through prayers.
Preventive Measures
Primitive man had skills in massage, fomentation, bone setting, amputation, hot and cold baths, abdominal sections and heat to control hemorrhage.
Treatment
The treatment was done by Shaman, medicine man or witch-doctor or priest physician. The practice was not to give rest and quietness to the sick person. Instead, to encourage the evil spirit to depart from the person's body by using certain another tricks and methods used on the sick person.
For example:
- Startling the evil spirit with a frightening mask and deafening noises.
- Jolting the person by shaking, biting, pinching and kicking.
- Using noxious odors.
- Giving purgatives and emetics.
- Plunging them in hot and cold water.
- Pacifying the evil spirit by sacrifice.
- Encouraging the evil spirit to come out, using chants and mantras.
- Using certain herbal medicines, e.g. bark of tree for rheumatism.
- Trephining the skull with stone if the above methods failed.
- Healing depends on the faith of the person.
MEDICINE IN EARLY CIVILIZATIONS
Egyptian Medicine
The oldest medical records came from Egypt in 1600 BC. The records were written on papyrus and were preserved in Egypt's hot dry sands. One of the best-known records was brought in AD 1874 by Dr Eber's of Germany. Medicine was thought to be of divine origin and the priest physician was in charge of it. One outstanding priest physician was Imgolep, which means, “He who cometh in peace was liked by all and was elevated to the rank of God, because of his pleasing and kind personality.” Temples were built in his name and sick people were brought to these temples for healing. The medical area of the temple had a comparison to a modern outpatients' clinics of present day with the physician examining and the medical students observing. There were medical specialists at this time taking care of a special ailment.
The Egyptian pharmacobia included innumerable drugs. The Egyptians embalmed and mummified the dead carefully to preserve the body in the pyramids, so that the wandering soul would come back at any time. In Egypt, they had medical laws as fixed codes. The law stated what a doctor could do and could not do. If the doctor follows the recognized laws from the sacred books and is yet unable to heal the sick person, he was guiltless. But if he does anything contrary to the written law, he was to get death penalty.
The Egyptian physicians were co-equals to priests trained in schools within the temples. There were no practical demonstration in anatomy. For Egyptians religion enjoined strict preservation of the human body. Specialization prevailed in the Egyptian times. There were doctors of the eye, head, tooth, etc. They were officials paid by the state.
The Egyptian medical science believed that the disease was due to the absorption of intestine by harmful substances which gave rise to purification of blood and formation of pus. They believed that the pulse was the speech of the heart. Heart diseases were treated with cathartics, enema, blood letting and a wide range of drugs. The best medical manuscript was written on surgery by Edwin Smith Papyrus (3000–2500 BC). It accurately describes about partial paralysis, followed by cerebral lesions in skull fractures. The Ebber's papyrus which was found along with a mummy on the banks of the Nile, is a unique record of some 800 prescriptions based on some 700 drugs. Castor oil, tannic acid, opium, certain minerals and root drugs were all used by the Egyptian physicians.
Chinese Medicine
Chinese medicine claims to be the world's first organized body of medical knowledge dating back to 2700 BC. It is based on two principles, the Yang and Yin.
Yang is believed to be an active masculine principle and Yin is believed to be a feminine 3principle. The balance of these two opposing forces meant good health. Hygiene, dietetics, hydrotherapy, massage and drugs were all used by the Chinese physician. The Chinese were early pioneers of immunization. To a Chinese, the great doctor is one who treats not someone who is already ill, but someone who is not yet ill. The Chinese have great belief in their traditional medicine which is fully integrated with modern medicine. The Chinese system of barefoot doctors, and acupuncture are world famous.
Indian Medicine
The medical systems that are truly Indian in origin are the Ayurveda and the Siddha systems. Ayurveda is practised throughout India; but siddha system is practised only in the Tamil-speaking areas of South India. Ayurveda by definition implies the knowledge of life or the knowledge by which life may be prolonged. Its origin is traced back to the Vedic times, about 5000 BC. During this period, medical history was associated with mythological figures, sages and seers. Dhanvantari, the Hindu god of medicine, is said to have been born as a result of the churning of the oceans during the war between gods and demons. According to some authorities, the medical knowledge in the Atharva Veda gradually developed into the science of Ayurveda.
In ancient India, the celebrated authorities in Ayurvedic medicine were Atreya, Charaka, Susruta and Vaghbhatt. Atreya (800 BC) is acknowledged as the first Indian physician and teacher of the ancient university of Taxila. Charaka (AD 200), the most popular name in Ayurvedic medicine, was a court physician to the Buddhist king, Kanishka. Based on the teachings of Atreya, Charaka compiled his famous treatise on medicine; the Charaka Samhita. Charaka mentioned some 500 drugs. The Indian snakeroot (rauwolfia) was employed for centuries by the Indian physicians before resarpine was extracted from the root and found spectacularly effective in the treatment of hypertension.
Susruta, the father of Indian surgery, compiled the surgical knowledge of his time in his classic Susruta Samhita. This was compiled between 800 BC and AD 400. This includes medicine, pathology, anatomy, midwifery, ophthalmology, hygiene and bedside manners. The early Indians had set fractures, performed amputations, excised tumors and repaired hernias. During the Buddhist times, Indian surgeons suffered a setback because of the doctrine of ahimsa. Hygiene was given an important place in ancient Indian medicine.
The laws of Manu were a code of personal hygiene. Archeological excavation in the Indus Valley shows their knowledge of sanitation, water supply and engineering. The golden age of Indian medicine was between 800 BC and AD 600.
Unani-tibb and homeopathy which was introduced by the Greeks came to India through Muslim rulers during the sixth century AD. In thirteenth century, unani system of medicine was intrenched in certain towns and cities like New Delhi, Lucknow and Aligarh. In the eighteenth century, homeopathy which was propounded by Samuel Hohnemann of Germany (1755–1843) gained foothold in India. It is a system of pharmacodynamics based on the treatment of disease by the use of small amount of drug in healthy persons, which produces symptoms similar to those of the disease being treated. It is practised in India by greater proportions of practitioners in the world.
Greek Medicine
The classic period of Greek medicine was between the years 460 and 136 BC. They taught in terms of why and how. An early leader in Greek medicine was Aesculapius (1200 BC). He had two daughters, Hygila and Panacea. Hygila was worshiped as the goddess of health and Panacea as the goddess of medicine. They both gave rise to dynasties of healers (curative medicine) and hygienists (preventive medicine) with different philosophies. Thus, the dichotomy between curative medicine and preventive medicine began early, and we know it remains true today.
Aesculapius is still cherished in medical circles. Medical staff, entwined by a serpent, continues to be the symbol of medicine.
Hippocrates (460–370 BC), a Greek medicine physician, is called the Father of Medicine. He studied and classified diseases based on observation and reasoning. He initiated the application of clinical methods in medicine. Hippocrates' lectures and writings were compiled later by Alexandrian scholars into the Corpus Hippocraticum which encompassed all branches of medicine. Hippocrates Oath has become the keystone of medical ethics. It sets a high moral 4standard for the medical profession and demands absolute integrity of doctors.
Roman Medicine
The Romans borrowed their medicine largely from the Greeks whom they had conquered. The Romans were a more practical-minded people than the Greeks. They had a keen sense of sanitation. Public health was born in Rome with the development of baths, sewers and aqueducts.
Galen was born in the Greek city of Pergamon in Asia Minor. He was a physician to the Roman emperor, Marcus Aurelius. Galen observed that disease is due to three factors; predisposing, exciting and environmental factors, which were a truly modern idea.
MIDDLE AGES
During the period between AD 500 and 1500, Dark Ages in Europe, Arabs took upperhand and translated the Graeco-Roman medical literature into Arabic and helped preserve the ancient knowledge, and they developed their own system of medicine known as unani. Arabs, in general, were in the field of pharmacology, seeking the elixir of life. They developed pharmaceutical chemistry, introducing a large number of drugs—herbal and chemical. They invented the art of writing prescriptions—an art invented by our modern pharmacists. The golden age of Arabic medicine was between AD 800 and 1300. In AD 937, Yark, the new hospital, was built in England.
The Dawn of Scientific Medicine
After the Industrial Revolution, medicine also evolved (AD 1453–1600). The Swiss-born Paracelsus publicly burnt the works of Galen and Avicenna and attacked superstition and dogma and helped turn medicine towards rational research. Ambroize Pare (AD 1510–1590), a French army surgeon, did a lot for surgery and earned the title, the Father of Surgery. In 1540, the United Company of Barber Surgeons was established in England, which later became the Royal College of Surgeons. The 17th and 18th centuries were full of even more exciting discoveries; Harvey's discovery of the circulation of blood, Leuwenhock's microscope (AD 1670) and Jenner's vaccination against smallpox (AD 1796). In the 19th century, Morgagni (AD 1682–1771) found a new branch of medical science, pathological anatomy.
MODERN MEDICINE
The dichotomy of medicine into two major branches namely curative medicine and public health preventive medicine was evident at the close of the 19th century. After 1900, it moved faster towards specialization and a rational, scientific approach to disease. The pattern of Koffer of Munich (1819–1901) was first mooted. His concepts of multifactorial causation of disease, was revived by epidemiologists who have contributed significantly to our present-day understanding of multifactorial causation of disease and risk factors in the etiology of disease.
Medicine as a science dates to the renaissance and the exciting discovery that the experimental method was the key to new knowledge. Search was the spirit of the age and many great men possessed this idea. Copernicus, Leonardo da Vinci, Galileo, Napier, Leuwenhock, Bacon, Vesalicus and Harvey are numbered among its standard bearers. The development of the microscope and the telescope and the broad implications of the law of falling bodies and the science of logarithms provided man with the tools of discovery and revealed new works to conquer.
HISTORICAL PERSPECTIVES OF SURGERY
Surgery is that branch of medicine which uses manipulative as well as other modalities in the treatment of injury and disease.
The first of the specialists was called to cut for the stone, however, parallelling man's inventiveness were the increasingly destructive exigencies of war. The surgeon was a craftsman of a sort, meeting such problems with the red hot rod; boiling off, the septic ligature or amputation. Surgery was a bitter task; abused by charlatans and outlawed at times by the politics of organized religion, with suffering and death as its consequences.
Celsius, a Greek who learned much about anatomy, lived in the first century lied down to do surgical operations as those for cataracts and hernias.
In the second century, Galen who was educated in Alexandria, Egypt, practised dissection on animals. He learned about the anatomy, physiology of the heart and circulation, respiration and nervous 5system. Galen translated the writings of Hippocrates, and the Arabs thought that to be the chief medical authority. Soranus, a Greek student from the great school of Alexandria, became a famous obstetrician and pediatrician and he did studies of muscles, glands and nerves.
In 1543, Vesalicus, a professor of surgery at Padua, effected revolution in medicine with the publication of DE Corporis Human Ferbrica Libriseptem. Benievieni, Malpighi, and Valsalva soon demonstrated that the postmortem examination could reveal the hidden causes of disease and the science of clinical pathology was born. William Harvey introduced the experimental method into medicine in 1628 with the publication of DC Motu Crodisit Sanguinis in Animalibus, and John Hunter (1728–1793) extended the study of surgery.
1493–1541: In symbolic act Paracelsus burned the books of Galen and Avicenna and then instructed his students to study, to observe and to experiment.
1510–1590: Ambroize Pare, a French army surgeon, chronicled his war experience and with enquiring mind, raised again and again the inevitable why? Then in his wisdom and humanity, and based on his own observations and experience, Pare rejected the cautery and boiling out for more beneficial Leuwenhock's methods of treatment.
The nineteenth century is notable for the evolution of concepts and the development of techniques that are the basis of modern surgery.
1821–1902: Virchow established the cellular basis of pathology. In 1864, Louis Pasteur demonstrated that fermentation is dependent on living organisms.
HISTORY OF SURGICAL NURSING
In the midnineteenth century, surgery became a medical specialty. Surgery gave physicians the means to treat conditions that were difficult or impossible to manage by pure medicine. However, early surgeons had little knowledge of the principles of Asepsis and anesthesia techniques were primitive and unsafe. Nurses first working in the operating rooms, cleaned the rooms and equipment. With the advent of antiseptic and later asepetic practices, surgery became a treatment of choice for many conditions.
The years of 1840s made it possible for surgeons to operate on a client who was free of pain. This was a revolution for surgery.
The development of safer anesthetic gases allowed surgeons to conduct longer operative procedures. All surgery was conducted in hospital settings and nurses required special training for new responsibilities such as assisting, preparing, and caring, for a surgical patient.
In 1876, in Massachusetts, general hospital provided the first operating room education for nurses. This trend continued into the 1900s as nursing schools included operating room experience in each nurse's clinical instruction.
In 1956, the association of operating room nurses was formed to gain knowledge of surgical principles and explore methods to improve nursing care of surgical clients. The associations of operating room nurses overcame the idea that operating room nurses were only technically skilled practitioners. This organization also developed standard of nursing practice to establish the need for registered nurses in the operating room.
In 1970s, a change occurred in nursing education with a focus on the importance of nurses acquiring a broad knowledge base, resulted in less emphasis on operating room techniques.
There has also been a new development in the setting for operative procedures:
- Ambulatory surgery: It was also referred to as outpatient, or
- One-day surgery: This health care service is presently growing rapidly in numbers and various types of procedures such as invasive and noninvasive procedures are performed. Ambulatory surgery is a scheduled surgical procedure provided for a client who does not remain overnight in a hospital, e.g. biopsies, cosmetic surgery, cataract extractions.
In 1995, sixty percent of all surgeries were conducted on ambulatory basis.
Discovery of anesthetic drugs that metabolize rapidly with a few after effects allows shorter operative times. Nurses recognize the benefit of early postoperative ambulation and encourage clients to assume an active role in recovery. Ambulatory surgery also offers cost savings by eliminating the need for hospital stays. It decreases the possibility of acquiring nosocomial infections. Their normal skin flora changes and they soon become colonized with bacteria found in the hospital (Morales and Andrews 1993).
Procedures such as tumor biopsies and gallbladder removal, can now be done using laser procedures; for example, a laser or laparoscopic cholecystectomy only involves a few hours to 24 hours of hospital stay and a recovery period of a week. But, a traditional cholecystectomy usually involves 3 to 5 days of hospitalization and at least a 4-week recovery period. Thus, many surgeons use laser procedures instead of traditional surgical procedures, thereby decreasing the length of surgery, hospitalization, and the associated costs.
Ambulatory and same day surgical programs provide challenges for surgical nurses. Before surgery, nurses must find creative ways to educate clients and family members. The preparation time before surgery is shortened, so nurses must perform complete assessment efficiently. Mostly, assessments are begun in a preadmission clinic (OPD) or any reference from private clinic where clients may answer a self-report inventory. A rudimentary physical examination is completed by a surgical nurse, lab tests may be drawn or completed, teaching is begun, questions are answered, and paper work is initiated. This stream takes the care required by the client on the day of surgery. The nurse has to take care of the clients according to changing trends in case of surgical clients and act according to their role.
Reasons for Lack of Development in Surgery
Inadequate Knowledge of Anatomy
- Very little was known of internal human anatomy, so doctors could not do much surgery, as they did not know what was inside.
- It was illegal to do autopsies, so internal anatomy could not be studied.
- Galen was a surgeon of the second century (AD 101–199).
- Vesalius (AD 1514–1563) Advancements in the study of anatomy were made by Versalius. He could do these advancements as he was a surgeon. He did not accept the work of Hippocrates and Galen without doing further study. He did autopsies to learn anatomy. He and other doctors sometimes stole dead bodies from the graves to do autopsies and advance the study of anatomy. Other times, they were able to get a dead body of a person who had no family and unclaimed.
Measures were not Available to Control or Stop Hemorrhage
- The first surgeries were mostly done to amputate diseased or injured limbs. They did not know how to tie off (ligate) blood vessels, so the patients often hemorrhaged to death.
- 1510–1590: Pare began using ligatures to tie off blood vessels and thus control hemorrhage.
Inability to Prevent Infection
- If the operation was successful and the patient did not die from hemorrhage, he usually died from infection.
- Most people and doctors thought infection was caused by the air seasons.
- Inadequate knowledge of bacteriology.
- Nonavailability of antiseptic agents or antibacterial medications.
- Improper practice of aseptic technique:
- Doctors did not wash their hands or instruments before performing an operation.
- Doctors used the same blood-stained clothes for each operation. They did not change to clean clothes in between the two operations.
- In 1857, Louis Pasteur, while studying fermentation, discovered the presence and activity of microorganisms. His studies showed that purification is a fermentation caused by the growth of the microorganisms and these organisms were killed by heat. He found that purification could be avoided by preventing the entrance of these organisms into a wound.
- In 1865, Joseph Lister used the findings of Louis Pasteur. He found that carbolic acid kills microorganisms, so he treated and used to treat the wounds, as a cleansing agent to skin, surgical instruments, materials, hand washing. He sprayed it into the air to dry and destroy the organisms in the air.
Lack of Anesthesia to Inhibit Pain
- In early days, there were no anesthetics, so five or six men held the patient down while the amputation was performed.
- Often, the pain was so severe that patients would go into shock and die of shock.
- Surgery was difficult without relaxed muscles, especially abdominal surgery.
- In 1846, William Morton, a dentist who later studied medicine, successfully anesthetized a patient for an operation, in which he used sulfuric ether (sulfuric acid and alcohol).
- In 1947, James Simpson successfully demonstrated the use of chloroform, though somebody else had discovered it in 1831. Queen Victoria of England permitted herself to be anesthetized with a chloroform at the time of her delivery. So anesthesia became more widely accepted.
ADVANCEMENT IN SURGERY
There has been rapid advancement in surgery since the 19th century:
- The principles of Lister are the same, but more knowledge and experience have caused his methods to be modified and improved.
- Heat is now used more than chemical sterilization (autoclaving, boiling).
- It has been found that there is no need to “sterilize” the air because a clean wound has natural power of self-protection against bacteria.
- Surgical procedures have advanced from the antiseptic (against putrification) methods of Lister to the aseptic (without infection) techniques of today.
- Great advancement in pharmacology has provided more efficient and less toxic anesthetics and also antibiotics and other antibacterial drugs allowing successful surgery even in the presence of an existing infection.