Surgery is a medical specialty that uses operative manual and instrumental techniques on a patient to investigate or treat a pathological condition such as a disease or injury, to help improve bodily function or appearance or to repair unwanted ruptured areas.
The act of performing surgery may be called a “surgical procedure”, “operation”, or simply “surgery”. In this context, the verb “operate” means to perform surgery. The adjective “surgical” means pertaining to surgery; e.g. surgical instruments or surgical nurse. The patient or subject on which the surgery is performed can be a person or an animal. A surgeon is a person who practices surgery and a surgeon’s assistant is a person who practices surgical assistance. A surgical team is made up of surgeon, surgeon’s assistant, anaesthesia provider, circulating nurse and surgical technologist. Surgery usually spans minutes to hours, but it is typically not an ongoing or periodic type of treatment. The term “surgery” can also refer to the place where surgery is performed, or, in British English, simply the office of a physician, dentist, or veterinarian.
Surgical treatments date back to the prehistoric era. The oldest for which there is evidence is trepanation, in which a hole is drilled or scraped into the skull, thus exposing the dura mater in order to treat health problems related to intracranial pressure and other diseases.
Prehistoric surgical techniques are seen in Ancient Egypt, where a mandible dated to approximately 2650 BC shows two perforations just below the root of the first molar, indicating the draining of an abscessed tooth. Surgical texts from ancient Egypt date back about 3500 years ago. Surgical operations were performed by priests, specialized in medical treatments similar to today, and used sutures to close wounds. Infections were treated with honey.
Remains from the early Harappan periods of the Indus Valley Civilization (c. 3300 BC) show evidence of teeth having been drilled dating back 9,000 years. Susruta was an ancient Indian surgeon commonly credited as the author of the treatise Sushruta Samhita. He is dubbed as the “founding father of surgery” and his period is usually placed between the period of 1200–600 BC. One of the earliest known mention of the name is from the Bower Manuscript where Sushruta is listed as one of the ten sages residing in the Himalayas. Texts also suggest that he learned surgery at Kasi from Lord Dhanvantari, the god of medicine in Hindu mythology. It is one of the oldest known surgical texts and it describes in detail the examination, diagnosis, treatment, and prognosis of numerous ailments, as well as procedures on performing various forms of cosmetic surgery, plastic surgery and rhinoplasty.
In ancient Greece, temples dedicated to the healer-god Asclepius, known as Asclepieia (Greek: Ασκληπιεία, sing. Asclepieion Ασκληπιείον), functioned as centers of medical advice, prognosis, and healing. In the Asclepieion of Epidaurus, some of the surgical cures listed, such as the opening of an abdominal abscess or the removal of traumatic foreign material, are realistic enough to have taken place. The Greek Galen was one of the greatest surgeons of the ancient world and performed many audacious operations – including brain and eye surgery – that were not tried again for almost two millennia.
Surgery was developed to a high degree in the Islamic world. Abulcasis (Abu al-Qasim Khalaf ibn al-Abbas Al-Zahrawi), an Andalusian-Arab physician and scientist who practiced in the Zahra suburb of Córdoba. His works on surgery, largely based upon Paul of Aegina’s Pragmateia, were influential.
In Europe, the demand grew for surgeons to formally study for many years before practicing; universities such as Montpellier, Padua and Bologna were particularly renowned. In the 12th century, Rogerius Salernitanus composed his Chirurgia, laying the foundation for modern Western surgical manuals. Barber-surgeons generally had a bad reputation that was not to improve until the development of academic surgery as a specialty of medicine, rather than an accessory field. Basic surgical principles for asepsis etc., are known as Halsteads principles.
There were some important advances to the art of surgery during this period. The professor of anatomy at the University of Padua, Andreas Vesalius, was a pivotal figure in the Renaissance transition from classical medicine and anatomy based on the works of Galen, to an empirical approach of ‘hands-on’ dissection. In his anatomic treatis De humani corporis fabrica, he exposed the many anatomical errors in Galen and advocated that all surgeons should train by engaging in practical dissections themselves.
The second figure of importance in this era was Ambroise Paré (sometimes spelled “Ambrose”), a French army surgeon from the 1530s until his death in 1590. The practice for cauterizing gunshot wounds on the battlefield had been to use boiling oil; an extremely dangerous and painful procedure. Paré began to employ a less irritating emollient, made of egg yolk, rose oil and turpentine. He also described more efficient techniques for the effective ligation of the blood vessels during an amputation.
The discipline of surgery was put on a sound, scientific footing during the Age of Enlightenment in Europe. An important figure in this regard was the Scottish surgical scientist, John Hunter, generally regarded as the father of modern scientific surgery. He brought an empirical and experimental approach to the science and was renowned around Europe for the quality of his research and his written works. Hunter reconstructed surgical knowledge from scratch; refusing to rely on the testimonies of others, he conducted his own surgical experiments to determine the truth of the matter. To aid comparative analysis, he built up a collection of over 13,000 specimens of separate organ systems, from the simplest plants and animals to humans.
He greatly advanced knowledge of venereal disease and introduced many new techniques of surgery, including new methods for repairing damage to the Achilles tendon and a more effective method for applying ligature of the arteries in case of an aneurysm. He was also one of the first to understand the importance of pathology, the danger of the spread of infection and how the problem of inflammation of the wound, bone lesions and even tuberculosis often undid any benefit that was gained from the intervention. He consequently adopted the position that all surgical procedures should be used only as a last resort.
Other important 18th- and early 19th-century surgeons included Percival Pott (1713–1788) who described tuberculosis on the spine and first demonstrated that a cancer may be caused by an environmental carcinogen (he noticed a connection between chimney sweep’s exposure to soot and their high incidence of scrotal cancer). Astley Paston Cooper (1768–1841) first performed a successful ligation of the abdominal aorta, and James Syme (1799–1870) pioneered the Symes Amputation for the ankle joint and successfully carried out the first hip disarticulation.o
Modern pain control through anesthesia was discovered in the mid-19th century. Before the advent of anesthesia, surgery was a traumatically painful procedure and surgeons were encouraged to be as swift as possible to minimize patient suffering. This also meant that operations were largely restricted to amputations and external growth removals. Beginning in the 1840s, surgery began to change dramatically in character with the discovery of effective and practical anaesthetic chemicals such as ether, first used by the American surgeon Crawford Long, and chloroform, discovered by Scottish obstetrician James Young Simpson and later pioneered by John Snow, physician to Queen Victoria. In addition to relieving patient suffering, anaesthesia allowed more intricate operations in the internal regions of the human body. In addition, the discovery of muscle relaxants such as curare allowed for safer applications.
Unfortunately, the introduction of anesthetics encouraged more surgery, which inadvertently caused more dangerous patient post-operative infections. The concept of infection was unknown until relatively modern times. The first progress in combating infection was made in 1847 by the Hungarian doctor Ignaz Semmelweis who noticed that medical students fresh from the dissecting room were causing excess maternal death compared to midwives. Semmelweis, despite ridicule and opposition, introduced compulsory handwashing for everyone entering the maternal wards and was rewarded with a plunge in maternal and fetal deaths; however, the Royal Society dismissed his advice.
In the mid-19th century the French microbiologist Louis Pasteur developed an understanding of the relationship of bacteria to infectious diseases, and the application of this theory to wound sepsis by the British surgeon Joseph Lister from 1867 resulted in the technique of antisepsis, which brought about a remarkable reduction in the mortality rate from wound infections after operations. The twin emergence of anesthesia and antisepsis marked the beginning of modern surgery.
Wilhelm Conrad Röntgen’s  discovery of X-rays at the turn of the 20th century added an important diagnostic tool to surgery, and the discovery of blood types in 1901 by Austrian biologist Karl Landsteiner made transfusions safer. New techniques of anesthesia involving not only new agents for inhalation but also regional anesthesia accomplished by nerve blocking (spinal and local anesthesia) were also introduced. The use of positive pressure and controlled respiration techniques (to prevent the lung from collapsing when the pleural cavity was opened) made chest surgery practical and relatively safe for the first time. The intravenous administration (injection into the veins) of anesthetic agents was also adopted. In the period from the 1930s to the 1960s, the replenishment of body fluids by intravenous infusion, the introduction of chemicals and antibiotics to fight infection and to treat the metabolically disturbed body, and the development of heart-lung machines helped bring surgery to a state in which every body cavity, system, organ, and area could safely be operated on.
Contemporary surgical therapy is greatly helped by monitoring devices that are used during surgery and during the postoperative period. Blood pressure and pulse rate are monitored during an operation because a fall in the former and a rise in the latter give evidence of a critical loss of blood. Other items monitored are the heart contractions as indicated by electrocardiograms; tracings of brain waves recorded by electroencephalograms, which reflect changes in brain function; the oxygen level in arteries and veins; carbon dioxide partial pressure in the circulating blood; and respiratory volume and exchange. Intensive monitoring of the patient usually continues into the critical postoperative stage.
Asepsis, the freedom from contamination by pathogenic organisms, requires that all instruments and dry goods coming in contact with the surgical field be sterilized. This is accomplished by placing the materials in an autoclave, which subjects its contents to a period of steam under pressure. Chemical sterilization of some instruments is also used. The patient’s skin is sterilized by chemicals, and members of the surgical team scrub their hands and forearms with antiseptic or disinfectant soaps. Sterilized gowns, caps, and masks that filter the team’s exhaled air and sterilized gloves of disposable plastic complete the picture. Thereafter, attention to avoiding contact with nonsterilized objects is the basis of maintaining asepsis.
During an operation, hemostasis (the arresting of bleeding) is achieved by use of the hemostat, a clamp with ratchets that grasps blood vessels or tissue; after application of hemostats, suture materials are tied around the bleeding vessels. Absorbent sterile napkins called sponges, made of a variety of natural and synthetic materials, are used for drying the field. Bleeding may also be controlled by electrocautery, the use of an instrument heated with an electric current to cauterize, or burn, vessel tissue. The most commonly used instruments in surgery are still the scalpel (knife), hemostatic forceps, flexible tissue-holding forceps, wound retractors for exposure, crushing and noncrushing clamps for intestinal and vascular surgery, and the curved needle for working in depth.
The most common method of closing wounds is by sutures. There are two basic types of suture materials; absorbable ones such as catgut (which comes from sheep intestine) or synthetic substitutes; and nonabsorbable materials, such as nylon sutures, steel staples, or adhesive tissue tape. Catgut is still used extensively to tie off small blood vessels that are bleeding, and since the body absorbs it over time, no foreign materials are left in the wound to become a focus for disease organisms. Nylon stitches and steel staples are removed when sufficient healing has taken place.
The practice and study of medicine in Persia has a long and prolific history. The Iranian academic centers like Gundeshapur University (3rd century AD) were a breeding ground for the union among great scientists from different civilizations. These centers successfully followed their predecessors’ theories and greatly extended their scientific research through history. Persians were the first establishers of modern hospital system.
In recent years, some experimental studies have indeed evaluated medieval Iranian medical remedies using modern scientific methods. These studies raised the possibility of revival of traditional treatments on the basis of evidence-based medicine.
The medical history of ancient Persia can be divided into three distinct periods. The sixth book of Zend-Avesta contains some of the earliest records of the history of ancient Iranian/Afghani medicine. The Vendidad in fact devotes most of the last chapters to medicine.
The Vendidad, one of the surviving texts of the Zend-Avesta, distinguishes three kinds of medicine: medicine by the knife (surgery), medicine by herbs, and medicine by divine words; and the best medicine was, according to the Vendidad, healing by divine words:Of all the healers O Spitama Zarathustra, namely those who heal with the knife, with herbs, and with sacred incantations, the last one is the most potent as he heals from the very source of diseases.
Although the Avesta mentions several notable physicians, the most notable–Mani, Roozbeh, and Bozorgmehr—were to emerge later.
The second epoch covers the era of what is known as Pahlavi literature, where the entire subject of medicine was systematically treated in an interesting tractate incorporated in the encyclopedic work of Dinkart, which listed in altered form some 4333 diseases.
The third era begins with the Achaemenid dynasty, and covers the period of Darius I of Persia, whose interest in medicine was said to be so great that he re-established the school of medicine in Sais, Egypt, which previously had been destroyed, restoring its books and equipment.
The first teaching hospital was the Academy of Gundishapur in the Persian Empire. Some experts go so far as to claim that, “to a very large extent, the credit for the whole hospital system must be given to Persia”.
According to the Vendidad, physicians, to prove proficiency, had to cure three patients of the followers of Divyasnan; if they failed, they could not practice medicine. At first glance, this recommendation may appear discriminant and based on human experimentation. But some authors have construed this to mean that, from the beginning, physicians were taught to remove the mental barrier and to treat adversaries as well as friends. The physician’s fee for service was based on the patient’s income.
The practice of ancient Iranian medicine was interrupted by the Arab invasion (630 A.D.). However, the advances of the Sassanid period were continued and expanded upon during the flourishing of Islamicate sciences at Baghdad, with the Arabic text Tārīkh al-ḥukamā crediting the Academy of Gondishapur for establishing licensure of physicians and proper medical treatment and training. Many Pahlavi scripts were translated into Arabic, and the region of Greater Iran produced physicians and scientists such as Abū ʿAlī al-Ḥusayn ibn ʿAbd Allāh ibn Sīnā and Muhammad ibn Zakariya al-Razi as well as mathematicians such as Kharazmi and Omar Khayyám. They collected and systematically expanded the Greek, Indian, and Persian ancient medical heritage and made further discoveries.
Some of most influential medical texts in medieval Persian medicine
One of the main roles played by medieval Iranian scholars in the scientific field was the conservation, consolidation, coordination, and development of ideas and knowledge in ancient civilizations. Some Iranian Hakim (practitioners) such as Muhammad ibn Zakariya ar-Razi, known to the West as Rhazes, and Ibn Sina, better known as Avicenna, were not only responsible for accumulating all the existing information on medicine of the time, but adding to this knowledge by their own astute observations, experimentation and skills. “Qanoon fel teb of Avicenna” (“The Canon”) and “Kitab al-Hawi of Razi” (“Continens”) were among the central texts in Western medical education from the 13th to the 18th centuries.
In the 14th century, the Persian language medical work Tashrih al-badan (Anatomy of the body), by Mansur ibn Ilyas (c. 1390), contained comprehensive diagrams of the body’s structural, nervous and circulatory systems.
Evidence of surgery dates to the 3rd century BC when the first cranial surgery was performed in the Shahr-e-Sukhteh (Burnt City) in south-eastern Iran. The archaeological studies on the skull of a 13-year-old girl suffering from hydrocephaly indicated that she had undergone cranial surgery to take a part of her skull bone and the girl lived for at least about 6 months after the surgery.
Several documents still exist from which the definitions and treatments of a headache in medieval Persia can be ascertained. These documents give detailed and precise clinical information on the different types of headaches. The medieval physicians listed various signs and symptoms, apparent causes, and hygienic and dietary rules for prevention of headaches. The medieval writings are both accurate and vivid, and they provide long lists of substances used in the treatment of headaches. Many of the approaches of physicians in medieval Persia are accepted today; however, still more of them could be of use to modern medicine.
An antiepileptic drug-therapy plan in medieval Iranian medicine is individualized, given different single and combined drug-therapy with a dosing schedule for each of those. Physicians stress the importance of dose, and route of administration and define a schedule for drug administration. Recent animal experiments confirm the anticonvulsant potency of some of the compounds which are recommended by Medieval Iranian practitioners in epilepsy treatment.
In The Canon of Medicine (c. 1025), Avicenna described numerous mental conditions, including hallucination, insomnia, mania, nightmare, melancholia, dementia, epilepsy, paralysis, stroke, vertigo and tremor.
In the 10th century work of Shahnama, Ferdowsi describes a Caesarean section performed on Rudaba, during which a special wine agent was prepared by a Zoroastrian priest and used as an anesthetic to produce unconsciousness for the operation. Although largely mythical in content, the passage illustrates working knowledge of anesthesia in ancient Persia.
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