Sunday, November 22, 2015

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14 Wise Quotes About World Peace by Figures We Look Up To...

Progress of surgery

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Lakshman Karalliedde

In the late 19th century, with the development of germ theory by Louis Pasteur and its subsequent application to surgical sterility by Joseph Lister, surgeons were able to operate with a substantially reduced risk of infection. Infection was the major contributor to morbidity and mortality rates, occurring after practically all operations and taking the lives of almost half of all surgical patients. The earliest known attempts to access the calvaria date to circa 10,000 BC. Skulls collected throughout the world show the square and ovoid marks left by the ancient "healers" who ground and scraped the skull with sharpened stones. Some patients survived, as evidenced by the smoothed corners of some Neolithic skulls found in East Africa.[4, 17] Nevertheless, it may be assumed that the mortality and morbidity rates were less than acceptable by today's standards.

Some years after the Neolithic era, surgeons may have taken a more conservative approach to opening skulls. Under the guidelines imposed by The Code of Hammurabi (circa 1750 BC), surgeons in Mesopotamia were provided monetary compensation for their services; however, if the patient died under their care, the surgeon's hands were amputated.[7] With these stakes, many surgeons may have limited their caseload of elective surgical procedures. Around this time the first account of attempted wound management appeared. The world's oldest medical text outlines the procedures for wound management practiced by the Sumerians. The wound was cleansed with beer and then bandaged with a cloth soaked in wine and turpentine.[4] The practice of using alcoholic beverages and turpentine would remain the treatment of choice until the modern era.[1]

The proliferation of medical texts originating from the Golden Age of Greece would provide guidelines for the practice of medicine for 2000 years. Nevertheless, because of the intellectual rigidity of the medical community, expansion on the ideas and practices of the Greeks would remain stagnant for the same two millennia.[7] Every few hundred years, courageous men dedicated to the practice of the healing arts would challenge the false assertions and even produce verifiable data to support their claims, but their ideas would not wield the influence necessary to cause change. In the practice of wound healing, two issues would become recurring points of contention: first, the role of suppuration; and second, the origin and transmissibility of infection.

As recounted in Alexander,[1] more than a century before Leeuwenhoek's microscope and three centuries before Pasteur's studies on putrefaction, Hieronymus Fracastorius (1478–1553) postulated that the cause of infectious disease was from invisible living seeds ( seminaria contagionum ). In his work, "De contagione," published in 1546, he described three modes of disease spread: direct contact with infected persons, indirect contact with fomites, and airborne transmission (see Meade).[11] As Hamby[8] reported, Ambroïse Paré (1510–1590), considered the father of modern surgery, similarly believed infection was introduced from the environment. Furthermore, others after Fracastorius and Paré correctly noted the importance of a sterile environment in the prevention of disease transmission. In 1822 Gaspard demonstrated the pathogenicity of suppuration by injecting pus into a dog, and when that dog fell ill, injecting its blood into another animal, causing death. According to two histories of surgery,[11, 17] in 1842 Oliver Wendell Holmes of Harvard recommended that physicians wash their hands with a calcium chloride solution to prevent the spread of infection from the autopsy rooms to the wards. Similarly, Ignaz Philipp Semmelweis (1818–1865), in his attempt to universalize the practice of hand washing, reported that hand washing with chloride of lime solution reduced puerperal sepsis mortality from 9.92 to 1.27% in 2 years. The views of both Holmes and Semmelweis encountered a cold reception from the medical community.

Joseph Lister (1827–1912; In April 1867 he published his ground-breaking paper on antisepsis, stating that "all the local inflammatory mischief and general febrile disturbance which follow severe injuries are due to the irritating and poisoning influence of decomposing blood or sloughs." Lister began applying carbolic acid to compound fracture wounds. The wound healed without suppuration, amputation was averted, and the mortality rate from amputation plummeted from 45 to 15%.

Keen was one of the few surgeons who realized the practical importance of infection control, and he became one of the first American surgeons to implement Lister's system.[7] The following is a description of Keen's surgical setup:

All carpets and unnecessary furniture were removed from the patient's room. The walls and ceiling were carefully cleaned the day before operation, and the woodwork, floors, and remaining furniture were scrubbed with carbolic solution. This solution was also sprayed in the room on the morning preceding but not during the operation. On the day before the operation, the patient's head was shaved, scrubbed with soap and water, and ether, and covered with wet corrosive sublimate dressing until operation, then ether and mercuric chloride washings were repeated. The surgical instruments were boiled in water for 2 hours, and new deep-sea sponges (elephant ears) were treated with carbolic and sublimate solutions before usage. The surgeon's hands were cleaned and disinfected by soap and water, alcohol, and sublimate solution.

in 1891 Ernst von Bergmann introduced heat sterilization of instruments, which proved superior to chemical sterilization. Sterile gowns and caps were introduced in 1883 by Gustav Neuber of Kieland, and then the surgical mask by Mikulicz in 1897. The use of rubber gloves became widespread after 1890 when William Stewart Halsted (1852–1922;) commissioned the Goodyear rubber company to fashion gloves for his nurse to protect her hands from the mercuric chloride solutions used to disinfect the instruments.

Harvey Cushing (1869-1939), under the tutelage of William Halsted, became committed to precision and meticulous surgical technique, producing phenomenal results. In 1915, of 130 surgically treated tumor cases, he reported an 8.4% mortality rate. Of these deaths, only one was due to infection; the patient died of streptococcal meningitis on the 6th day postsurgery. Cushing explained his success this way:

[Our results] depend so greatly on such details as perfection of anaesthesia, scrupulous technique, ample expenditure of time, painstaking closure of wounds without drainage, and a multitude of other elements, which so many operators impatiently regard as triviality.