9) A Brief History of Medicine Yuhai@zju.edu.cn

The History of TherapeuticsThe ups and down of blood-letting therapy The origin and development of surgery

The ups and down of bloodlettingThe therapy of Bloodletting (phlebotomy) began before Hippocrates time (Hippocrates believed that menstruation functioned to "purge women of bad humors).The theological basis of bloodletting is Four Humors blood, phlegm, yellow bile, black bile) Theory, it was said to curefever, apoplexy, headache and manic psychosisGalen created a complex system of how much blood should be removed based on the patient's age, constitution, the season, the weather and the place.Ancient Greek painting in a vase, showing a physician (iatros) bleeding a patient

The ups and down of bloodlettingApart from phlebotomy skin scratch, cupping and leeches were also used.Leechbecame the nick name for a doctor .

The ups and down of bloodletting

Blood letting was widely applied in the Middle AgesThe barber-surgeons undertook the procedure1540-1745

In 18th century medical text books described the detailed of bloodletting including the indications, location, the methods and tools used

The ups and down of bloodlettingThe tragedy of Washington December 13, 1799 George Washington got acute epiglottitis, the remedy his doctors gave was mixture of honey, vinegar and butter for gargle and bloodletting; within 10 hours total 124-126 ounces blood (3.75 liters)was withdrawn and he died 2 days later George Washington 1731-1799

The ups and down of bloodletting1840, French physician Pierre Louis conducted a clinical trial proving that bloodletting was useless or harmful for treatment of pneumoniaBloodletting, the therapy used for over 2000 year was abandoned except for some rare conditions like hemochromatosis, polycythemia vera and porphyria cutanea tarda. Pierre Louis

The History of Surgical Treatment

trephination

The early surgery-trephination (7000-3000B.C. Neolithic period)for both medical reasons (epileptic seizures,migraines and mental disorders andmystical practices by letting evil spirits escape The History of Surgery

Trephination 1497 Trephination

18th Century French trephinationTrepanationis surgery in which a hole isdrilled into the human skull to treatepiduraland subdural hematomas400 BC Hippocrates treated head injuries with Trephination

1st century Celsus and Galen performing trephination

Modern Neurosurgery: Remove Brain Hematoma

The early surgery was developed from the treatment of battle wounds: suturing lacerations, amputating insalvageable limbs, set bone and draining and cauterizing open wounds Roman surgeonIliad Odessey

Hippocratic Corpus described many methods for treatment of bone fractures(crookback)

According to History of Three Kingdoms (184-280) Hua Tuo invented the general anesthesia with Mafeisan which render a person unconscious and allow him to perform surgical procedures 145-208

Surgery in ancient IndiaIn Susrutha Samhita, he describes in exquisite detail the examination, diagnosis, treatment, and prognosis of numerous ailments, as well as procedures on performing various forms ofplastic surgery,Sushruta 600 BC(

Indian Rhinoplastynacta the nose cut off as a punishment Italian Gasparo Tagliacozzi 15461599Carpues Rhinoplasty 1814

Since the Pope Innocence banned surgerythere had been a career Barber-surgeon who performed the surgical procedures.1735, The Royal College of Surgeon was established and the surgeon became an independent career and a formal training was required, the status of surgeon gradually became equal to that of physicians

Early Surgical TreatmentSurgical treatment used be a cruel and painful experience-no anesthesia, no antisepsis, with boiled oil and burned iron to stop bleedingcauterizationcauters

amputation

Early surgery-amputation

MastectomyJohnnes Scultetus the Elder:Armetarium Chirurgicum (1744)Wilhelm Hildanus 15601634

On 30 September 1811, she underwent amastectomy performed by Dr Larrey The operation was performed in the manner of a battlefield operation under the command of M. Dubois. Burney was later able to describe the operation in detail, since she was conscious, as it took place before the development of anesthetics:

I saw the glitter of polished Steel I closed my Eyes. I would not trust to convulsive fear the sight of the terrible incision. Yet -- when the dreadful steel was plunged into the breast cutting through veins arteries flesh nerves I needed no injunctions not to restrain my cries. I began a scream that lasted unintermittingly during the whole time of the incision I almost marvel that it rings not in my Ears still? so excruciating was the agony. When the wound was made, the instrument was withdrawn, the pain seemed undiminished, for the air that suddenly rushed into those delicate parts felt like a mass of minute but sharp forked poniards, that were tearing the edges of the wound. I concluded the operation was over Oh no! presently the terrible cutting was renewed worse than ever, to separate the bottom, the foundation of this dreadful gland from the parts to which it adhered Again all description would be baffled yet again all was not over, Dr. Larry rested but his own hand -- Oh heaven! I then felt the knife (rack)ling against the breast bone scraping it! English novelist Frances Burney (17521840)

Break

Three Breakthroughs in Modern Surgery Pain, infection, bleeding were the three major obstacles to prevent surgery from progressing into modern science. The development of modern surgery has been benefited from three inventions:Anesthesia antisepsis and disinfection transfusion

Invention of anesthesiaBefore invention of anesthesia the most commonly used analgesic agents were: marijuana, opium, stramonium, belladonna, alcohol or hypnogenesis. The effects were rather poor, which cumber the number of elective surgical procedures

Invention of anesthesia 1772, British chemist Joseph Priesley seprated nitrous oxide (N2O), because it can relax diaphragm muscle and make people laughing so called laughing gas

1800,Humphry Davy found the analgesic effect of nitrous oxide

Invention of anesthesia Due to the euphoric effects of inhaling it, a property that has led to its recreational use as an inhalantdrug As dancing outreach (ecstasy) today

Invention of anesthesiaMarch 30,1842 a country doctor Crawford Long18151878successfully remove a neck tumor with ether anesthesia for a child, but the results not published His Alma Mater Johns Hopkins University recognized him as the first one using ether as anesthetic agentNational Doctors Day March 30 in USA (since 1993)

Invention of anesthesiaDecember1844 a American dentist Horace Wells(1815-1848) successfully extracted his own cheek teeth with inhaled N2OBut he failed in demonstration in Harvard Medical School Hospital February 18441864, American Association of Dentists gave the credit of invention of anesthesia to him.

Invention of anesthesiaOctober 16,1846, Wells assistant William Morton (1819-1868) during a public demonstration in MGH let a patient to inhale ether, and the famous surgeon Warren dissected a mandible tumor from the unconscious patient.Morton was recognized the inventor of surgical anesthesia

The first operation under anesthesia by Dr Morton1846.10.16

Obstetrician James Simpson1811-1870)applied Chloroform instead ether as anesthetic agentthe Queen Victoria inhaled chloroform during the child birth.

Invention of anesthesiaInventor and Revealer of Inhalation Anesthesia: Before Whom, in All Time, Surgery was Agony; By Whom, Pain in Surgery was Averted and Annulled; Since Whom, Science has Control of Pain. (to William MortonWho was the first one to use anesthesia has always been a big debate1868, in Boston a monument was erected to commemorate the first operation under anesthesia in 1846, in which engraved:To Ether or Either

Invention of Surgical AntisepsisSemmelweis a Hungarian obstetrician investigated the cause of high incidence of puerperal fever childbed fever in Vienna General Hospital and advocated hand wash with chloride of lime solution leading to the maternal death rate dropping from 18% to 1%.Ignac Semmelweis 1818-1865

Invention of Surgical AntisepsisSemmelweis was attacked by his conserved colleagues and incurred persecution.Ironically he died at 47 in an asylum from septicemia, but was honored as the savior of mothers after his death IQ Vs EQYour character is your destiny

Invention of Surgical AntisepsisIn middle of 19th century the sepsis caused by operation was most popular with a mortality rate of 50%Inspired by Pasteurs discovery Joseph Lister created using carbolic acid in surgical antisepsiswith this method he saved a 11-year boys life who suffered a open complicated fracture in 1865The fetal rate for amputationbefore antisepsis invention16/35(45.7%)after 6/40(15.0%) Joseph Lister 1827-1912

Listers antisepsis method was ignored in Britain and US1870, German adapted his method in Prussian-French war and saved many soldiers life.1877, Lister took the position of Department Head of Surgery in Kings Collegeand made his name in surgical circle and his surgical antisepsis was popularized18951900 Lister was appointed as the Chairman of British Royal Society.

Your character is your destiny

Progress of Surgical Techniques1877 German doctor von Bergmann sterilized the surgical instrument and dressing with high-temperature vapor1885 German surgeon Neuber: surgical gown1889 American surgeon Halsted: rubber glovesAustrian surgeon Mikulicz-Radecki: surgical mask1890,Halsted proposed the basic principles of surgerylaid the foundation of modern surgery

surgery 1870s (Dr Gross) surgery 1889 (Dr Billroth)

Surgery 1902Operating theater in early 20th century

Modern operating theater

Invention of Blood transfusionBlood loss is a threat for patients life, to control blood loss: cauterization, ligature, and blood replace1665, British physician Richard Lower first tried transfuse blood from sheep to a psychiatric patient Transfusion was soon banned because of death caused by transfusing animal blood

Invention of Blood transfusion1818, British obstetrician Blundell first transfused blood to a postpartum bleeding woman from her husbandAfterwards he tried 10 times and 5 was successful

Invention of Blood transfusion1875,Landois found the cause of transfusion reaction- agglutination of red cells1900, Austrian scientist Landsteiner discovered agglutination was caused by immune reactionand proposed the ABO blood types 193941 Rh type was found Rhesus monkey Karl Landsteiner 1868-1943

.ABO blood type system

Rh Blood Type Rh-Caucasian15%Chinese 0.3%

Therapy for newborn jaundice intrauterine transfusionBlood replacementPhototherapy

Invention of Blood transfusionDiscovery of blood type and the establishment of blood match laid the foundation of blood transfusion and promoted the development of surgery.Landsteiner obtained the Nobel Prize in 1930

Advances in Modern SurgeryOrgan transplantationMinimal invasion surgeryRobot surgeonTelesurgery

Organ TransplantationMain obstacles for organ transplantation: Blood vessel anastomosis Organ preservation Graft rejectionMore than 1 million people received organ transplantation worldwideRenal transplant is most common (500,000 cases) next is heart and liver."Limb Transplantation Miracle by Saints Cosmos and Damian," from around 1500.

Milstones of Organ Transplantation1931, Felatove performed first cornea transplant1954, Joseph Murry successfully conducted first kidney transplantation between two identical twines1963, Starzl: first liver transplantHardy: first lung transplant 1967, South African surgeon Barnard performed first heart transplantation1974, Thomasfirst bone marrow transplantation (graft-versus-host disease) 1980s Clinical application of Cyclosporin as immuno- suppressor drug

live donor liver transplantationKidney transplantationLiver transplantation

Face TransplantationThe first face transplantation was performed on November 27, 2005 in Amiens Hospital of France"The most difficult thing is to find myself again, as the person I was, with the face I had before the accident. But I know that's not possible," -Isabelle Dinoire1 month 3 months

First Chinese patient received face transplantation in April 14 2006 in Xijing Hospital, Xian BeforeAfter

20071220086

A French patient Pascal Coler suffered from Von Recklinghausens disease multiple neurofibromaface transplantation was performed March 2008

Connie Culp shot by her ex-husband on face in 2004received face transplant in Crifland Hospital Dec 10 2008, the operation lasted for 22 hours Photo taken before and after surgery (March 5 2009)

The First Full FacetransplantBOSTON 3/21/2011 A Texas construction worker horribly disfigured in a power line accident in 2008 has undergone the nation's first full face transplant in hopes of smiling again and feeling kisses from his 3-year-old daughter.Dallas Wiens, 25, received a new nose, lips, skin, muscle and nerves from an unidentified dead person in Brigham and Womens Hospital.

Face transplantation US 2012

1997 Richard Lee Norris (37y) suffered from gun shot injury on the face, underwent 12 operation, not only the face but also the maxillary bone, mandibular bone and teeth were transplanted

Laparoscopic Surgery Laparoscopy(application of Artificial pneumoperitoneum)

Laparoscopic Surgerycholecystectomy

Laparoscopic Surgery-Laparoscopic esophatectomy

Transvaginal nephrectomy

Natural orifice transluminal endoscopic surgery (NOTES)

Transgastric cholecystectomy

Transgastricappendectomy

Surgical scar conventional surgery

Surgical scar minimally-invasive surgery

Robot Surgeon2000,da Vinci robot surgeon system developed in US

TelesurgeryFirst telesurgery was in September between New York and Paris for cholecystectomyFirst Chinese telesurgery in September 10, 2003 between Beijing and Shenyang for a intracranial hematoma removal

nanorobots

Through the battle through defeat Moving yet and never stopping Pioneers! o Pioneers! - Walt Whitman (1819-1892) Andrew Balfour (1873-1931) the first Director of London School of Hygiene and Tropical Medicine (1923

The End