• LecturehallThe History of Surgery-The Instruments Tell the Tale
  • Lecture Transcript
  • TAPE STARTS – [00:00]


    Male Speaker: Our next speaker, Jarrod Shapiro. You heard him earlier today. He’s going to have a little fun with this, I think, talking about The History of Surgery – The Instruments Tell the Tale. Please welcome Jarrod back on the platform.

    Jarrod Shapiro: Well, good evening, I guess, or late afternoon. So this is low intellectual energy. Hopefully, you – your brain will not fry while we’re talking about this. This is a life skills lecture, but there’s no skill that comes out of this. So hopefully, just more for your enjoyment and perspective. So I still have no conflicts of interest.

    So the kind of point of this is to sort of help you, especially those of you who are residents, to sort of understand the place of where history is and where you’ll kind of – where you are in the world of medicine. So there’s also, as I have kind of grown interested in medical history over the years, I’ve realized that there are these interconnections between different people and different times and situations that are really kind of interesting and you see them and you’ll notice it.

    So I’m going to ask for just a very small amount of participation. So I’m going to ask you this first question. What’s this instrument? So if you’re a resident, maybe you can shout out. What do you call that? I think I heard it. Someone said, “A Freer.” So this is actually not a Freer. It’s going to sound weird, but this is actually a Freer elevator. So it’s named after this guy. This is Otto “Tiger” Freer. So the point of this instrument when Dr. Freer made – invented this in the kind of late 1800 or early 1900s was this is a nasal septum instrument.

    [2:04]

    So he would use this to slide it underneath the mucosa of the nasal septum and then, you know, do septal surgery. So it’s not to free things, really, it was just named after him as a – it’s a Freer elevator.

    So this kind of says to me that there are so many things that, you know, we sort of inherit information and sometimes that information is wrong.

    How about this one? What’s this instrument? You all use this in surgery quite a bit. If you see it’s got these kind of claws on the end of it, this is an Allis. Okay? So this instrument, this Allis, was invented again, around the 1900 and this was used to hold and grab parts of the intestine when you’re anastomosing two pieces of intestine together. This was not used to grab tendons or phalangeal heads or anything like that. This was actually something we stole from another specialty.

    And it turns out the podiatry and orthopedics, especially those of us in the, you know, kind of small-bone world, we’re really good at stealing things from other people. So that’s great. We’re a bunch of thieves, but for a good cause.

    So how about this one? So why do we wear gloves during surgery? What do you think? Does it seem kind of obvious? To like keep things clean, right, so you don’t contaminate your patient. Well, we’re going to come back to this one and I’m going to tell you that it – that’s what it’s for now, but that’s not what it was for originally. We’re going to come back to that later.

    So if we look back in time quite a bit, this is kind of around the 1500s, this is what the operating room would have looked like if you were a doctor.

    [4:04]

    You know, there were really no true surgeons. That didn’t exist yet. So that looks like maybe a little podiatrist-to-be, you know, 400 years early and you can see the guy’s face. It doesn’t look like he’s terribly happy as they’re doing something to his foot. And it looks like kind of dirty, not particularly pleasant place. It’s kind of dark, stingy. This is what surgery looked like for most of history.

    And then as we kind of get into the 1800s, it started to get a little bit better. So this is an operating theater. I’m sure you guys have heard the term operating theater before. And this really was a theater, in the true sense of the term in the past, where you’d have your patient down in the middle, you’d have your surgeon and a couple of folks to hold the patient down because there was no anesthesia yet. And so, if you did something, it had to be really quick and it was violent and very, I guess, like a movie, I suppose, and you’d have all your people up in the, you know, your students and, you know, other physicians who are watching. And they would be up and they’re kind of rafters there in the seats watching things happen. You imagine doing surgery, having like 50 people watching you.

    Okay. Well, this is what we’re more familiar with today, right? So this is the modern operating theater and that looks a lot different from, you know, that old kind of dirty, dark, dingey thing that people were living through before.

    Okay, so I think that we are part of a pedigree of their – those of us who were involved in surgery. There’s a long-standing pedigree. It goes back all the way to the beginning of – really, of, you know, human beings and whenever someone had the kind of cojones to try to do something to another human being, they became a surgeon. And the whole operating room is full of people in the past who’ve invented different things and you’re surrounded by this historical pedigree.

    [6:08]

    So we’re going to talk about some of that.

    So for the most part, this is what life was like, you know, for most of history. Thomas Hobbes said it was nasty, brutish, and short. And medicine, for many years, didn’t do anything to make it any better, so definitely nasty.

    This is from the 1500s. So this is limb deformity correction. So no Ilizarov, no IM nails, no CORA. Don’t worry about that. Just cut the leg off because that’s how you do – that’s how you fix a deformity. You say – take a look at that person that the lady there has a, you know, it has a thing draped over her. I can imagine that’s a wet towel to keep her from, you know, passing out or wanting to die. And there’s a person holding the leg, it doesn’t look like fun.

    And so you know, surgery had to be really fast, so we have these anecdotes of physicians who are incredibly quick at doing amputations. Can you imagine doing a – you’re – think about how long your last whatever amputation it was, transmetatarsal amputation, how long did it take you? Just imagine that and think about a person being awake the whole time, definitely not fun for them.

    So this kind of moves us into really what the – I would think is one of the first surgical instruments ever so, you guys know this is the trepan right? It’s just essentially a tube. It’s really good for doing bone biopsies and those kinds of things but it was used for something else in the past.

    This is a, you know, a person – used to be a person from about almost 2,500 years ago. You can see the hole in the top of the head, so this was trepanning. And they would essentially drill a hole in the top of the – in the skull. And the purpose of this was to get rid of evil spirits.

    [8:00]

    So I have a couple of points from – my wife and I will argue and I think maybe I need to get rid of some evil spirits, so maybe I might take care of this the next time I see her. I don’t think she would like that and I think I’d probably be in prison afterwards.

    I look at that person and I think this person is really kind of the true view of what medicine must have been like and what life must have been like for so much of history. It looked scared, you know, you can – you know the orbital for the eyes are – they’re just huge, it’s like the person is just freaked out trying to protect themselves. This is what medicine was sort of like.

    If you look at this kind of reconstruction of different skulls that had trepanning that occurred, you could see that some of them are – they looked pretty good, you know, they’re round and kind of smooth and then you got that one – the second one from the left has hash marks in it. So you could imagine what kind of instrument they had to use in order to make those hash marks in the skull, definitely not a trepan. You know probably something like a hammer or chisel or something along those lines. And of course, that person was conscious at that time that that occurred, definitely not what we think of as modern day surgery now.

    Okay, so if we move forward into history a bit and, you know, this about surgical instruments, the first one really is the scalpel. So we all use scalpels quite a bit. And for a long time, surgeons were barbers, so the person who cut your hair would also be the person who did your surgery. So for those of you, I’m going to guess mostly Ben who go to the barbershop, imagine going to that barber and then having them do some kind of surgical procedure on you. That kind of scares me knowing what my barber is like.

    And so the origin of the barber pole actually comes from medicine and your barber would either serve blue bloods or red bloods. Red bloods the kind of common folks, the blue bloods are the, you know, wealthy aristocrats and they would put up their pole.

    [10:06]

    Usually, it’s one or the other not both. And you would go and you get your treatment whatever that is.

    So I find it interesting that in this picture from around the 1500s, that person’s holding a scissor and a knife. And that’s kind of what they did for the most part. So barber surgeons were actually created because monks around a thousand AD, monks were the ones who decided to become sort of the doctors and take on the issues with patients. And for a while, the barbers would take care of patients, they would do their – whatever treatment they were going to get which is usually crazy stuff.

    And then around 11 – end of the 1100s, a mandate came about that said that the barber – that the monks were no longer allowed to do invasive procedures into patients. So the barbers who hung around the monks because the monks were not allowed to shave their own faces they had that somebody else do it for them, the barbers’ took the role of the surgeon and then have started to do what we will call surgical procedures. So it’s sort of a power vacuum which sounds a lot like podiatry back – way back when, you know, the orthopedist stop doing foot surgery and chiropodist became podiatrist and they started doing surgery. So we’re a lot like the barber surgeons in that sense. I think it’s an interesting perspective.

    So just for fun, this was a Jacques Lisfranc’s amputation knife. This is kind of a picture of what it looked like. That looks like something you might carve meat with and I can understand why Lisfranc could take off a foot in 30 seconds. Use that thing, it’s amazing.

    Okay so what you really – the surgery that was done for a very long time was really based off of this guy Galen and his view of the humerus.

    [12:01]

    You might have heard of this before that there were four humerus and disease came from imbalances in the humerus. And so your job as a surgeon was to somehow get those humerus back into balance, and this lasted for 1500 years.

    So all the way up until about the, you know, 1700s or so, people still believed that you could take care of disease by getting rid of the humerus. And the way you did that seemed invariably no matter what the problem was, was to blood let, to bleed them. So that’s what the scalpel was for, you poke a hole and you bleed a person and then, you know, somehow, you’re balancing back out the humerus.

    So if you take a look at this, this picture looks pretty benign. This is a barber surgeon who’s doing a bloodletting procedure. You could almost picture a nurse drawing blood or putting in an IV. It almost looks like that calm and nice.

    So they – in some cases, would drain out large amounts of blood. In fact, you guys know this person, this is George Washington. At the end of George Washington’s life, he went out one night in the cold, he got pneumonia and he had two of the best barber-surgeons come and take care of him. And they bled him of liters of blood and he eventually died from blood loss. It wasn’t the pneumonia that killed him, it was the doctors. That’s how the father of our country died.

    So here’s a question for you, what disease still uses bloodletting as a treatment? We actually still blood let people.

    Male Speaker: Polycythemia vera.

    Jarrod Shapiro: No, not polycythemia vera, that’s a good – that’s a good option though. So hemochromatosis. So, you know, excess iron makes a thicker blood and so, you will go through phlebotomy.

    [14:04]

    We don’t call it bloodletting. Can you imagine telling your patient you’re going to blood let them? They’re going to freak out and ran away from you. So we call it phlebotomy.

    Okay. So medicine and surgery kind of look like this for quite some time until this guy came around. This is Andreas Vesalius. And he looks like somebody very familiar to me when I saw this picture of him. So, my question to you is, who does he look like? If you’re a Game of Thrones fan, then I find that amazing. So that’s Peter Dinklage, the actor. It’s almost like he’s ready to make a movie about Andreas Vesalius. He’s got the clothing, he’s got the look. He’s even looking in the same direction as Andreas Vesalius in this picture.

    So Andreas Vesalius wrote this book that they call De humani corporis. And this book revolutionized, though – with our understanding of the human body. You know, prior to the 1500 year, doctors weren’t even allowed to look inside a patient. Anatomy was not something that surgeons really knew anything about. Imagine that one. So think about the anatomy that you know as a surgeon and not being allowed to even know that stuff.

    So he came up with this book and he drew this – had these pictures drawn, and this looks like nothing special, right? This looks like something from Netter or, you know, other than the really nice artistic poses that these corpses going through. This did not exist before. So he scientifically started to bring anatomy to surgery, and that changed things.

    So, in addition to that, this fella came along, this is Ambroise Paré, who’s, kind of, considered the father of modern surgery. He was a renaissance barber surgeon who really changed the way surgery was done up until that point.

    [16:05]

    And so the instrument involved here are really about sutures that’s, kind of, where he is. So, he has a famous, kind of, fortuitous experiment. So, he’s a – he was French and during all the wars that were occurring during the renaissance, he would be taking care of patients with gunshot wounds. And the way they took care of it was to pour boiling oil on the gunshot wound. That sounds like lots of fun. So they pour in boiling water on it and of course, the patients would get infected afterwards and then have all kinds of problems.

    So one day, he’s gone through about half of his patients. He’s poured this boiling oil on half of them, and he runs out of the oil. So he has to come up with something. So he takes some egg yolk and turpentine, and he makes poultices that he puts on the patients’ gunshot wounds, and he spends a sleepless night waiting for the next day, thinking that the half that he put the egg yolks are, were going to die. And of course, they did a lot better. This is like the first, you know, first wound care products before it’s a multibillion dollar industry.

    So, he learned that you can’t just pour boiling oil on things and actually get a person to heal. He also reintroduced sutures what we call ligature. He reintroduced sutures into things instead of cauterizing them. So you take, like, you know, a burning stick that was on fire and you burn it, the bleeding clothes after you did an amputation or something.

    And then of course, there is a connection between him and Vesalius that he popularized what Vesalius had written by translating the Latin that was originally, and then translating into French so that it could become the more, kind of, common thing.

    So, barber surgeons pretty much kept going up until about the 1700s where this fella, this is Guillaume Dupuytren.

    [18:08]

    You might have heard of Dupuytren’s contracture. You don’t want to get that obviously, that make surgery doing a little bit difficult. So Guillaume Dupuytren and another doctor named Peyronie. So you might have heard of Peyronie’s disease or Peyronie’s penile papulosis, they lobbied and were actually friends with the French king at the time. And they caused a split to occur so that barbers could no longer do surgery, and surgeons would actually become a specialty.

    So I think looking at Dupuytren’s contracture, it makes me wonder about Spider Man. Maybe he has Dupuytren’s contracture and it just makes it easier for him to shoot webs. I’m not really sure. He was of course, vicious enemies with our friend, Lisfranc. He kept him from getting hospital privileges. So for those of you, have you ever tried to keep someone for getting hospital privileges, watch out.

    How about this one, what’s this? Yeah, the bone cutting forceps but they’re specifically listed bone cutting forceps. So they’re invented by this guy, this is Robert Liston, who was a Scottish surgeon in the 1700s. And you could see him holding his knife there and apparently, he would roll up his sleeves and he would yell out, “Gentleman, time me.” They were no women there. So he says, “Gentleman, time me,” and he would do a one minute below-the-knee amputation. And he is actually credited with having a 300% amputation rate. Some of you might have heard of this. So, the patient that he did the below-the-knee amputation died of an infection as lots of people did, because he was moving so quickly, he cut his assistant, his assistant got infection and died. And then somebody in the audience apparently had a heart attack because they were so freaked out by the amount of blood that was gushing all over the place and that person died.

    [20:08]

    So he is the first surgeon that have a 300% mortality rate.

    Okay, how about that? What’s this? You know what this thing is, you know – yeah, it’s an Esmarch. So this Esmarch, Johannes Friedrich August von Esmarch. He was a German physician who had a very cool beard. I don’t know how that’s going to fit underneath the mask, but that was pretty neat.

    So he really pioneered military medicine. And he was the assistant to a guy with the name that comes with this. This is a Langenbeck retractor. So if you ever want to ask for this thing, I think it looks kind of neat, you ask for Langenbeck and that’s what they should give you. This was Dr. Langenbeck who’s actually one of the biggest surgeons of his time. He was German. And he – his instrument was a precursor to these things, you know what those are, army navies. They look awfully like the Langenbeck retractor. And whether it’s an army or a navy, is up to you, I suppose. If you’re in the army, then I guess they’re armies.

    So you can also call this a Parker-Langenbeck if you really want to freak out your scrub tech, ask for a Parker-Langenbeck.

    Now this guy happened to be a teacher to lots of different people. And one of them was this doctor named Theodor Billroth. He was again, one of the biggest surgeons of his time. He invented several procedures including abdominal ones that some of you have gone through like general surgery rotations, they talk about a Billroth I and a Billroth II procedure, they’re basically anastomosis procedures where you lose part of the stomach and then attach it to the intestines.

    [22:03]

    So – and then there’s this guy who has something to do with podiatry, back to us again. He looks like a pretty, pretty handsome guy. So he invented this instrument. Can anybody tell me what this one is? Say it loud. I can’t hear you. It’s a Kocher. Absolutely. This is Emil Theodor Kocher, one of two surgeons in history to get the Nobel Prize. So we know now, we’re kind of towards the end of the 1800s here.

    So my residents like to use this to take bone and they think they’re hanging on to it and then they crush it into pieces, which drives me crazy. So Kocher actually used this for the thyroid. That’s where this really came from. He pioneered thyroid surgery and used the Kocher, the instrument to grab the thyroid and the parts around it. He actually was apparently a better surgeon than Theodor Billroth, who would remove the parathyroids commonly. And Kocher was such a good surgeon that he wouldn’t remove the parathyroids and the patients would do a lot better.

    How about this? Yeah, these are Lister bandage scissors. And I’m going to bet all the residents are carrying one in their white coats. So this is going to move us really into kind of the modern age.

    So this is Lister and if you just really quickly before we talk about Lister, you know, Lister was the fellow who came up with antisepsis. But somebody else had come up with the idea before him and this is Ignaz Semmelweis, who was a German physician who noticed that women who were giving birth in the hospital were dying at greater rates than those who would be giving birth by a midwife out in the field.

    [24:00]

    These women were dying at huge rates of what was called puerperal fever. So what he – after some good epidemiologic work, he found out that he and his residents and, you know, doctors in the hospital would do their dissections in the morning to find out, you know, why patients were dying and without washing their hands, they would go and birth babies. And they’re transferring a strep infection to the women so they would die.

    Now he – when he realized this and he found out that you should be washing your hands in doing those kinds of things, he went around the world telling doctors, “You’re killing your patients.” Everybody ignored him. So I guess that’s sort of an idea that you should be a bit more diplomatic, I guess.

    He actually went crazy. They think he had early onset Alzheimer’s. So he disappeared from history and then in his place, came Joseph Lister. So Lister was – he was an English doctor who knew a little bit about microbiology. He’d read some of Pasture’s work at the time and then he came up with a whole method to clean surgical areas and that type of thing. And he used 5% carbolic acid to do this.

    So this is kind of what it looked like. He’d have a guy would be spraying everything and you sprayed everything. The patient, you, they would literally walk through a mist, they would constantly spray the room and, you know, people would end up having like all kinds of irritations. This is carbolic acid, it’s also used to treat this. You know what these are. You treat like a zillion of them a day probably.

    So carbolic acid is also called phenol. And he used 5%, you know, we use 89%, so that’s why. So he has a direct connection to podiatry by giving us something that we can use or to do our PNAs with.

    [26:01]

    He’s also indirectly – this would be a hint, the reason why we wear gloves today. So, we’re going to get to that shortly.

    It turns out that Lister was the son-in-law to James Syme, who was himself a Scottish surgeon of – world renowned. You guys have heard of Syme’s amputation. Syme was enemies with Liston. They hated each other, because they are very different people. But interestingly, Syme is sort of a case study in connections.

    So he was – he trained this guy, this is Dr. Joe Bell. Joe Bell was a surgeon who was also apparently really good at diagnosing people. He walk in, he see what kind of dirt you had on your shoe and he’d know what part of the city you came from and what your diseases were and all those kinds of things. It was really amazing. And one of his students was this guy.

    This is Sir Arthur Conan Doyle. So, you know, Sir Arthur Conan Doyle was a physician before he was an author. And he was the one who came up with Sherlock Holmes. So we think that Sherlock Holmes was based off of Dr. Joe Bell. It has to be somebody who’d came from, right?

    Okay, how about this one. This is going to bring us almost to the end of things. So what’s that? That’s not a Kelly and it’s a little hard to see because it’s – there’s no proportion to this. So this is a Halsted or a mosquito, because you guys are used to using mosquito, you use them all the time in surgery, right? But it’s actually called the Halstead, and it was invented by this guy, this is William Stewart Halsted.

    He was considered the greatest surgeon in the world of his day. He’s American and he worked here, which his Johns Hopkins Hospital.

    [28:00]

    This is what Johns Hopkins looked like in 1893, and he and some other guys started Johns Hopkins Hospital and Medical School, which completely revolutionized the way our education in medicine is done. This is what Johns Hopkins looks like today. That’s a pretty different building from what it was before.

    So, there were four doctors who actually started this, and they’re called the Big 4, and Halsted is there up at the top standing there. You’ll know a couple of these other guys. What’s interesting is that the guy, kind of, in the front sitting, that is William Osler. You’ve might have heard of Osler’s Nodes. They’re actually called Osler’s Nodes because William Osler was – he was Canadian, and he came down, and it turns out that William Osler helped to hide a cocaine and morphine addiction that Halstead had for almost his entire career.

    So, remember one of the first local anesthetics we use was cocaine. So not lidocaine, Marcaine, or Carbocaine, or any of those, it was actually cocaine. And you know what you could do with cocaine now, that’s pretty obvious, but you can also use it to anesthetize things. And so, Halsted was experimenting, legitimately experimenting, but then also they were illegitimately using it, they became addicted to it.

    And so, to hide this, so, you know, we call this drug diversion nowadays, right? You can’t do this now, but these famous doctors, these were literally world-famous doctors, nobody knew what was going on with them until later on in history. So the guy who sort of started this was William Welch. He was a pathologist and he was the first dean of the college.

    You might know of Walter Reed, he was a teacher to him, Walter Reed Hospital.

    [30:03]

    Then here’s William Osler with the Osler’s Nodes. He was an internist. Basically he essentially started internal medicine. He was considered a great diagnostician and he would sit down with his patients. He would go on rounds. Rounds didn’t exist in America before these guys. The entire way that we do – we do our residency training and our medical school training now is really due to these guys.

    Okay, so how about this one? Now, you’re going to say what you said before. So, this is a Kelly. And this, a Kelly, we all know that. This is the Kelly of the Kelly Hemostat. This is Robert Atwood Kelly, who started surgical obstetrics and gynecology as a specialty in the world, I guess. He was a very religious man. He would actually make his surgical staff pray before going into surgery. Now, I’ve had a couple of times where I’ve wanted to pray before going into cases too, but I’m not so sure that I made it a regular habit.

    So, how about these. It’s a little hard to see, it’s a little out of screen. So this is Harvey Cushing. You’ve heard of Cushing’s disease. This is who it’s named after. So Harvey Cushing was probably the greatest surgeon in history, at least according to the stories. He trained under Halsted. And he was one of the guys who actually kind of helped to hide Halsted’s addiction. But he also was involved with inventing these two things.

    So that’s a Cushing retractor, which is a little hard to see, but he started neurosurgery. That’s the specialty. It didn’t exist before him. So he would use his Cushing retractor to very gently retract bits of brain while he was doing surgery. So some of my students that I worked with, they wanted to like hold that retractor and pull the thing for everything that worth.

    [32:05]

    You can imagine doing that with somebody’s brain. But then he also worked with this guy, this is William Bovie. So he asked for a Bovie and this the physicist who worked with Cushing to invent that. Cushing’s also credit with starting the use of pneumatic tourniquets.

    Now, we use them on the ankle and he used them on the head. So he would have a tourniquet that would wrap around, essentially the far head. It would cut the blood supply off to the scalp and allow him to make an incision without the heavy the heavy bleeding that occurs with the scalp wound.

    Okay, so I promised you I was going to tell you about how we wear gloves and this where we’re going to end. So, I mentioned to you about William Halsted and he was this great surgeon. He was doing these amazing operations that had been really groundbreaking and he really kind of created a surgical method that we have now. But interestingly, he met this young lady. Her name was Caroline, and she was his nurse or his scrub tech.

    And because of their using carbolic acid, phenol from back with a Lister, she would get this really bad dermatitis. And as a result of this dermatitis, it would be really difficult for her to work with him. So, he’s got the hots for her, they’re still dating, and he’s got to make a really good impression, right?

    So he goes to the Goodyear Tire Company, so now we’re on cars, I guess. He goes to the Goodyear Tire Company and says, “I need you to make me gloves that my staff can use.” So, she started using the gloves. Her rash went away, and everybody liked the gloves so much, that everybody started using them.

    [34:00]

    And even up to today, we’re now using gloves because a drug addict had the hots for his nurse. So, there’s love in the air, and on that, I’m going to say thank you very much for your time.

    Tape Ends [0:34:17]