When did the period of modern surgery begin? Main stages in the development of surgery
The history of surgery is a separate, most interesting section that deserves a lot of attention. The history of surgery can be written in many volumes in the form of an intriguing thriller, where sometimes comical situations coexist with tragic events, and there were certainly more sad, tragic facts in the development of surgery. The history of medicine is a separate specialty that is taught in universities. But it is simply impossible to start getting acquainted with surgery without mentioning its history and development. Therefore, in this chapter we will draw your attention to the most important fundamental discoveries and events that significantly influenced the further development of surgery and all medicine; we will recall the brightest personalities of surgeons, which no educated person can be unaware of.
The emergence of surgery dates back to the very origins human society. Having started to hunt and work, a person was faced with the need to heal wounds, remove foreign bodies, stop bleeding and other surgical procedures. Surgery is the most ancient medical specialty. At the same time, it is forever young, since it is unthinkable without the use of the latest achievements of human thought, the progress of science and technology.
MAIN STAGES IN THE DEVELOPMENT OF SURGERY
The development of surgery can be represented in the form of a classical spiral, each turn of which is associated with certain major achievements of great thinkers and practitioners of medicine. The history of surgery consists of 4 main periods:
Empirical period, covering the time from the 6th-7th millennium BC to the end of the 16th century AD. "
Anatomical period - from the end of the XVI century to the end 19th century.
The period of great discoveries of the late XIX - early XX centuries.
Physiological period - surgery of the 20th century.
The most important turning points in the development of surgery were the end of the 19th and beginning of the 20th centuries. It was at this time that three surgical directions arose and began to develop, which determined a qualitatively new development of all medicine. These areas are asepsis with antiseptics, anesthesiology and the study of combating blood loss and blood transfusion. It was these three branches of surgery that ensured the improvement of surgical treatment methods and contributed to the transformation of the craft into a precise, highly developed and almost omnipotent medical science.
EMPIRICAL PERIOD 1. SURGERY OF THE ANCIENT WORLD
What could people do in ancient times?
The study of hieroglyphs, manuscripts, surviving mummies, and excavations made it possible to get a certain idea of surgery starting from the 6th-7th millennium BC. The need to develop surgery was associated with the elementary desire to survive, to provide assistance to a wounded relative.
Ancient people knew how to stop bleeding: for this they used compression of wounds, tight bandages, poured hot oil into the wounds, and sprinkled them with ash. Dry moss and leaves were used as a kind of dressing material. Specially prepared opium and cannabis were used for pain relief. In case of injuries, foreign bodies were removed. There is information about the first operations being performed at this time: craniotomy, amputation of limbs, removal of stones from Bladder, castration. Moreover, according to archaeologists, some of the operated patients died only many years after the surgical interventions!
The most famous is the surgical school of the ANCIENT INDIANS. The manuscripts that have reached us describe clinical picture a number of diseases (smallpox, tuberculosis, erysipelas, anthrax etc.). Ancient Indian doctors used more than 120 instruments, which allowed them to perform quite complex interventions, in particular C-section. Gained particular fame in Ancient India plastic surgery. The history of “Indian rhinoplasty” is interesting in this regard.
For theft and other offenses, slaves in Ancient India usually had their noses cut off. Subsequently, to eliminate the defect, skilled healers began to replace the nose with a special pedunculated skin flap cut from the forehead area. This method of Indian plastic surgery entered the annals of surgery and is still used today.
The history of ancient surgery cannot do without mention of the first known physician, HIPPOCRATES (460-377 BC). Hippocrates was an outstanding person of his time, everything comes from him modern medicine. Therefore, it is the Hippocratic oath that is pronounced by people who are ready to devote their whole lives to this difficult but wonderful profession.
Hippocrates distinguished between wounds that healed without suppuration and wounds that became complicated purulent process. He believed the cause of infection was air. When changing dressings, he recommended maintaining cleanliness, using boiled rainwater and wine. When treating fractures, Hippocrates used a kind of splints, traction, gymnastics; Hippocrates’ method for reducing a dislocation is still known. shoulder joint. To stop bleeding, he suggested an elevated position of the horse, and even before our era he carried out drainage of the pleural cavity. Hippocrates created the first works on various aspects of surgery, which served as original textbooks for his followers.
Apparently, the image of Hippocrates in to the greatest extent(answers to the beautiful words from Homer’s Iliad: *One skillful physician is worth many people: he will cut out the arrow and sprinkle medicine on the wound*.
IN Ancient Rome The most famous followers of Hippocrates were Cornelius CELUS (30 BC - 38 AD) and Claudius GALEN
(130-210).
Celsus created a thorough treatise on surgery, which described many operations (stone cutting, craniotomy, amputation), treatment of dislocations and fractures, methods of stopping bleeding! However, we must first of all be grateful to Cornelius Celsus for his two main achievements:
1. Celsus was the first to propose applying a ligature to a bleeding vessel. Ligation (ligation) of blood vessels is still one of the fundamentals of surgical work. During runtime surgical intervention surgeons are sometimes forced to ligate vessels of various diameters dozens of times, thus paying tribute to the great surgeon of antiquity.
2. Celsus was the first to describe the classical signs of inflammation, without which the study is unthinkable inflammatory process and diagnostics of surgical infectious diseases. Galen, despite his idealistic philosophical views, became the ruler of medical thought for many years. He collected a large amount of material on anatomy and physiology and introduced an experimental research method. Galen proposed surgery for developmental defects upper jaw(so-called cleft lip), used the method of twisting the bleeding vessel to stop bleeding.
The largest representative ancient Eastern medicine Ibn SINA, better known in Europe under the name AVICENNA (9180-1087).
Ibn Sina was a scientist - an encyclopedist, educated in philosophy, natural science and medicine, the author of approximately 100 scientific works. Ibn Sina wrote the “Canon of Medical Art” in 5 volumes, where he outlined issues of theoretical and practical medicine. This book became the main guide for doctors over the next few centuries.
2. SURGERY IN THE MIDDLE AGES
In the Middle Ages, the development of surgery, especially in Europe, slowed down significantly. The dominance of the church made scientific research impossible, and operations involving spills were prohibited. blood”, and autopsies. Galen's views were canonized by the church; the slightest deviation from them became grounds for accusations of heresy. Many universities in Europe opened medical faculties, but official medical science did not include surgery. Surgeons were formed in a circle of barbers, artisans, artisans, and more long years they had to seek recognition of themselves as full-fledged doctors.
The achievements of some surgeons of the Middle Ages were quite significant. The Italian surgeon Lucca back in the 13th century (!) used special sponges soaked in substances for pain relief, inhalation of the vapors of which led to loss of consciousness and pain sensitivity. Bruno de Langoburgo in the same XIII century identified the fundamental difference between primary and secondary wound healing, introduced the terms - primary and secondary intention. The French surgeon Mondeville proposed putting different sutures on the wound, opposed its probing, tied general changes in the body with the nature of the flow local process. There were other notable achievements, but still the basic principles of surgery in the Middle Ages were: *Do no harm* (Hippocrates), *Most best treatment- this is peace” (Celsus), “Nature itself heals wounds” (Paracelsus), and in general: - the doctor cares. God heals.
The stagnation of the Middle Ages gave way to the flourishing of the Renaissance - a time of the brightest rise of art, science and technology. In medicine, as in other industries, a struggle began against religious canons and the authorities of ancient scientists. There was a desire to develop medical science based on the study of the human body.
The empirical approach to surgery ended and the anatomical era of surgery began.
ANATOMICAL PERIOD
The first outstanding anatomist - researcher of the structure human body became Aidreas VESALIUS (1515-1564). Many years of research on human corpses, reflected in his work *………………………………….*, allowed him to refute many of the provisions of medieval medicine and mark the beginning of a new stage in the development of surgery. At that time, for this progressive work, Vesalius was expelled from the University of Padua to Palestine to atone for his sins before God and died tragically on the way.
The Swiss physician and naturalist PARACELS (Theophrastus Bombastus von Hohenheim, 1493-1541) and the French surgeon Ambroise PARÉ (1517-1590) made a great contribution to the development of surgery of that time.
Paracelsus, participating in many wars, significantly improved methods of treating wounds, using astringents and other special chemical substances. He also suggested various medicinal drinks to improve general condition wounded.
Ambroise Pare, also a military surgeon, continued to improve the process of treating wounds. In particular, he proposed a kind of hemostatic clamp and opposed pouring boiling oil into wounds. A. Pare developed an amputation technique, and in addition, introduced a new obstetric manipulation - turning the fetus on a leg. The most important thing in A. Pare’s work was the study of gunshot wounds. He proved that they were not poisoned by poisons, but were a type of bruised wound. Important for further development surgery was also the fact that Pare again proposed to use the method of vascular ligation, already forgotten by that time, introduced by C. Celsus back in the 1st century.
The most important event in the development of medicine during the Renaissance was the discovery of the laws of blood circulation in 1628 by William HARVEY (1578-1657). Based on the research of A. Vesalius and his followers, W. Harvey established that the heart is a kind of pump, and the arteries and veins are unified system vessels. In his classic work *Exermaio anapolotca ae toi cor (From e1 n^mta t attabiis) (1628), he first identified the systemic and pulmonary circulation and refuted the prevailing ideas since the time of Galen that air circulates in the vessels of the lungs. Recognition Harvey's discovery did not happen without a struggle, but it was it that created the prerequisites for the further development of surgery, and indeed all medicine.
Great importance for the development of surgery there were advances in physiology, chemistry and biology. First of all, it is necessary to note the invention of A. Levenguk (1632-1723) of a magnifying device, the prototype modern microscope, and M. Malpighi’s (1628-1694) description of capillary circulation and his discovery of blood cells in 1663. An important event The 17th century saw the first human blood transfusion performed by Jean Denis in 1667.
Fast development surgery led to the need to reform the training system for surgeons and change their professional status. In 1731, the Surgical Academy was established in Paris, which for many years became the center of surgical thought. Following this, surgical hospitals and medical schools for teaching surgery were opened in England. The surgery began to progress quickly. This largely contributed to great amount wars that were taking place in Europe at that time. The number and volume of surgical interventions performed increased significantly, and their technique, based on an excellent knowledge of topography, progressively improved. Now it’s hard to even imagine how the French surgeon, Napoleon’s physician D. Larrey, personally performed 200 (!) amputations of limbs in one day after the Battle of Borodino. Nikolai Ivanovich Pirogov (1810-1881) performed operations such as amputation of the mammary gland or opening of the bladder in 2 minutes (!), and osteoplastic amputation of the foot (by the way, which has retained its significance to this day and went down in history as osteoplastic amputation feet according to N.I. Pirogov) - in 8 minutes (!). In many ways, however, such speed was forced due to the impossibility of complete pain relief during surgery.
However, the rapid development of surgical technology has not been accompanied by equally significant progress in treatment results. Thus, in the sixties of the 19th century, in the Hospice House of Count Sheremetev in Moscow (now the N.V. Sklifosovsky Institute of Emergency Medicine), the mortality rate after operations was 16%, that is, every sixth patient died. And this was one of the best results at that time (?!). *The fate of science is no longer in our hands operative surgery... favorable outcome The operation depends not only on the skill of the surgeon... but also on happiness* (N.I. Pirogov).
Three main problems have become obstacles to the development of surgery:
1. The powerlessness of surgeons to prevent wound infection during surgery and ignorance of how to combat infection.
2. Lack of pain relief methods to minimize the risk of developing surgical shock.
3. Inability to fully stop bleeding and compensate for blood loss.
All these three problems were fundamentally resolved at the end of the 19th and beginning of the 20th centuries.
PERIOD OF GREAT DISCOVERIES LATE XIX - BEGINNING XX centuries
The development of surgery during this period is associated with three fundamental achievements:
1. Introduction of asepsis and antisepsis into surgical practice.
2. The occurrence of pain relief.
3. Discovery of blood groups and the possibility of blood transfusions.
1. HISTORY OF ASEPSIS AND ANTISEPTICS
The powerlessness of surgeons in the face of infectious complications was simply terrifying. Thus, N.I. Pirogov’s 10 soldiers died from sepsis, which developed only after bloodletting (1845), and of the 400 patients he operated on in 1850-1862, 159 died mainly from infection. In the same year, 1850, 300 patients died in Paris after 560 operations.
The great Russian surgeon N.A. Velyaminov very accurately described the state of surgery in those days. After visiting one of the large Moscow clinics, he wrote: *I saw brilliant operations and... the kingdom of death.”
This continued until the doctrine of asepsis and antiseptics became widespread in surgery at the end of the 19th century. This doctrine did not arise out of nowhere; its appearance was prepared by a number of events.
In the emergence and development of asepsis and antisepsis, five stages can be distinguished:
Empirical period (the period of application of individual scientifically unsubstantiated methods),
Prelister antiseptics of the 19th century,
Lister antiseptic,
The emergence of asepsis
Modern asepsis and antiseptics.
(1) EMPIRICAL PERIOD
The first, as we now call * antiseptic methods, can be found in many descriptions of the work of doctors in ancient times. Here are just a few examples.
"Ancient surgeons believed mandatory removal foreign body from the wound.
Ancient Hebrew history: In the laws of Moses, it was forbidden to touch a wound with your hands.
Hippocrates preached the principle of cleanliness of a doctor’s hands and spoke of the need to cut nails short; used rainwater and wine to treat wounds; shaved hairline With surgical field; spoke about the need for clean dressing material. However, targeted, meaningful actions of surgeons to prevent purulent complications began much later - only in the middle of the 19th century.
(2) PRE-LISTER ANTISEPTICS OF THE 19TH CENTURY
In the middle of the 19th century, even before the works of J. Lister, a number of surgeons began to use methods to destroy infection in their work. Special role I. Semmelweis and N. I. Pirogov played a role in the development of antiseptics during this period.
a) I. Semmelweis
The Hungarian obstetrician Ignaz Semmelweis in 1847 suggested the possibility of women developing puerperal fever (endometritis with septic complications) due to the introduction of cadaveric poison by students and doctors during vaginal examination (students and doctors also studied in the anatomical theater).
Semmelweis suggested before internal research treat hands with bleach and achieved phenomenal results: at the beginning of 1847, postpartum mortality due to the development of sepsis was 18.3%, in the second half of the year it dropped to 3%, and the next year - to 1.3%. However, Semmelweis was not supported, and the persecution and humiliation that he experienced led to the fact that the obstetrician was placed in a psychiatric hospital, and then, by a sad irony of fate, in 1865 he died of sepsis due to panaritium, which developed after a finger injury while performing one from operations.
b) N. I. Pirogov
N.I. Pirogov did not create comprehensive works to combat infection. But he was half a step away from creating the doctrine of antiseptics. Back in 1844, Pirogov wrote: We are not far from the time when a thorough study of traumatic and hospital miasmas will give surgery a different direction* (t1auta - pollution, Greek). N. I. Pirogov respected the works of I. Semmelweis and himself, even before Lister, used in some cases antiseptic substances (silver nitrate, bleach, tartar and camphor alcohol, zinc sulfate).
The works of I. Semmelweis, N. I. Pirogov and others could not make a revolution in science. Such a revolution could only be accomplished using a method based on bacteriology. The emergence of Lister antiseptics was undoubtedly facilitated by the work of Louis Pasteur on the role of microorganisms in the processes of fermentation and putrefaction (1863).
(3) LISTER ANTISEPTIC
In the 60s 19th Vienna in Glasgow, English surgeon Joseph Lister, familiar with the works of Louis Pasteur, came to the conclusion that microorganisms enter the wound from the air and from the surgeon’s hands. In 1865, he, convinced of antiseptic effect carbolic acid, which the Parisian pharmacist Lemaire began to use in 1860, used a bandage with its solution in the treatment open fracture and sprayed carbolic acid into the operating room air. In 1867, in the journal *…………..* Lister published an article “On a new method of treating fractures and ulcers with comments on the causes of suppuration*,” which outlined the basics of the antiseptic method he proposed. Later Lister improved the technique, and in its full form it already included the whole complex events.
Antiseptic measures according to Lister:
Spraying operating carbolic acid into the air;
Treatment of instruments, suture and dressing material, as well as the surgeon’s hands with a 2-3% solution of carbolic acid;
Treatment of the surgical field with the same solution;
Use of a special dressing: after the operation, the wound was covered with a multilayer dressing, the layers of which were impregnated with carbolic acid in combination with other substances.
Thus, the merit of J. Lister consisted primarily in the fact that he did not just use antiseptic properties carbolic acid, but created a complete way to fight infection. Therefore, it was Lister who went down in the history of surgery as the founder of antiseptics.
Lister's method was supported by a number of major surgeons of the time. A special role in the spread of Lister antiseptics in Russia was played by N. I. Pirogov, P. P. Pelekhin and I. I. Burtsev.
N. I. Pirogov used medicinal properties carbolic acid in the treatment of wounds, supported, as he wrote *in the form of injections*.
Pavel Petrovich Pelekhin, after an internship in Europe, where he became familiar with the works of Lister, began to ardently preach antiseptics in Russia. He became the author of the first article on antiseptic issues in Russia. It must be said that such works have existed before, but they were not published for a long time due to the conservatism of the editors of surgical journals.
Ivan Ivanovich Burtsev is the first surgeon in Russia to publish the results of his own use of the antiseptic method in Russia in 1870 and draw cautious but positive conclusions. I. I. Burtsev worked at the Orenburg hospital at that time, and later became a professor at the Military Medical Academy in St. Petersburg.
It should be noted that Lister’s antiseptics, along with ardent supporters, also had many irreconcilable opponents.
This was due to the fact that J. Lister “poorly” chose an antiseptic substance. Toxicity of carbolic acid, irritant effect on the skin of both the patient and the surgeon’s hands sometimes forced surgeons to doubt the value of the method itself.
The famous surgeon Theodor Billroth ironically called the antiseptic method *listing*. Surgeons began to abandon this method of work, since its use killed not so much microbes as living tissue. J. Lister himself wrote in 1876: “An antiseptic in itself is a poison. to the extent it has bad influence on fabric." Lister's antisepsis was gradually replaced by asepsis.
(4) THE ARISE OF ASEPSIS
Advances in microbiology, the works of L. Pasteur and R. Koch put forward a number of new principles as the basis for prevention surgical infection. The main one was to prevent bacteria from contaminating the surgeon’s hands and objects in contact with the wound. Thus, surgery included the cleaning of the surgeon’s hands, sterilization of instruments, dressings, linen, etc. l, /
The development of the aseptic method is associated primarily with the names of two scientists: E. Bergman and his student K. Schimmelbusch. The name of the latter is immortalized by the name of the bix - a box still used for sterilization - Schimmelbusch's bix.
At the X International Congress of Surgeons in Berlin in 1890, the principles of asepsis in the treatment of wounds received universal recognition. At this congress, E. Bergman demonstrated patients operated on under aseptic conditions, without the use of Lister antiseptics. Here the basic postulate of asepsis was officially adopted; “Everything that comes into contact with the wound must be sterile.”
First of all, high temperature was used to sterilize the dressing material. R. Koch (1881) and E. Esmarch proposed a method of sterilization with flowing steam. At the same time, in Russia, L.L. Heidenreich was the first in the world to prove that steam sterilization under high blood pressure, and in 1884 proposed using an autoclave for sterilization.
In the same 1884, A.P. Dobroslavin, a professor at the Military Medical Academy in St. Petersburg, proposed a salt oven for sterilization, the active agent in which was steam saline solution, boiling at 108°C. Sterile material required special conditions storage, cleanliness environment. Thus, the structure of operating rooms and dressing rooms was gradually formed. Much credit goes to this Russian surgeons M. S. Subbotin and L. L. Levshin, who essentially created the prototype of modern operating rooms. N.V. Sklifosovsky was the first to propose distinguishing operating rooms for operations with different levels of infectious contamination.
After the above, and knowing current situation affairs, the statement seems very strange famous surgeon Volkmann (1887): “Armed with an antiseptic method, I am ready to perform an operation in a railway latrine *, but it once again emphasizes the enormous historical significance of Lister’s antiseptics.
The results of asepsis were so satisfactory that the use of antiseptics began to be considered unnecessary, not corresponding to the level scientific knowledge. But this misconception was soon overcome.
(5) MODERN ASEPSIS AND ANTISEPTICS
Heat, which is the main method of asepsis, could not be used for processing living tissues or treating infected wounds. Thanks to the successes of chemistry for the treatment of purulent wounds and infectious processes, a number of new antiseptic agents have been proposed that are much less toxic to the tissues and body of the patient than carbolic acid. Similar substances began to be used for processing surgical instruments and objects surrounding the patient. Thus, asepsis gradually became closely intertwined with antiseptics, and now surgery is simply unthinkable without the unity of these two disciplines.
As a result of the spread of aseptic and antiseptic methods, the same Theodor Billroth, who had recently laughed at Lister’s antiseptics, said in 1891: “Now clean hands and a clear conscience
an inexperienced surgeon can achieve best results"than before the most famous professor of surgery." And this is not far from the truth. Now the most ordinary surgeon can help a patient much more than Pirogov, Billroth and others, precisely because he knows the methods of asepsis and antisepsis. The following figures are indicative: before the introduction of asepsis and antisepsis postoperative mortality in Russia in 1857 it was 25%, and in 1895 - 2.1%.
In modern asepsis and antiseptics, thermal sterilization methods, ultrasound, ultraviolet and X-rays are widely used; there is a whole arsenal of various chemical antiseptics, antibiotics of several generations, as well as a huge number of other methods of fighting infection.
2. DISCOVERY OF PAIN RELIEF AND HISTORY OF ANESTHESIOLOGY
Surgery and pain have always gone side by side since the first steps in the development of medicine. According to the famous surgeon A. Velpo, surgery it was impossible to carry out without pain; general anesthesia was considered impossible. In the Middle Ages Catholic Church and completely rejected the very idea of eliminating pain as anti-God, passing off pain as punishment sent by God to atone for sins. Until the mid-19th century, surgeons could not cope with pain during surgery, which significantly hampered the development of surgery. In the middle and end of the 19th century, a number of turning points occurred that contributed to the rapid development of anesthesiology - the science of pain management.
(1) THE EMERGENCE OF ANESTHESIOLOGY
a) Discovery of the intoxicating effect of gases
In 1800, Devi discovered the peculiar effect of nitrous oxide, calling it “laughing gas.”
In 1818, Faraday discovered the intoxicating and sensitivity-suppressing effect of ether. Devy and Faraday suggested the possibility of using these gases for pain relief during surgical operations.
b) First operation under anesthesia
In 1844, dentist G. Wells used nitrous oxide for pain relief, and he himself was the patient during tooth extraction (removal). Later, one of the pioneers of anesthesiology suffered tragic fate. During a public anesthesia with nitrous oxide, which was performed in Boston by G. Wells, the patient almost died during the operation. Wells was ridiculed by his colleagues and soon committed suicide at the age of 33.
To be fair, it should be noted that back in 1842, the very first operation under anesthesia (ether) was performed by the American surgeon Long, but he did not report his work to the medical community.
c) Date of birth of anesthesiology
In 1846, the American chemist Jackson and dentist Morton showed that inhaling ether vapors turns off consciousness and leads to loss of pain sensitivity, and they proposed using ether for tooth extraction.
On October 16, 1846, in a Boston hospital, 20-year-old patient Gilbert Abbott, Harvard University professor John Warren, removed (1) a tumor of the submandibular region under anesthesia. Dentist William Morton narcotized the patient with ether. This day is considered the birth date of modern anesthesiology, and October 16 is celebrated annually as anesthesiologist's day.
d) First anesthesia in Russia
On February 7, 1847, the first operation in Russia under ether anesthesia produced by Moscow University professor F.I. Inozemtsev. A. M. Filamofitsky and N. I. Pirogov also played a major role in the development of anesthesiology in Russia.
N. I. Pirogov used anesthesia on the battlefield, studied various methods of introducing ether (into the trachea, into the blood, into gastrointestinal tract), became the author of rectal anesthesia. He owns the words: “Etheric steam is a truly great remedy, which in a certain respect can give a completely new direction to the development of all surgery” (1847).
(2) DEVELOPMENT OF NARCOSIS
a) Introduction of new substances for inhalation anesthesia
8 1947 Edinburgh University professor J. Simpson used chloroform anesthesia.
In 1895, chlorethyl anesthesia began to be used.
In 1922, ethylene and acetylene appeared.
In 1934, cyclopropane was used for anesthesia, and Waters proposed including a carbon dioxide absorber (sodium lime) in the breathing circuit of the anesthesia apparatus.
In 1956, fluorotane entered into anesthesiological practice, and in 1959, methoxyflurane.
Currently, halothane, isoflurane, and enflurane are widely used for inhalation anesthesia.
b) Discovery of drugs for intravenous anesthesia
In 1902, V.K. Kravkov first used intravenous anesthesia as a one-year-old. In 1926, hedonal was replaced by avertin.
In 1927, perioctone was used for intravenous anesthesia for the first time - the first narcotic barbituric series.
In 1934 sodium thiopental was discovered, a barbiturate that is still widely used in anesthesiology.
In the 60s sodium hydroxybutyrate and ketamine appeared, which are also still used today.
IN last years appeared a large number of new drugs for intravenous anesthesia (brietal, propanidide, diprivan).
c) The occurrence of endotracheal anesthesia
An important achievement in anesthesiology, there was the use of curare-like substances for relaxation (relaxation) of muscles, which is associated with the name of G. Griffiths (1942). During operations, artificial controlled respiration began to be used, for which the main merit belongs to R. McIntosh. He also became the organizer of the first department of anesthesiology at Oxford University in 1937. The creation of devices for artificial ventilation of the lungs and the introduction of muscle relaxants into practice contributed to widespread endotracheal anesthesia - main modern way pain relief during major traumatic operations.
Since 1946, endotracheal anesthesia began to be successfully used in Russia, and already in 1948 a monograph by M. S. Grigoriev and M. N. Anichkov *Intratracheal anesthesia in thoracic surgery* was published.
(3) HISTORY OF LOCAL ANESTHESIA
The discovery by Russian scientist V.K. Anrep in 1879 of the local anesthetic properties of cocaine and the introduction into practice of the less toxic novocaine (A. Eingorn, 1905) served as the beginning of the development of local anesthesia.
A huge contribution to the doctrine of local anesthesia contributed by the Russian surgeon A.V. Vishnevsky (1874-1948).
After opening local anesthetics A. Vir (1899) developed the basics of spinal and epidural anesthesia. In Russia, the method of spinal anesthesia was first widely used by Ya. B. Zeldovich.
Anesthesiology has undergone such rapid development in just over a hundred years.
3. DISCOVERY OF BLOOD GROUPS AND HISTORY OF BLOOD TRANSFUSION
The history of blood transfusion goes back centuries. People in publications appreciated the importance of blood for the vital functions of the body, and the first thoughts about the use of blood for medicinal purposes appeared long before our era. In ancient times, blood was seen as a source vitality and with its help they sought healing from serious illnesses. Significant blood loss resulted in death, which<
has been repeatedly confirmed during wars and natural disasters. All this contributed to the emergence of the idea of moving blood from one organism to another.
The entire history of blood transfusion is characterized by undulating development with rapid ups and downs. It can be divided into three main periods:
Empirical,
Anatomical and physiological,
Scientific.
(1) EMPIRICAL PERIOD
The empirical period in the history of blood transfusion was the longest in duration and the poorest in facts covering the history of the use of blood for therapeutic purposes. There is evidence that even during the ancient Egyptian wars, herds of sheep were chased after troops to use their blood in the treatment of wounded soldiers. In the writings of ancient Greek poets there is information about the use of blood for the purpose of treating patients. Hippocrates wrote about the usefulness of mixing the juices of sick people with the blood of healthy people. He recommended drinking the blood of healthy people to those with epilepsy and the mentally ill. Roman patricians drank the fresh blood of dead gladiators directly in the arenas of the Roman circus for the purpose of rejuvenation.
The first mention of blood transfusion is in the works of Libavius, published in 1615, where he describes the procedure of transfusing blood from person to person by connecting their vessels with silver tubes, but there is no evidence that such a blood transfusion was done to anyone.
(2) ANATOMIC-PHYSIOLOGICAL PERIOD
The beginning of the anatomical and physiological period in the history of blood transfusion is associated with the discovery of the laws of blood circulation by William Harvey in 1628. From that moment on, thanks to a correct understanding of the principles of blood movement in a living organism, the infusion of medicinal solutions and blood transfusion received an anatomical and physiological basis.
In 1666, the outstanding English anatomist and physiologist R. Lower successfully transfused crumbs from one dog to another using silver tubes, which served as an impetus for the use of this Manipulation in humans. R. Lower has the priority of the first experiments on intravenous infusion of medicinal solutions. He injected wine, beer and milk into the veins of the dogs. The good results obtained from blood transfusions and the administration of certain fluids allowed Lower to recommend their use in humans. ".
The first blood transfusion from an animal to a person was carried out in 1667 in France by J. Denis. He transfused blood from a lamb to a mentally ill young man who was dying from repeated bloodletting - then fashionable
method of treatment. The young man recovered. However, at that level of medical development, blood transfusions, naturally, could not be successful and safe. Blood transfusion to the fourth patient resulted in his death. J. Denis was put on trial, and blood transfusions were prohibited. In 1675, the Vatican issued a prohibitory edict, and research on transfusionology was stopped for almost a century. In total, in the 17th century, 20 blood transfusions were performed for patients in France, England, Italy and Germany, but then this method was forgotten for many years.
Attempts to perform blood transfusions were resumed only at the end of the 18th century. And in 1819, the English physiologist and obstetrician J. Blendel performed the first human-to-human blood transfusion and proposed a blood transfusion apparatus, which he used to treat bleeding women in labor. In total, he and his students performed 11 blood transfusions, and the blood for transfusion was taken from the patients’ relatives. Already at that time, Blendel noticed that in some cases, patients experience reactions during blood transfusion, and came to the conclusion that if they occur, the transfusion should be stopped immediately. When infusing blood, Blendel used something similar to a modern biological sample.
Matvey Pekan and S.F. Khotovitsky are considered the pioneers of Russian medical science in the field of transfusiology. At the end of the 18th and beginning of the 19th centuries, they described in detail the technique of blood transfusion and the effect of transfused blood on the patient’s body.
In 1830, the Moscow chemist Herman proposed intravenous infusion of acidified water to treat cholera. In England, the doctor Latta in 1832, during a cholera epidemic, administered an intravenous infusion of a solution of table salt. These events marked the beginning of the use of blood replacement solutions.
(3) SCIENTIFIC PERIOD,
The scientific period in the history of blood transfusion and blood-substituting drugs is associated with the further development of medical science, the emergence of the doctrine of immunity, the emergence of immunohematology, the subject of which was the antigenic structure of human blood, and its significance in physiology and clinical practice.
The most important events of this period:
1901 - the discovery by the Viennese bacteriologist Karl Landsteiner of three human blood groups (A, B, C). He divided all people into three groups according to the ability of the serum and red blood cells of their blood to produce the phenomenon of isohemagglutination (adhesion of red blood cells).
1902 - Landsteiner's employees A. Decastello and A. Sturli found people whose blood group differed from the red blood cells and sera of the three groups mentioned. They viewed this group as a deviation from Landsteiner's scheme.
"1907 - Czech scientist J. Jansky proved that the new blood group is independent and all people, according to the immunological properties of blood, are divided not into three, but into four groups, and designated them with Roman numerals (I, II, III and IV).
1910-1915 - discovery of a method for stabilizing blood. In the works of V. A. Yurevich and N. K. Rosengart (1910), Yusten (1914), Levison (1915), Agote (1915), a method was developed for stabilizing blood with sodium citrate, which binds calcium ions and thus prevents blood clotting . This was the most important event in the history of blood transfusion, as it made... It is possible to preserve and store donor blood.
"1919 - V.N. Shamov, N.N. Elansky and I.R. Petrov received the first standard sera to determine blood group and performed the first blood transfusion, taking into account the isohemagglutinating properties of the donor and recipient.
1926 - the world's first Institute of Blood Transfusion (now the Central Institute of Hematology and Blood Transfusion) was created in Moscow. Following this, similar institutes began to open in many cities, blood transfusion stations appeared and a coherent blood service system and donation system were created, ensuring the creation of a blood bank (stock), its thorough medical examination and a guarantee of safety for both the donor and the recipient.
1940 - discovery by K. Landsteier and A. Wiener of the reus factor - the second most important antigenic system, playing an important role in immunohematology. Almost from this moment on, the antigenic composition of human blood began to be intensively studied in all countries. In addition to the already known erythrocyte antigens, platelet antigens were discovered in 1953, leukocyte antigens in 1954, and antigenic differences in blood globulins were discovered in 1956.
In the second half of the 20th century, methods for preserving blood began to be developed, and targeted drugs obtained by fractionating blood and plasma were introduced into practice.
At the same time, intensive work began on the creation of blood substitutes. Preparations have been obtained that are highly effective in their replacement functions and lack antigenic properties. Thanks to the advances in chemical science, it became possible to synthesize compounds that model individual components of plasma and blood cells, and the question arose about creating artificial blood, illasma. With the development of transfusiology, new methods of regulating body functions during surgical interventions, shock, blood loss, and in the postoperative period are being developed and applied in the clinic.
Modern transfusiology has many effective methods for correcting the composition and function of the blood and can influence the functions of various organs and systems of the patient. ,
PHYSIOLOGICAL PERIOD
Asepsis and antiseptics, anesthesiology and the doctrine of blood transfusion became the three pillars on which surgery developed in a new quality. Knowing the essence of pathological processes, surgeons began to correct the impaired functions of various organs. At the same time, the risk of developing fatal complications was significantly reduced. The physiological period of development of surgery has arrived.
At this time, the largest German surgeons B. Langenbeck, f. lived and worked fruitfully. Trendelenburg and A. Wier. The works of the Swiss T. Kocher and Ts. Ru will forever go down in the history of surgery. T. Kocher proposed a hemostatic clamp that is still in use today, and developed a technique for operations on the thyroid gland and many other organs. A number of operations and intestinal anastomoses bear the name Ru. He proposed plasty of the esophagus with the small intestine, a method of surgery for inguinal hernia.
French surgeons are better known in the field of vascular surgery. R. Leriche made a great contribution to the study of diseases of the aorta and arteries (his name is immortalized in the name Leriche syndrome). A. Carrel received the Nobel Prize in 1912 for the development of types of vascular suture, one of which currently exists as the Carrel suture.
In the USA, successes were achieved by a whole galaxy of surgeons, the founder of which was W. Mayo (1819-1911). His sons created the world's largest surgery center. In the USA, surgery from the very beginning was closely connected with the latest achievements of science and technology, therefore it was American surgeons who stood at the origins of cardiac surgery, modern vascular surgery, and transplantology.
A feature of the physiological stage was that surgeons, no longer especially afraid of lethal complications of anesthesia, infectious complications, could afford, on the one hand, to operate calmly and for quite a long time in various areas and cavities of the human body, sometimes performing very complex manipulations, and on the other On the other hand, to use the surgical method not only as a last resort to save the patient, as a last chance, but also as an alternative method of treating diseases that do not directly threaten the patient’s life.
Surgery of the 20th century developed rapidly. So, what is surgery today?
MODERN SURGERY
The modern period of development of surgery at the end of the 20th century can be called a technological triode. This is due to the fact that the progress of surgery in recent years is determined not so much by the development of some anatomical and physiological concepts or improvement
manual surgical abilities, and above all, more advanced technical support and powerful pharmacological support.
What are the most striking achievements of modern surgery?
1. Transplantology
Even when performing the most complex surgical procedures, it is not possible to restore organ function in all cases. And surgery has gone further - the affected organ can be replaced. Currently, hearts, lungs, livers and other organs are successfully transplanted, and kidney transplantation has become quite common. Such operations seemed unthinkable just a few decades ago. And the point here is not about problems with the surgical technique of performing interventions.
Transplantology is a huge industry. In order to transplant an organ, it is necessary to resolve issues of donation, organ conservation, immunological compatibility and immunosuppression. Anesthesiology and resuscitation problems and transfusiology play a special role.
2. Cardiac surgery
Was it possible to imagine before that the heart, the work of which has always been associated with human life, can be artificially stopped, various defects corrected inside it (replace or modify the valve, sutured a ventricular septal defect, create coronary artery bypass grafts to improve the blood supply to the myocardium), and then restore it again? run. Such operations are now performed very widely and with very satisfactory results. But to carry them out, a well-functioning technical support system is required. Instead of the heart, while it is stopped, a heart-lung machine operates, not only dispersing blood, but also oxygenating it. We need special tools, high-quality monitors that monitor the work of the heart and the body as a whole, devices for long-term artificial ventilation lungs and much, much more. All these problems have been fundamentally solved, which allows heart surgeons, like real wizards, to truly work miracles.
3. Vascular surgery and microsurgery
The development of optical technology and the use of special microsurgical instruments made it possible to reconstruct the thinnest blood and lymphatic vessels and suture nerves. It has become possible to reattach (replant) a limb or part of it cut off as a result of an accident with complete restoration of function. The method is also interesting because it allows you to take a section of skin or some organ (intestines, for example) and use it as a plastic material, connecting its vessels with arteries and veins in the required area.
4. Endovideosurgery and other methods of minimally invasive surgery Using the appropriate technology, it is possible to perform quite complex operations without performing traditional surgical incisions under the control of a video camera. This way you can examine cavities and organs from the inside, remove polyps, stones, and sometimes entire organs (appendix, gall bladder and others). Without a large incision, through special narrow catheters, it is possible to restore its patency from the inside of the vessel (endovascular surgery). Under ultrasound guidance, closed drainage of cysts, abscesses and cavities can be performed. The use of such methods significantly reduces the morbidity of surgical intervention. Patients practically get up from the operating table healthy, and postoperative rehabilitation is quick and easy.
The most striking, but, of course, not all, achievements of modern surgery are listed here. In addition, the pace of development of surgery is very high - what only yesterday seemed new and was published only in special surgical journals, today becomes routine, everyday work. Surgery is constantly improving, and now 21st century surgery is ahead!
“...It would be a mistake to consider the history of surgery, and the history of medicine in general, as a chaotic change of various “finds” - methods and methods, theories, teachings, scientific directions, caused either by chance or by the whim of fate.” M.B.Mirsky.
INTRODUCTION
The history of surgery is an interesting section that deserves special attention. It is simply impossible to begin the study of surgery without at least a brief overview of its history. Studying most sections of general surgery, we will have to return to historical events to understand the current state of the problem. It is impossible to study the issues of blood transfusion, anesthesia, asepsis, etc., without imagining how surgeons solved these issues in different periods of history.
The history of surgery is full of events that were often tragic in nature; many outstanding personalities determined the development of this branch of medicine through their activities.
Main periods of development of surgery
The historical path of surgery is inextricably linked with the history of human development. Therefore, events occurring in human society invariably affected the development of surgery. If there was a heyday, then the rapid development of surgery was sure to be noted; if an era of decline began, then surgery slowed down its development.
The development of surgery can be represented in the form of a spiral, each turn of which is associated with certain major achievements of mankind and the activities of great scientists.
Surgery has traveled a path equal to the development of mankind, but as a science it was formed only in the 19th century. Its historical path is longer than other branches of medicine.
There are four periods in the development of surgery:
1. Empirical period - from the 6th -7th millennium BC to the end of the 16th century AD.
2. Anatomical period - from the end of the 16th to the end of the 19th century.
3. The period of great discoveries - from the end of the nineteenth to the beginning of the twentieth century.
4. Physiological period - from the beginning of the twentieth century to the present.
EMPIRICAL PERIOD
No one can pinpoint the birth date of surgery. Perhaps it is fair to say that surgery is the same age as humans. It was the day when the creature, perhaps no longer a monkey, but not yet a man, helped its wounded relative and should be considered the starting point of the historical path of surgery. The need to develop surgery was associated with the desire to survive. Ancient people provided themselves and their relatives with basic surgical care.
A person was forced to learn how to stop bleeding, remove foreign bodies, and heal wounds. People in ancient times stopped bleeding by squeezing the wound, raising the limb upward, pouring hot oil, sprinkling ash on the wound and applying a bandage.
Dry moss, leaves, etc. were used as dressing materials. Archaeological excavations of ancient human sites indicate that the first operations were performed at that time: craniotomy, amputation of limbs. Moreover, some patients remained alive for a long time. There is evidence that the Neanderthal knew how to open ulcers and apply sutures to the wound. The accumulation of experience in providing medical care led to the selection of people who did it more skillfully. It should be noted that the primary division of medicine into specialties arose among ancient people. The successful treatment of diseases that have external manifestations (wounds, bruises, fractures, etc.) and require the use of mechanical techniques has prompted people to attempt to treat diseases that do not have external manifestations. Accordingly, such diseases were treated with various herbs, infusions, etc. etc. A division into surgical and internal diseases appeared, which led to the division into surgeons and physicians. This division persisted for millennia, with surgeons relegated to a lower position.
The further development of civilization led to the creation of states. Accordingly, the centers for the development of medicine and surgery in particular were located in the most developed states at that time. The development of writing made it possible to preserve data on the state of medicine in ancient countries. Ancient surviving manuscripts, hieroglyphs, and surviving mummies have provided some insight into the development of surgery since the 6th-7th millennium BC. The main centers of civilization at that time were Ancient Egypt, Ancient India, Ancient China, Ancient Greece, Ancient Rome, and Byzantium.
Ancient Egypt. Ancient Egypt is one of the first ancient states. Therefore, it is he who is the center of the development of medicine in the 6-7 millennia BC. e. Surviving written sources indicate that the level of development of surgery here was quite high. Egyptian doctors knew how to perform craniotomy, amputation of limbs, removal of stones from the bladder, and castration. Moreover, they knew methods of pain relief; for this they used opium and hemp juice. Already at that time, hardening bandages were used for fractures, various natural products were used to treat wounds - honey, oil, wine, and ointments were prepared. In Ancient Egypt, there was a specialization of doctors, and it was brought to the point that one doctor treated one disease. Some are teeth, others are eyes, others are stomach, etc. etc.
Ancient India. The development of medicine has always been determined by the level of culture of the country. Ancient India in the 5-7 millennium BC was the most highly developed country of that period. There were cities there that had no equal in other countries. The very first books appeared in India. Therefore, it is not surprising that a lot of data has reached us about the development of medicine there. The most famous written monuments of Ancient India include the Vedas (Rigveda, Samaveda, Atharveda and Yajurveda). Ancient Indian doctors Charak and Sushruta, commenting on the Vedas, describe in their manuscripts the main features of medicine in Ancient India.
In Ancient India there was a system of training doctors - they were trained in special schools and universities. Patients were treated both at home and in hospitals. Ancient Indian surgeons were familiar with anatomy, in their work they used special sets of instruments (needles, trephines, trocars, syringes, saws, knives, etc., more than 120 instruments), and the instruments were processed - washed in hot water, disinfected by calcination or juices Silk, cotton, and plant fibers were used as dressing materials.
In India, surgeons were able to perform craniotomy, laparotomy, and obstetric operations (caesarean section). Fistulas were treated by cauterization with a hot iron, bleeding was stopped with a pressure bandage and boiling oil. Ancient Indian surgeons can rightfully be considered the founders of plastic surgery; they not only knew how to connect the edges of a wound with sutures, but also plastic surgery. The Indian method of skin grafting has survived to this day. In ancient India, the nose was cut off as punishment for theft and other offenses. To eliminate the defect, surgeons replaced the nose with a pedunculated skin flap cut from the forehead area.
Successful operations are only possible with good pain relief; for this, ancient Indian surgeons used opium and Indian copli juice. Ancient Indian doctors laid the foundations of deontology. Ayurveda sets out the rules of conduct for a doctor and the requirements for his personality.
Ancient China. One of the centers of development of medicine in the ancient world was Ancient China. The Chinese book on the nature of life “Huang Di Nei Ching”, which is an encyclopedia of medical knowledge, has survived to this day. 4 thousand years BC the foundations of original Chinese medicine were laid, many diagnostic and treatment methods are still used today.
The high level of medicine of that period also determined the development of surgery. The most famous Chinese surgeon is Hua Tuo. Using hashish, opium, and Indian hemp preparations for anesthesia, he successfully performed laparotomy and craniotomy. Hua Tuo treated fractures and introduced special physical exercises into practice. Many of the discoveries of Chinese medicine were forgotten and rediscovered in Europe centuries later.
It is interesting that already in ancient times the responsibility of doctors for poor quality treatment was determined. Thus, in the code of King Hammurabi, written in Babylonia, the punishment for a poorly performed operation was determined: “If a doctor performs a serious operation on someone with a bronze knife and causes death to the patient, or if he removes a cataract from someone’s eye and destroys the eye, then he is punished cutting off a hand." It is interesting that in Babylonia and Assyria there was a special class of surgeons and only surgeons were considered doctors. This was a rare exception; for centuries, surgeons were in a humiliated position, they were not classified as doctors.
Doctors of Ancient Egypt, Ancient India, Babylonia and China laid the initial foundations of surgery. However, being under the control of religion, its theoretical foundations were often based on various prejudices and superstitions, which hampered the development of its scientific base.
Information on natural science in those days was extremely primitive or extremely elementary, surgical activity was based only on experience, and not on scientific knowledge. Therefore, the first period of development of surgery is called empirical. Starting from the 6-7 millennium BC. e. it lasted until the 16th century AD. e.
Ancient Greece. Ancient Greece was the first civilized state in Europe. Therefore, it became the cradle of European science and art. The high level of cultural development in Ancient Greece also determined the progress of surgery. The Greek troops had special doctors who knew how to stop bleeding, remove foreign bodies, treat wounds, and perform amputations. “One skilled healer is worth many warriors,” this saying of Homer shows how much the art of doctors was valued at that time. Ancient Greece gave the world many scientists. In the field of medicine, she put forward Hippocrates (460-377 BC), an outstanding scientist who is rightfully considered the founder of modern scientific medicine and surgery.
Hippocrates was born in 460 BC. e. in a family of doctors and lived 84 years. His father was a doctor, his mother a midwife. His first teacher was his father. Hippocrates devoted seven decades to medicine.
Without precise information on anatomy and physiology, Hippocrates empirically laid the foundations of scientific surgery. 59 of his works are known, devoted to many areas of medicine.
Hippocrates applied the achievements of philosophy of that time to medicine. He believed that disease is a manifestation of the life of the body as a result of a change in the material substrate, and not a manifestation of the divine will of an evil spirit. In his opinion, the causes of disease are in the environment, and disease is the body’s reaction to their influence.
Hippocrates put forward the principle - “The doctor should not treat the disease, but the patient.” Being the founder of scientific medicine, he fought against numerous charlatans and contributed to the guild organization of doctors. He owns the first professional charter. Even in the 21st century, the Hippocratic Oath is taken by people who are ready to devote their entire lives to the difficult and wonderful profession of a doctor.
His contribution directly to the development of surgery is invaluable.
Hippocrates wrote the first works on various aspects of surgery, which became a kind of textbook for his followers. He described tetanus and identified sepsis as an independent disease.
Hippocrates paid a lot of attention to the issues of diagnosing diseases and recommended carefully examining and observing patients. conduct examination of urine, feces, and sputum. He described the classic symptom of peritonitis - the “Hippocrates Mask”.
He believed that the cause of purulent infection was air. Therefore, I recommended keeping cleanliness when changing dressings, preparing the surgical field, using boiled rain water, wine, sea water (hypertonic solution). He proposed metal drainage for wound treatment. He owns the basic principle of treating purulent complications - “Uvi pus ibi evacue” (“When you see pus, evacuate”), which is fundamental in the treatment of purulent-inflammatory diseases in our time. The surgical treatment of pleural empyema, developed by Hippocrates, which turned out to be unclaimed by his followers, found application only in the 19th century. He paid a lot of attention to the treatment of dislocations and fractures. Hippocrates used limb immobilization with splints for fractures, and traction to compare fragments, as well as massage and gymnastics. In his treatise “On Joints,” the great scientist described all existing dislocations. The method he proposed for reversing a dislocated shoulder is still used today.
The significance of Hippocrates' works is so great that for many centuries surgical practice was based on his teachings.
Ancient Rome. The fall of Ancient Greece under the pressure of the Roman legions led to the decline of the Greek economy, culture, and science.
The center of development of European civilization moved to Rome.
Ancient Roman doctors became followers of ancient Greek physicians. The most famous doctors in Ancient Rome were Cornelius Celsus and Claudius Galen. Both scientists considered themselves followers of Hippocrates.
Cornelius Celsus (30 BC - 38 AD) lived at the turn of two millennia, two eras of human development. Celsus created the encyclopedic work “Arts” (“Artec”). In the sections on surgery, he described many operations (stone cutting, craniotomy, cataract removal, amputation), treatment of dislocations and fractures, and methods to stop bleeding. In many ways, his work contained the scientific principles of Hippocrates, but two of his achievements made it possible for his name not to be lost in history. Firstly, Celsus described the classical signs of inflammation (calor, dolor, tumor, ruber), they are used by all doctors in the diagnosis and treatment of inflammatory processes, surgical infectious diseases even today. Secondly, he suggested applying a ligature to the vessel to stop bleeding. Modern surgeons perform this surgical technique many times during any operation.
Claudius Galen (130-210 AD) was the master of medical thought for many years. He collected a large amount of material on anatomy and physiology, developed an operation for a defect of the upper jaw (cleft lip), used the method of twisting a bleeding vessel to stop bleeding, proposed new suture materials - silk, thin strings, and studied the formation of callus in fractures. However, his main merit as a scientist is that he introduced an experimental research method into medicine by systematizing data on anatomy and physiology. The experimental direction he created determined the development of surgery for several centuries.
The importance of Hippocrates, Celsus and Galen in the history of surgery lies in the fact that they laid the first scientific foundations of medicine.
Byzantium. The disintegration of the Roman Empire, its destruction by barbarians led to the decline of culture and science. The center for the development of medicine moved to Byzantium. Byzantium, which arose from the ruins of the Roman Empire, was unable to play the same role in the development of culture and science as Ancient Greece and Ancient Rome. Medicine was no exception.
At the very least, Byzantine science was not able to give the world scientists equal to the Greek and Roman ones. Perhaps we can focus on one major Byzantine surgeon. Pavel Eginsky (VII century) developed and performed complex operations using vascular ligation - amputations, removal of aneurysms, tumors. Byzantium's loss of independence led to economic decline and stagnation in science and culture. Europe began to plunge into the darkness of the Middle Ages, losing for a long period its dominant role in the development of human civilization.
Surgery in the era of feudalism
The Middle Ages were characterized by the dominance of the church, the decline of science and culture, which led to a long stagnation in development and surgery.
Arab countries. Against the backdrop of the decline of European states, a center of distinctive culture and science emerged in the countries of the East. At the end of the first and beginning of the second millennium AD, surgery in Arab countries was at a high level. Arab doctors, having adopted the achievements of Greek and Roman scientists, made their invaluable contribution to the development of medicine. Arab medicine produced such surgeons as Abu Said Konein (809-923), Abu Bekr Muhammad (850-923), Abul Qasim (early 11th century). Arab surgeons considered air to be the cause of suppuration of wounds; for the first time they began to use alcohol to fight infection, used hardening protein dressings to treat fractures, and introduced stone crushing into practice. It is believed that gypsum was first used in Arab countries.
Many achievements of Arab doctors were subsequently forgotten, although many scientific works were written in Arabic.
Avicenna (980-1037) The largest representative of Arab medicine was IBN-SINA, in Europe he is known as AVI-CENNA. Ibn Sina was born near Bukhara. Even in his youth, he showed extraordinary abilities that allowed him to become a major scientist. Avicenna was an encyclopedist who studied philosophy, natural science and medicine. He is the author of about 100 scientific papers. The most famous is his major work “The Canon of Medical Art” in 5 volumes, translated into European languages. This book was the main guide for doctors until the 17th century. In it, Avicenna outlined the main issues of theoretical and practical medicine.
Much attention is paid to surgery. Ibn Sina recommended using wine to disinfect wounds, using traction, a plaster cast, and a pressure bandage to stop bleeding to treat fractures. He drew attention to the early detection of tumors and recommended excision of them within healthy tissues with cauterization with a hot iron. Avicenna described operations such as tracheotomy, removal of kidney stones, and was the first to use nerve suture. For pain relief during operations, he used narcotic substances (opium, mandrake and henbane). In terms of his contribution to the development of medicine, Avicenna rightfully stands next to Hippocrates and Galen.
European countries. The dominance of the church in Europe in the Middle Ages sharply slowed down the development of surgery. Scientific research was virtually impossible. Dissection of corpses was considered blasphemy, so anatomy was not studied. Physiology as a science did not yet exist during this period. The Church canonized Galen's views; deviation from them was grounds for accusations of heresy. Without natural scientific foundations, surgery could not develop. In addition, in 1215 it was forbidden to practice surgery on the grounds that the Christian Church was “disgusted by the shedding of blood.” Surgery was separated from medicine and equated to the work of barbers. Despite the negative activities of the church, the development of medicine was an urgent need. Already in the 9th century, hospitals began to be created. The first was opened in Paris in 829. Later, medical institutions were founded in London (1102) and Rome (1204).
An important step was the opening of universities in the late Middle Ages. The first universities were created in the 13th century in
Italy (Padua, Bologna), France (Paris), England (Cambridge, Oxford). All universities were under the control of the church, so it is not surprising that only internal medicine was studied in medical faculties, and surgery was excluded from teaching. The ban on teaching surgery did not exclude its existence. People constantly needed help; it was necessary to stop bleeding, treat wounds, fractures, and reduce dislocations. Therefore, there were people who, without a university education, studied on their own and passed on surgical skills to each other from generation to generation. The volume of surgical operations at that time was small - amputations, stopping bleeding, opening abscesses, dissecting fistulas.
Surgeons were formed in guild associations of barbers, artisans, and artisans. For many years they had to strive to give surgery the status of a medical science and classify surgeons as doctors.
Despite the difficult times and humiliated situation, surgery, although slowly, continued its development. French and Italian surgeons made a significant contribution to the development of surgery. The Frenchman Mondeville proposed applying early sutures to the wound; he was the first to come to the conclusion that general changes in the body depend on the nature of the local process. The Italian surgeon Lucca (1200) developed a method for treating wounds with alcohol. He essentially laid the foundation for general anesthesia by using sponges soaked in substances that, when inhaled, caused loss of consciousness and sensation. Bruno de Langoburgo (1250) was the first to distinguish two types of wound healing - primary and secondary intention (prima, secunda intentie). Italian surgeons Rogerius and Roland developed the intestinal suture technique. In the 14th century surgeon Branco in Italy created a method of nose surgery, which is still used today under the name “Italian”. Despite the achievements of individual surgeons, it should be noted that throughout the entire medieval period, not a single name appeared that could be put on a par with Hippocrates, Celsus, and Galen.
By the 16th century, nascent capitalism inevitably began to destroy the feudal system. The Church was losing its power, and its influence on the development of culture and science weakened. The dark period of the Middle Ages gave way to an era called in world history the Renaissance. This period was characterized by the struggle against religious canons, the flourishing of culture, and the science of art. For two millennia, surgery was based on empirical observations, with the advent of the era
Renaissance medicine began to develop based on the study of the human body. The empirical period of the development of surgery ended in the 16th century, and the anatomical period began.
ANATOMICAL PERIOD
Many doctors of that period were convinced that the development of medicine was possible only with a deep knowledge of anatomy. The scientific foundations of anatomy were laid by Leonardo da Vinci (1452-1519) and A. Vesalius (1514-1564).
A. Vesalius is rightfully considered the founder of modern anatomy. This outstanding anatomist considered knowledge of anatomy to be the basis for surgical activity. During the period of the most brutal Inquisition, he began in Spain to study the structure of the human body by dissecting corpses with an anatomical and topographical description of the location of organs. In his work “De corporis humani fabrica” (1543), based on enormous factual material, Vesalius presented a lot of new, at that time unknown, information about the anatomy of the human body and refuted many provisions of medieval medicine and church dogma. For this progressive work and for the fact that he established the fact of an equal number of ribs in men and women, Vesalius was accused of heresy, excommunicated from the church and sentenced to a penitential journey to Palestine to the “Holy Sepulcher” to atone for sins before God. While making this journey, he died tragically. The works of Vesalius did not disappear without a trace; they gave a huge impetus to the development of surgery. Among the surgeons of that time, one should remember T. Paracelsus and Ambroise
Pare. T. Paracelsus (1493-1541), a Swiss military surgeon, participating in many wars, significantly improved methods of treating wounds using various chemical astringents. Paracelsus was not only a surgeon, but also a chemist, so he widely applied the achievements of chemistry in medicine. They offered various medicinal drinks to improve the general condition of patients, introduced new drugs (concentrated alcohol tinctures, plant extracts, metal compounds). Paracelsus described the structure of the heart septum and studied occupational diseases of miners. When treating, he attached great importance to natural processes, believing that “nature itself heals wounds,” and the doctor’s task is to help nature.
Ambroise Pare (1509 or 1510-1590) was a French military surgeon; he wrote a number of works on anatomy and surgery. A. Pare was engaged in improving methods of treating wounds. His contribution to the study of gunshot wounds is invaluable; he proved that a gunshot wound is a type of bruised wound, and not one poisoned by poisons. This made it possible to abandon the treatment of wounds by pouring boiling oil over them. A. Pare proposed a kind of hemostatic clamp and resurrected the method of stopping bleeding by applying a ligature. This method, proposed by Celsus, was completely forgotten by that time. Ambroise Pare improved the amputation technique, again began to use forgotten operations - tracheotomy, thoracentesis, cleft lip surgery, and developed various orthopedic devices. Being at the same time an obstetrician, Ambroise Pare introduced a new obstetric manipulation - turning the fetus on a leg during pathological childbirth. This method is still used in obstetrics today. The work of Ambroise Paré played a major role in giving surgery the status of a science and recognizing surgeons as full-fledged medical specialists.
The most significant event of the Renaissance for the development of medicine, of course, is the discovery of the laws of blood circulation in 1628 by W. Harvey.
William Harvey (1578-1657) English physician, experimental anatomist, physiologist. Based on the research of A. Vesalius and his followers, he conducted many experiments over 17 years to study the role of the heart and blood vessels. The result of his work was a small book “Exertitatio anatomica de moti cordis et sanguinis in animalibus” (1628). In this revolutionary work, V. Harvey outlined the theory of blood circulation. He established the role of the heart as a kind of pump, proved that arteries and veins represent a single closed circulatory system, identified the systemic and pulmonary circulation, indicated the true meaning of the pulmonary circulation, refuting the prevailing ideas since the time of Galen that blood circulates in the vessels of the lungs. air. The recognition of Harvey's teachings occurred with great difficulties, but it was it that became the cornerstone in the history of medicine and created the prerequisites for the further development of medicine and surgery in particular. The works of V. Harvey laid the foundations of scientific physiology - a science without which it is impossible to imagine modern surgery.
The discovery of V. Harvey was followed by a whole chain of discoveries that were significant for all medicine. First of all, this is the invention of a microscope by A. Leeuwenhoek (1632-1723), which made it possible to create a magnification of up to 270 times. The use of a microscope allowed M. Malpighi (1628-1694) to describe capillary blood circulation and discover blood cells - erythrocytes - in 1663. Subsequently, the French scientist Bichat (1771-1802) described the microscopic structure and identified 21 tissues of the human body. His research laid the foundations of histology. Advances in physiology, chemistry and biology were of great importance for the development of surgery.
Surgery began to develop rapidly and by the beginning of the 18th century the question arose about reforming the system of training surgeons and changing their professional status. In 1719, the Italian surgeon Lafranchi was invited to the Faculty of Medicine of the Sorbonne to lecture on surgery. This event can rightfully be considered the second birth of surgery, since it finally received official recognition as a science, and surgeons received the same rights as doctors. From this time on, the training of certified surgeons begins. Treatment of surgical patients has ceased to be the lot of barbers and bathhouse attendants.
A huge event in the history of surgery was the creation in 1731 in Paris of the first special educational institution for training surgeons - the French Surgical Academy. The first director of the academy was the famous surgeon J. Piti. Opened thanks to the efforts of surgeons Peytroni and Marechal, the academy quickly became a center of surgery. She was engaged not only in training doctors, but also in conducting scientific research. Following this, medical schools for training in surgery and surgical hospitals began to open. The recognition of surgery as a science, giving surgeons the status of a doctor, and the opening of educational and scientific institutions contributed to the rapid development of surgery. The number and scope of work performed have increased surgical interventions, their technique, based on an excellent knowledge of anatomy, improved. Despite the favorable environment for its development, in the late 18th and early 19th centuries surgery faced new obstacles. Three main problems stood in her way:
- Ignorance of infection control methods and lack of ways to prevent wound infection during surgery.
- Inability to deal with pain during.
- Inability to fully combat bleeding and lack of methods to compensate for blood loss.
In order to somehow overcome these problems, surgeons of that time focused all their efforts on improving surgical techniques in order to reduce the time of surgical intervention. A “technical” direction emerged, which produced unsurpassed examples of operational technology. It is difficult even for an experienced modern surgeon to imagine how the French surgeon, Napoleon’s personal physician D. Larrey, personally performed 200 amputations of limbs in one night after the Battle of Borodino.
Nikolai Ivanovich Pirogov (1810-1881) performed removal of the mammary gland or a high section of the bladder in 2 minutes, and osteoplastic amputation of the foot in 8 minutes.
However, the rapid development of the “technical” direction has not led to a significant improvement in treatment results. Patients often died from postoperative shock, infection, and unrecovered blood loss. Further development of surgery became possible only after overcoming the above problems. In principle, they were resolved at the end of the 19th and beginning of the 20th centuries. A period of great discoveries has begun.
PERIOD OF GREAT DISCOVERIES
The late 19th and early 20th centuries were truly a period of great discoveries. Currently, it is impossible to imagine modern surgery without the fundamental achievements of this period. These include:
1. discovery of asepsis and antiseptics.
2. discovery of pain relief methods.
3. discovery of blood groups and the possibility of blood transfusions
Thanks to the work of J. Lister, I Semmelweis, E. Bergman and K. Shimelbusch, the doctrine of asepsis and antiseptics was created, methods of prevention and control of infection were developed.
Chemist C. Jackson and dentist W. T. Morton used ether anesthesia in 1846 and laid the foundation for the development of anesthesiology.
The discovery of blood groups by L. Landsteiner (1901) and J. Jansky (1907) made it possible to develop methods of blood transfusion and replenishment of blood loss.
It was these three discoveries that formed the basis for the creation of modern surgery.
The ability to prevent the development and destruction of a surgical infection, adequate pain relief during surgery, and the possibility of replenishing blood loss made it possible to perform operations on the organs of the chest, abdominal cavities, brain and spinal cord. At the end of the 19th century, abdominal surgery began to develop.
Its founder is considered to be the Viennese surgeon Billroth, who performed gastric resection for the first time in 1881. At the end of the 19th century, mass surgical treatment of a number of diseases began: hernias, hemorrhoids, varicose veins. Biliary tract surgery began to develop. Many operations that are widely used today were developed during this period.
It is noteworthy that from this period emergency surgery began to develop rapidly. Surgeons began to successfully treat diseases such as intestinal obstruction, acute appendicitis, perforated ulcers, etc. etc. The first appendectomy was performed in 1884 by Kronlein in Germany and Mohamed in England. Before this, surgeons only opened appendiceal abscesses. The widespread introduction of asepsis gave impetus to the development of urology, orthopedics and traumatology. Until this time, only a few operations were performed on bones and joints: arthrotomies, removal of sequestration, resection of joints in case of damage. Oncology and neurosurgery also began to develop.
At the beginning of the 20th century, surgery, rapidly developing, entered the next period of its history - physiological.
PHYSIOLOGICAL PERIOD
The physiological period covers the entire 20th century. Within one century, surgery made leaps beyond anything achieved in the previous two millennia. Asepsis and antisepsis, anesthesiology and the doctrine of blood transfusion, which formed the foundation of surgery, allowed it to develop in a new quality.
A feature of the physiological period is that surgeons, knowing the essence of pathological processes, were able to correct dysfunctions of various organs. Surgeons in the 20th century were able to safely and for a long time operate in various areas and cavities of the human body, especially without fear of lethal complications of anesthesia, infectious complications, and hemodynamic disorders. This made it possible to perform complex operations and apply surgical treatment methods for diseases that were not directly life-threatening for patients and were previously the domain of therapists.
In the twentieth century, abdominal, thoracic, cardiovascular, plastic surgery, transplantology, neurosurgery, etc. rapidly developed.
Conclusion. The story of surgery is not over. Currently, its rapid development continues based on modern achievements of fundamental sciences and technology. In the last decades of the twentieth century, surgery entered a new period of its development. It can be called technological. This definition of the modern period of development of surgery is due to the fact that its successes are largely due to the improvement of technical and pharmacological support for surgeons. The introduction of new technologies into medicine has led to the emergence of new areas - endovideosurgery, endovascular surgery, microvascular surgery.
Details
Empirical, anatomical and morphological, Great discoveries, physiological periods.
The development of surgery is a classic spiral.
- Empirical period – 6-7 thousand BC. – late 16th century
- Anatomical and physiological – end 16 – end 19
- Great discoveries – end of 19 - beginning of 20
- Physiological – 20th century
- Modern - late 20's - our time
The most important - Great discoveries, when Asepsis/Antiseptics, Anesthesiology/Transfusiology appeared
Empirical period:
The first finds indicating some kind of surgery are 6-7 thousand years BC. Skulls with healed post-trepanation wounds, severe injuries (multiple fractures of the ribs, femur - such a Neanderthal skeleton was found)). Bandages with moss and leaves (based on rock paintings), etc.
Surgical school of ancient India, many clinical cases are described. pictures of diseases (smallpox, tuberculosis, erysipelas, anthrax, etc.), more than 120 instruments were in use. They performed cesarean sections, amputations, stone sections, etc. Separately, Indian rhinoplasty (replacement of the nose with a pedicled flap from the forehead) is popular because The punishment for theft was cutting off the nose.
Ancient Egypt – Imhotep papyrus (3000 BC, the technique of various operations is described). The walls of the tombs depict operations on limbs. Hippocrates (460-337 AD), the last of the Asclepiads, in his honor is the oath that all doctors take. He distinguished between clean and purulent wounds, considered air to be the cause of suppuration and demanded cleanliness when dressing dressings, used boiled water and wine, used splints in the treatment of fractures, and traction. Came up with a way to reduce a dislocated shoulder. Performed drainage pleural cavity, to stop bleeding, he recommended placing the limb in an elevated position. Author of the first works on various aspects of surgery.
Ancient Rome - Cornelius Celsus (30 BC -38 AD) and Claudius Galen (130-210). Celsus is the author of another treatise describing surgical techniques. He also came up with the idea of ligating a bleeding vessel (the method was forgotten and revived only by Ambroise Pare) and described the classic signs of inflammation (calor rubor tumor dolor) Avicenna (980-1037) author of 100 scientific works, the main one in medicine - “The Canon of Medical Art” (the main guide for doctors in the next few centuries). In the Middle Ages, the development of surgery was very slow. Galen's views on the primacy of the soul were canonized, the power of the church, the ban on “shedding blood” during operations and autopsies. Universities and medical faculties are opening, but surgery is not taught. Surgeons are barbers, artisans, farriers, executioners. But nevertheless - Lucca, 13th century, used sponges soaked in narcotic substances for pain relief (inhalation loss of consciousness and analgesia), Bruno de Langoburgo, 13th century, introduced the term healing by primary intention and secondary intention. The main thing is “Do no harm,” “Medicus curat, deus sanat.” The doctor cares, God heals. The stagnation ended with the beginning of the Renaissance (rejection of religious dogmas, lifting of prohibitions)
Anatomical-Morphological period:
Andreas Vesalius (1514 -1564), at 23 years old - professor. "De corpori humani fabrica" based on autopsies. For this work he was expelled from the University of Padua to the Holy Land to atone for his sins, and died on the way back.
Paracelsus (Theophrastus Bombastus von Hohenheim, 1493-1541) and Ambroise Pare (1517-1590). Paracelsus significantly improved many methods of treatment, using decoctions, astringents, and metal preparations.
Ambroise Paré - Invented the hemostatic clamp, revived the ligation of blood vessels according to Celsus, was against treating wounds with boiling oil (it was actively used before). He examined the gunshot wounds and showed that they were bruise wounds. He introduced an obstetric manipulation - turning on the leg.
W. Harvey discovered the laws of blood circulation in 1628 (they recognized then that in the vessels of the small circle there is blood, not air, but they recognized it with difficulty and reluctantly)
Leeuwenhoek (1632 -1723) invented the Microscope, Malpighi (1628-1694) saw red blood cells in the blood. First blood transfusion to a human Jean Denis 1667 (from a lamb)
In 1731, a surgical academy was opened in Paris; surgeons are now also doctors.
Excellent operating techniques, knowledge of anatomy and lack of anesthesia - D. Larre (Napoleon's physician) after the Battle of Borodino personally performed 200 amputations in one day. N.I. Pirogov opened the bladder and removed the mammary gland in 2 minutes. A Amputated the foot osteoplastically in 8 minutes. In the 1860s, the mortality rate from operations in the Sheremetyev Hospital (the best indicator then) was 16%. Problems - there is no method of fighting infection, no anesthesia, no blood transfusion.
Great discoveries:
Solving these 3 questions. Antiseptics and asepsis - development is divided into 5 periods: empirical, pre-Lister in the 19th century, Lister, the emergence of asepsis, modern.
Empirical - Hippocrates (purely on bandages), the Laws of Moses (it was forbidden to touch the wound with your hands), etc.
Dolisterovskaya - I. Semmelweis in 1847 (gynecologist) began to wash his hands and forced everyone to do it before examinations - as a result, a decrease in postpartum mortality from 18.3% to 1.3% He was not supported, he was ridiculed, he ended up in a mental hospital. He died of sepsis as a result of the development of felon after a finger wound during surgery. N.I. Pirogov. 1844: “The time is not far from us when a careful study of traumatic and hospital miasmas will give surgery a different direction.” Pirogov respected the works of Semmelweis and actively used these methods himself.
Lister's antiseptics - after 1863 (Pasteur's discovery) suggested that the cause of infection and suppuration is microorganisms. They come from the surgeon's hands and from the air. I started using carbolic acid. They sprayed it in the operating room, the surgeons washed her hands, put bandages with it on the wound - a decrease in the number of infectious complications, but very good. Lots of side effects. Effects (damage to surgeons’ skin, spiritual tract, patient’s skin). Not everyone supported it - carbolic acid was too poisonous.
The emergence of asepsis - Bergman and Schimmelbusch. (Schimmelbusch bix, 72 hours sterility). 1890 Recognition of asepsis ideas. The role of antiseptics began to decline, some began to abandon it completely. Asepsis developed, Esmarch in 1881 proposed sterilization with flowing steam, in Russia L.L. Heidenreich demonstrated the method of sterilization in an autoclave.
Modern Asepsis and Antiseptics - realized that it is bad to abandon antiseptics and replace it with asepsis, it is necessary to combine them. In 1857 Postoperat. Mortality in Russia is 25%, in 1895 – 2.1% (The value of these methods).
Problem of Pain Relief – 1800 shows the narcotic effect of nitrous oxide. 1818 g – ether. The first use of anesthesia was in 1842 by the American surgeon Long (did not tell anyone). in 1844, dentist G. Wells, while extracting a tooth to himself. Then, during a public demonstration, he almost lost a patient and was ridiculed; at the age of 33 he committed suicide. In 1846, chemist Jackson and dentist Morton proposed using ether in dental extraction (again). On October 16, 1846, in Boston, John Warren removed a submandibular tumor from a 20-year-old patient, Gilbert Abbott, under ether anesthesia - the birthday of anesthesiology.
In Russia, the first operation was performed by Inozemtsev on February 7, 1847. This method began to be actively used by pirogues - by September 1847 he had already performed about 200 operations under ether anesthesia. In 1847 - chloroform, 1895 - chloroethyl, 1922 - ethylene and acetylene, 1934 - cyclopropane and a new idea - soda lime (carbon dioxide absorber in the apparatus circuit), 1956 - halothane, 1959 - methoxyflurane. Then there are many different ones (now they use sevoflurane, isoflurane). Intravenous anesthesia - 1902 - hedonal. 1927 - pernoctin (1st barbiturate), 1934 - sodium thiopental (still used), in the 1960s - sodium oxybate and ketamine (also used) Recently - a bunch of new ones (methohexital, propofol, etc.) Local anesthesia since 1879 Russian scientist K. Anrep (cocaine), in 1905 A. Eingoron - procaine. In 1899, A. Beer developed SMA and epidural anesthesia.
The issue of blood transfusions. 3 periods – empirical, anatomical-physiological, scientific.
Empirical: (blood was mainly used internally), The first description of transfusion was in 1615. (it is unclear whether they did it) Anatomical and physiological - 1628. The laws of blood circulation were discovered (W. Harvey), in 1666 R. Lower blood transfusion from dog to dog. J. Denis - 1667 the first transfusion to a person from a lamb. (Successfully)!. The second and third were also successful (!lucky!). Only the fourth patient died. J. Denis was tried, and the Vatican issued a ban on transfusions in 1875 (in the 17th century, about 20 transfusions were carried out in Europe). Long stagnation. The next transfusions were only in 1819. J. Blendel, the first transfusion from person to person). Sometimes it helped, sometimes it didn't. Blood was taken from relatives mostly (more often it helped). They didn’t know why.
Scientific period.
Scientific period - 1901 discovery of 3 blood groups, 1907 - discovery of 4 groups. 1915 – citrate for blood stabilization and storage. 1919 – Shamov, Elansky, Negrov – sera for determining groups, 1926 – the world’s first blood transfusion institute in Moscow. 1940 – K. Landsteiner and A. Wiener – the Rh factor is discovered.
In the second half of the 20th century - new blood preservatives and blood substitutes.
Physiological period.
3 problems have been solved, a lot of new surgical techniques have been developed, transplantology has been developed, a vascular suture (Carrel) has been invented, etc. Very rapid growth.
Modern surgery.
Transplantology, Cardiac surgery, Endovideosurgery, endovascular surgery, microsurgery, da Vinci, etc.
In the centuries-old history of the development of surgery, four main periods can be distinguished. The first period was before the discovery of anesthesia, antisepsis and asepsis, i.e. until the second half of the 19th century. In ancient times, surgery was primarily manual. Then they corrected external defects with their hands or the simplest instruments and provided assistance for injuries.
Surgery achieved particular success in Ancient Greece and Ancient Rome. Doctors enjoyed great respect from the population, as evidenced by the lines of Homer: “One skilled healer is worth many warriors.” Hippocrates (460-377 BC), who opened a hospital on the island of Kos, prescribed massage and physical therapy as remedies. He treated broken bones, dislocations and wounds. He described tetanus. Among many purulent diseases, Hippocrates identified a common purulent infection. Hippocrates also created the first code of medical honor, called the “Hippocratic Oath,” which still underlies the oath of a doctor who receives the right to treat patients.
After the fall of Ancient Greece, Rome became the center of scientific development. The works of Celsus and Galen occupied a special place in Roman medicine of that time. Celsus (30 BC-38 AD) left numerous treatises testifying to the achievements of surgery of that time (cataract removal, craniotomy, stone cutting, treatment of fractures and dislocations). They were offered ways to stop bleeding - using tamponade and applying ligatures to the bleeding vessel.
The works of the outstanding scientist and physician Galen (130-210) remained fundamental for more than 1000 years after his death. He devoted a lot of time to the study of anatomy, described many surgical techniques that have not yet lost their significance (twisting a bleeding vessel, suturing with silk threads), developed a surgical technique for cleft lip, etc.
The works of Ibn Sina (980-1037), known in Europe under the name Avicenna, were of great importance. In his book “The Canon of Medical Science” many chapters are devoted to surgery - recognition of tumors, suturing of nerves, tracheotomy, treatment of wounds and burns, etc.
In European countries, the beginning of significant progress in science dates back to the Renaissance (XY1st century). The works of Vesalius and Harvey on anatomy and physiology played a special role. The most prominent representative of the surgical direction of medicine of that time was the French surgeon Ambroise Paré (1517-1590). He created a new doctrine about gunshot wounds: he proved that these were a special type of bruised wounds, and not poisoned with poisons, as was believed at that time. The second period (second half of the 19th century) is associated with the discovery and introduction into practice of anesthesia, antisepsis and asepsis. The first public demonstration of the use of ether anesthesia was held on October 16, 1846. dentist M. Morton in Boston (USA). Already in December 1846, Liston operated under ether anesthesia in England and N.I. Pirogov in Russia.
The pioneers of the use of local anesthesia were our country’s surgeons V.K. Anrep (1880) and A.I. Lukashevich (1886). N.M.’s clinic played a big role in this. Monastyrsky (1847-1880), where abdominal operations were performed for the first time under local anesthesia.
A new era in the development of local anesthesia began in 1905, when the German chemist Eingorn synthesized novocaine, which quickly became widespread as a local anesthetic. The development of local anesthesia is associated with the name of A.V. Vishnevsky (1874-1948). The method of infiltration anesthesia proposed by him has received the most widespread use in all areas of surgery.
The greatest event of the 19th century was the work of L. Pasteur, who discovered the microcosm and laid the foundation for microbiology. D. Lister, comparing his observations of the course of the wound process, came to the conclusion that suppuration is associated with the penetration of microorganisms into the wound and, in order to prevent this complication, they must be destroyed. To do this, he proposed using a solution of carbolic acid. This is how the antiseptic method in surgery was born, and then the aseptic method, which was based on the principle: everything that touches the wound must be sterile. The introduction of asepsis and anesthesia created conditions for the rapid development of abdominal surgery.
The third period (the beginning of the 20th century) can be called physiological-experimental due to the decisive influence on the development of surgery of the experimental physiological studies of Sechenov and Pavlov. They created conditions for the emergence of new surgical directions and the development of anesthesiology and transfusiology. urology , neurosurgery, etc.
The fourth period (modern) - the period of restorative and reconstructive surgery is characterized by an in-depth scientific search for new ideas in the development of diagnostic and treatment methods, based on widespread implementation in Scientific research and the practice of surgery, microsurgery, new devices and equipment, physical, pharmacological and other methods of influencing the human body for various diseases, as well as organ and tissue transplants, the use of artificial organs and tissues.
The conventionality of such periodization is obvious because in the history of surgery, these periods were layered one on top of the other; there were not only periods of prosperity, but also a slowdown in the pace of movement, stagnation and even regression, when much that had already been achieved was lost in order to be revived and gain recognition and dissemination.
In Russia, surgery began to develop much later than in Western countries. Until the 18th century, there were no surgeons in Russia; surgical assistance was provided by barbers and healers, who only performed cauterizations, opening abscesses, “letting blood” and others. The beginning of organized training for chiropractors involved in surgery is considered to be 1654, when Tsar Alexei Mikhailovich issued a decree on the creation of chiropractic schools.
In 1706, Peter 1 founded the first state medical institution - a hospital in Moscow across the Yauza River - now the hospital named after N.V. Burdenko, which simultaneously became the first higher medical-surgical school.
By decree of Peter 1, a military hospital was opened in St. Petersburg in 1716, and in 1719 the Admiralty Hospital, which became a school for training Russian doctors in surgery. During the 18th century, the Medical and Surgical Academy was opened in St. Petersburg and on the initiative of M.V. Lomonosov - Moscow University with the Faculty of Medicine. At the Faculty of Medicine in Moscow, a group of anatomists arose, headed by the famous scientist P.A. Zagorsky (1764 – 1646). He wrote the first Russian textbook on anatomy. A group of scientist-surgeons was formed under the leadership of E.O. Mukhin, a former paramedic in Suvorov’s troops, who wrote the book “Description of Surgical Operations.” We owe him the nomination of N.I. Pirogov. The St. Petersburg Medical-Surgical Academy formed a team of surgeons headed by I.F. Bush (1771–1843), who created the first Russian manual on surgery. His student Professor I.V. Buyalsky created an anatomical and surgical atlas.
ROLE OF N.I. PIROGOV IN THE DEVELOPMENT OF RUSSIAN SURGERY.
The great 19th century physician Nikolai Ivanovich Pirogov is deservedly considered the founder of Russian surgery. He was born in 1810 in Moscow
Graduated from the Faculty of Medicine of Moscow University. Then he undergoes special training for professorship at Yuryev University. At the age of 26, he took the chair of surgery and soon published the work “Surgical Anatomy of the Arterial Trunks and Fascia.” It was the first scientific study of anatomy subordinated to the tasks of surgery.
Previously, surgeons turned to anatomy along the way. N.I. Pirogov posed the question differently: “Surgery is not possible without accurate and complete knowledge of anatomy.” If an anatomist studies anatomy by systems, then the surgeon must know the layer-by-layer anatomy of the organ where the operation is performed and the organ on which the operation is performed. This innovation by Pirogov led to the emergence of a new science - topographic anatomy. This science is the basis of modern surgery, but at that time it was not sufficiently developed. N.I. Pirogov studied the topographic anatomy of all areas of the human body. To do this, he proposed and developed in detail methods for freezing corpses and cutting them up. The positions of various organs and their relationship with surrounding tissues were studied on the cuts.
The result of many years of activity of N.I. Pirogov became a four-volume atlas of anatomy (1852) - a fundamental work to which all those involved in topographic anatomy and operative surgery turn. N.I. Pirogov developed the technique of many operations and proved the possibility of performing osteoplastic surgical interventions.
N.I. Pirogov did not ignore the fact that the operation itself, as a tissue injury, is associated with very acute pain. He was the first to understand the message of the dentist Morton and the chemist Jackson (1846) about ether anesthesia and developed the theory of anesthesia with ether. He conducted a series of experiments on animals, tested the effect of ether on himself, and then for the first time in the world, ether anesthesia was widely used during operations during the war in the Caucasus in 1847.
In order to prevent suppuration of wounds, Pirogov organized a special operating regime for the surgical department. He demanded that rooms for patients be well ventilated, that doctors monitor the cleanliness of their hands and instruments, and introduced special kettles from which wounds were washed with running boiled water. As microbiology developed, Pirogov began to point out that “spores”, “fungi”, “embryos”, as the first researchers called pathogenic bacteria, are the same “miasmas” mentioned by Hippocrates, the origin of which has been discussed and debated for centuries in medicine.
D. Lister (1867) was the first to prove the causes of purulent infection of wounds and showed that if appropriate measures are taken against bacteria, then suppuration may not occur. However, Pirogov foresaw all this before Lister. He came up with the idea that the “miasmas” that complicate the course of wounds are living beings that can and should be fought. Taking all this into account, Pirogov should be recognized as the founder of the science of surgical infection in Russia.
N.I. Pirogov is rightfully considered the founder of military field surgery. He introduced into practice the concept: war is a “traumatic epidemic.” In the book “The Beginnings of General Military Field Surgery,” in addition to measures to prevent and treat wounds, N.I. Pirogov proposed paying special attention to triage of the wounded “at the theater of military operations.” For the first time in Russia and the world, they proposed plaster casts for the treatment of fractures.
Brilliant scientist and organizer N.I. Pirogov, not only in Russia, but also abroad, is deservedly considered the founder of such important branches of surgery as surgical anatomy and military field surgery. He was an erudite scientist who wrote works in all branches of surgery (anesthesia, shock, wound healing, treatment of fractures etc.) Pirogov’s teachings and works served as the basis for the training of subsequent generations of Russian surgeons.
A domestic school of Russian surgery was founded, freed from the influence of Western schools.
In the post-Pirogov period (80s of the 19th century), not only Moscow and St. Petersburg surgical schools appeared, but peripheral ones, and zemstvo surgery also developed.
N.V. Sklifosovsky (1836-1904) is an outstanding surgeon, scientist and public figure who developed operations for goiter, cerebral hernias, etc. He is the creator of the first Russian surgical journals and the founder of the Pirogov congresses.
S.I. Spasokukotsky (1870-1943), the founder of a large surgical school, enriched this branch of medicine with fundamental research on the surgery of purulent diseases of the lungs and pleura. He developed various aspects of blood transfusion. The method of treating the surgeon’s hands according to Spasokukotsky-Kochergin has not lost its importance today.
N.N. Burdenko (1878-1946) was the first president of the USSR Academy of Sciences. His works on military field surgery and shock, wound treatment, neurosurgery, etc. played a major role in the progress of surgery. Occupying the post of chief surgeon of the Soviet army, he developed a doctrine of providing assistance to the wounded at all stages of treatment during the Great Patriotic War, which made it possible to return 73% of the wounded to duty.
A.V. Vishnevsky (1874-1948) devoted all his research to the problem of the trophic function of the nervous system. He developed novocaine blockades, which are part of a complex of therapeutic measures for many diseases, and proposed an oil-balsamic dressing, which played an important role during the Second World War in the treatment of wounds. He was a passionate promoter of local anesthesia. He created a special type of infiltration anesthesia, which is still used today for the most serious operations.
N.P. Petrov (1876-1962) creator of the modern system of fighting cancer.
Thoracic and vascular surgery has developed rapidly in the last decade. A student of S.I. Spasokukotsky, Academician A.N. Bakulev, was a pioneer of cardiovascular surgery in our country and made a huge contribution to the development of this branch of medicine.
Many complex operations, including heart surgery, and heart transplantation are not possible without the use of artificial circulation, which was proposed in 1927. Soviet surgeon S.s. Bryukhonenko. He designed and used in the experiment a special apparatus - an auto-projector.
Modern surgery continues to develop rapidly. Transplantology, reconstructive surgery, and microsurgery continue to improve.
Main stages in the development of surgery
Surgery is one of the most ancient specialties in the history of medicine.
In the states of the Ancient East (Egypt, India, China, Mesopotamia), traditional medicine remained the basis for a long time; healing. There were rudiments of surgical knowledge that were used in peaceful life and on the battlefield: they removed arrows, bandaged wounds, stopped bleeding, using pain-reducing agents during operations: opium, henbane, mandrake. During excavations on the territory of these states, many surgical instruments were discovered.
Doctors of Ancient Greece and Ancient Rome, such as Asclepius (Aesculapius) had a great influence on the development of surgery! Asclepiades (128 - 56 BC). Celsus (1st century BC) wrote a major work on surgery, where he was the first to list the signs of inflammation: rubor (inflammation), tumor (swelling), caler (fever), dolor (pain), and suggested the use of ligatures for ligating blood vessels during surgery, described methods of amputation and reduction of dislocations, and developed the doctrine of hernias. Hippocrates (460 -370 BC) wrote several works on surgery. He was the first to describe the features of wound healing, signs of phlegmon and sepsis, symptoms of tetanus, and developed the operation of rib resection for purulent pleurisy. Claudius Galen (131 - 201) proposed the use of silk for suturing wounds.
Surgery received significant development in the Arab caliphates (VII-XIII centuries). Outstanding doctors Ar-Razi (Razes) (865 - 920) and Ibn Sina (Avicenna) (980-1037) lived and worked in Bukhara, Khorezm, Merv, Samarkand, Damascus, Baghdad, Cairo.
Medicine of the Middle Ages (XII-XIII centuries) was under the yoke of church ideology. The centers of medicine during this period were the Universities of Salerno, Bologna, Paris (Sorbonne), Padua, Oxford, Prague, and Vienna. However, the charters of all universities were controlled by the church. At that time, the most developed area of medicine, due to the constantly ongoing wars, was surgery, which was practiced not by doctors, but by chiropractors and barbers. Surgeons were not accepted into the so-called community of medical scientists; they were considered ordinary performers. This situation could not last long. Experience and observations on the battlefield created the prerequisites for the active development of surgery.
During the Renaissance (XV-XVI centuries) a galaxy of outstanding doctors and natural scientists appeared who made a significant contribution to the development of anatomy, physiology and surgery: Paracelsus (Theofast von Hohenheim) (1493-1541), Leonardo da Vinci (1452-1519), V. Harvey (1578-1657). The outstanding anatomist A. Vesalius (1514-1564) was handed over to the Inquisition only for claiming that a man has 12 pairs of ribs, and not 11 (one rib should have been used to create Eve).
In France, where surgery was stubbornly not recognized as a field of medicine, surgeons were the first to achieve equality. It was here that the first schools of surgeons opened, and in the middle of the 18th century. - higher educational institution - surgical academy. A prominent representative of the French school of surgeons was the founder of Scientific Surgery of the Modern Age, A. Paré (1517-1590).
In the 19th century new demands appeared on medical science, but led to new discoveries in the field of surgery. In 1800, the English chemist G. Devi described the phenomena of intoxication and convulsive laughter when inhaling nitrous oxide, calling it laughing gas. In 1844, nitrous oxide was used as an anesthetic in dental practice. In 1847, the Scottish surgeon and obstetrician J. Simeon used chloroform for pain relief, and in 1905, the German physician A. Eingorn synthesized novocaine.
The main problem of surgery in the second half of the 19th century. suppuration of wounds appeared. The Hungarian obstetrician I. Semmelweis (1818 - 1865) began to use chlorine water as a disinfectant in 1847. The English surgeon J. Lister (1827 - 1912) proved that the cause of suppuration is living microorganisms entering the wound from the air, and proposed the use of carbolic acid (phenol) to combat infectious agents. Thus, in 1865 he introduced antisepsis and asepsis into surgical practice.
In 1857, the French scientist L. Pasteur (1822-1895) discovered the nature of fermentation. In 1864, the American dentist W. Morton used ether for pain relief during tooth extraction. The German surgeon F. Esmarch (1823-1908), one of the pioneers of asepsis and antisepsis, in 1873 proposed the use of a hemostatic tourniquet, an elastic bandage and an anesthesia mask. The instruments of the Swiss surgeons T. Kocher (1841 - 1917) and J. Pean (1830 - 1898) made it possible to operate in a “dry” wound. In 1895, the German physicist W. K. Roentgen (1845 - 1923) discovered rays capable of penetrating opaque bodies.
The discovery of blood groups (L. Landsteiner, 1900; Ya. Yamsky, 1907) gave surgeons an effective means of combating acute blood loss. French physiologist C. Bernard (1813-1873) created experimental medicine.
In Russia, surgery began to develop much later than in Western European countries. Until the 18th century In Russia, surgical care was almost completely absent. Manipulations such as bloodletting, cauterization, and opening abscesses were performed by healers and barbers.
Under Peter I in 1725, the St. Petersburg Academy of Sciences, military land and admiralty hospitals were opened. Schools began to be created on the basis of hospitals, which in 1786 were transformed into medical-surgical schools. In 1798, medical-surgical academies were organized in St. Petersburg and Moscow. In 1755, on the initiative of M.V. Lomonosov, Moscow University was opened, and in 1764, the Faculty of Medicine was opened under it.
First half of the 19th century gave the world such wonderful Russian scientists as P.A. Zagorsky, I.F. Bush, I.V. Buyalsky, E.O. Mukhin, F.I. Inozemtsev, I.N. Sechenov, I.P. Pavlov, N.E. Vvedensky, V.V. Pashugin, I.I. Mechnikov, S.N. Vinogradsky, N.F. Gamaleya, L. I. Lukashevich, L. O. Heidenreich, M. S. Subbotin, M. Y. Preobrazhensky, A. A. Bobrov, P. I. Dyakonov and others.
The great surgeon and anatomist N.I. Pirogov (1810-1881) is rightfully considered the founder of Russian surgery. Using methods of freezing corpses and cutting them, he studied in detail all areas of the human body and wrote a four-volume atlas on topographic anatomy, which for a long time was a reference book for surgeons. N.I. Pirogov headed the department of surgery at the University of Dorpat, the department of hospital surgery and pathological anatomy at the St. Petersburg Medical-Surgical Academy. N.I. Pirogov, before L. Pasteur, suggested the presence of microorganisms in a purulent wound, and for this purpose allocated a department in his clinic for “those infected with hospital miasmas.” It was N.I. Pirogov who was the first in the world to use ether anesthesia during the Caucasian war (1847). Being the founder of military field surgery, the scientist developed the principles of organizing care for the wounded - triage depending on the urgency of care, evacuation, hospitalization. He introduced qualitatively new methods of immobilization, treatment of gunshot wounds, and introduced a fixed plaster cast. N.I. Pirogov organized the first detachments of nurses who provided assistance to the wounded on the battlefield.
N.V. Sklifosovsky (1836-1904) developed operations for tongue cancer, goiter, and cerebral hernias.
V.A. Oppel (1872-1932) - military field surgeon, founder of the doctrine of staged treatment of the wounded, was one of the founders of endocrine surgery in Russia. V.A. Oppel was involved in the study of vascular diseases and abdominal surgery.
S.I. Spasokukotsky (1870-1943) worked in many areas of surgery, developed a highly effective method of preparing the surgeon’s hands for surgery, and new methods of operations for inguinal hernias. He was one of the pioneers of thoracic surgery and was also one of the first to use skeletal traction in the treatment of fractures.
S.P. Fedorov (1869-1936) was the founder of Russian urology and biliary surgery.
P.A. Herzen (1871 - 1947) was one of the founders of Soviet clinical oncology. He proposed methods for treating hernias and, for the first time in the world, successfully performed an operation to create an artificial esophagus.
A.V. Vishnevsky (1874-1948) developed various types of novocaine blockades, dealt with issues of purulent surgery, urology, neurosurgery, and was the organizer of the Institute of Surgery of the USSR Academy of Medical Sciences in Moscow.
Surgeons - the first academicians of the USSR Academy of Medical Sciences
1st row - V.P. Filatov (1); S.S. Girgolav (2); S.S. Yudin (4); N.N. Burdenko (5);
2nd row - V.N. Shevkunenko (6); Yu.Yu.Dzhanelidze (8); P.A. Kupriyanov (12)
N.N. Burdenko (1876-1946), a general surgeon, was the chief surgeon of the Red Army during the Great Patriotic War. He became one of the founders of Soviet neurosurgery and the first president of the USSR Academy of Medical Sciences.
L.N. Bakulev (1890-1967) was one of the founders of cardiovascular and pulmonary surgery, subsections of thoracic surgery in the USSR.
Alexander Nikolaevich Bakulev (1890-1967)
S.S. Yudin (1891-1954) in 1930 was the first in the world to transfuse human cadaveric blood. He also proposed a method for creating an artificial esophagus. S.S. Yudin was for a long time the chief surgeon of the Institute of Emergency Medicine named after. N.V. Sklifosovsky.
Currently, Russian surgery continues to develop successfully. Outstanding surgeons, academicians V.S. Savelyev, V.D. Fedorov, M.I. Kuzin, A.V. Pokrovsky, M.I. Davydov, G.I. Vorobyov and others made a great contribution to the development of modern domestic surgery. areas include operations in hyperbaric chambers, microsurgery, plastic surgery, transplantation of organs and tissues, open-heart surgery using a heart-lung machine, etc. Work in these areas continues successfully. Already proven techniques are constantly being improved, new technologies are being actively introduced using the most modern tools, devices and devices.
1.3. Organization of surgical care in Russia
In Russia, a coherent system of providing surgical care to the population has been created, ensuring the unity of preventive and therapeutic measures. Surgical care is provided by several types of medical institutions.
1. Paramedic and midwife stations mainly provide emergency first aid, and also carry out the prevention of diseases and injuries.
2. Local hospitals (polyclinics) provide emergency and urgent surgical care for certain diseases and injuries that do not require extensive surgical interventions, and also manage the work of paramedic and obstetric centers.
3. Surgical departments of central district hospitals (CRH) provide qualified surgical care for acute surgical diseases and injuries, as well as planned treatment of the most common surgical diseases (hernia repair, cholecystectomy, etc.).
4. Specialized surgical departments of multidisciplinary city and regional hospitals, in addition to the full scope of general surgical care, provide specialized types of care (urological, oncological, traumatological, orthopedic, etc.). In large cities, specialized care can be provided in hospitals that are fully specialized in accordance with one or another type of surgical care.
5. In surgical clinics of medical universities and postgraduate training institutes, they provide both general surgical and specialized surgical care, carry out scientific development of various areas of surgery, train students, interns and improve the qualifications of doctors.
6. Research institutes provide specialized surgical care depending on their profile and are scientific and methodological centers.
There are emergency (urgent) and planned, outpatient and inpatient surgical care.
Emergency surgical care in urban conditions, during the daytime, it is provided by local surgeons at polyclinics or emergency doctors who provide it around the clock. They establish a diagnosis, provide first aid and, if necessary, ensure transportation of patients to on-duty surgical departments, where qualified and specialized surgical care is provided for urgent indications.
In rural areas, emergency care is provided at a feldsher-midwife station or local hospital. In the absence of a surgeon, if acute surgical pathology is suspected, the patient must be transported to a district hospital or central district hospital. At this stage, qualified surgical care is provided in full, and in some cases, patients are transported to the regional center or the appropriate specialist is called from the regional center.
Planned surgical care It appears both in surgical departments of clinics, where minor and simple operations on superficial tissues are performed, and in hospitals. In the compulsory health insurance (CHI) system, the patient must be sent for a planned operation within 6-12 months after visiting the clinic and establishing a diagnosis.
Outpatient surgical care to the population is the most widespread and consists of conducting diagnostic, therapeutic and preventive work. This assistance to patients with surgical diseases and injuries is provided in varying amounts in surgical departments and clinics, outpatient clinics of local hospitals, and emergency rooms. First aid can be provided at paramedic health centers and paramedic-midwife stations.
Inpatient surgical care carried out in general surgical departments, specialized departments and highly specialized centers.
Surgical departments are organized as part of district and city hospitals (color insert, Fig. 1). They provide basic types of qualified inpatient surgical care to most of the country's population. In surgical departments, more than half of the patients are patients with acute surgical pathology and a quarter are with injuries and diseases of the musculoskeletal system. Every year, emergency surgical care is provided to an average of one in 200 Russian residents. In large hospitals, surgical departments are reorganized into specialized ones: traumatology, urology, coloproctology, etc. In medical departments without specialization, profiled beds are allocated.
Surgical departments are organized, as a rule, with 60 beds. The number of beds in a specialized department can be reduced to 25 - 40 units. Providing emergency surgical care to patients with acute surgical diseases and injuries of the abdominal organs constitutes the majority of the work of surgical hospitals. The number of surgical beds required to provide emergency care is calculated according to standards 1 .5 - 2.0 beds per 1,000 people Providing emergency surgical care in large departments with round-the-clock operation of laboratory, X-ray, and endoscopic services significantly improves treatment results.
1.4. The role of the paramedic in the treatment of surgical patients
A paramedic - a paramedic - is the closest and direct assistant to a doctor. In some cases, the patient’s life depends on the correctness and efficiency of the paramedic’s work. In rural hospitals, a paramedic may be assigned daily duty in the hospital or emergency department.
A paramedic devotes about a third of his working time to surgical activities. He needs to know the basics of surgery and master certain manipulations that the paramedic must apply, if necessary, at any period of his activity. He must be able to:
· promptly diagnose acute surgical diseases, most surgical diseases and, if they are suspected, refer patients to the hospital;
· quickly navigate in case of accidents and damage;
· quickly and competently provide pre-hospital medical care;
· organize proper transportation of the victim to a medical facility (choose the correct type of transport and the position of the patient during transportation).
The participation of a paramedic in the treatment of a surgical patient is no less important than the participation of a surgeon. The result of the operation depends not only on the careful preparation of the patient for the operation by paramedics, but also on the organization of the implementation of medical prescriptions and care for the patient in the postoperative period and during the rehabilitation period (restoration of performance and elimination of the consequences of the operation).
When working with surgical patients, you should always remember deontology. Basic deontological principles are formulated in the Hippocratic Oath. Deontology includes maintaining medical confidentiality.
Healthcare professionals need to communicate professionally and sensitively with patients. Wrong actions, a carelessly spoken word, test results or medical history that become available to the patient can lead to psychological discomfort, fear of illness, and often cause complaints or even litigation.
The nature of the work of a paramedic is different and depends on the medical unit in which he works.
The work of a paramedic as part of an emergency medical team. Mobile teams are divided into paramedic and medical teams, which will not be discussed in the textbook. The paramedic team consists of two paramedics, an orderly and a driver and provides the necessary medical care within the limits of professional competence. It solves the following problems:
· immediate departure and arrival at the place of call;
· establishing a diagnosis, providing emergency medical care;
· implementation of measures to help stabilize or improve the patient’s condition, and, if indicated, delivery of the patient to a surgical hospital;
· transfer of the patient and relevant medical documentation to the hospital doctor on duty;
· ensuring medical triage of sick and injured people, establishing the priority and sequence of medical measures in case of mass injuries and other emergency situations.
The work of a paramedic in a surgical hospital. In a surgical hospital, a paramedic can perform the duties of a ward, procedure or dressing nurse, anesthetist nurse or intensive care unit nurse.
On the day of admission, each patient must be examined by the attending (duty) doctor and the nurse (ward attendant); he must be prescribed the necessary examinations, an appropriate diet, regimen and treatment. If the patient’s condition allows, the paramedic introduces him to the internal regulations.
The ward nurse (paramedic) has the most duties and responsibilities. In the preoperative period, when the patient is undergoing examination, the paramedic monitors the timely conduct of diagnostic studies and compliance with all the rules of preparation for them prescribed by the doctor. Any inaccuracy during the study can lead to erroneous results, incorrect assessment of the patient’s condition and, as a result, cause an unfavorable outcome of treatment.
The outcome of the operation may depend on how accurately the paramedic carries out various medical procedures prescribed by the doctor before the operation. For example, an incorrectly performed cleansing enema in a patient with a disease of the colon can cause rupture of sutures and peritonitis, which in most cases ends in his death.
The paramedic should pay special attention to the operated patient. The paramedic must promptly identify complications that arise during the postoperative period and be able to provide the assistance necessary in each specific case. Timely measures taken at the slightest deterioration of the patient’s condition can prevent dangerous and even fatal complications. It is easier to prevent complications than to treat them, therefore, at the slightest deterioration in the patient’s condition - changes in pulse, blood pressure (BP), breathing, behavior, consciousness - the paramedic is obliged to immediately report this to the doctor.
The paramedic must care for the sick, feed the seriously ill, and carry out sanitary treatment of surgical patients upon admission. As prescribed by the doctor, the paramedic applies all types of bandages, makes subcutaneous injections and infusions, intramuscular injections, gives enemas, performs venipuncture and intravenous infusions. Under the supervision of a doctor, a paramedic can catheterize the bladder with a soft catheter, make dressings, and perform intubation of the stomach.
The paramedic is an active assistant to the physician during puncture of cavities and removal of exudate from them, application of bandages, venipuncture and intravenous infusions, blood transfusions, and catheterization of central veins.
The work of a paramedic at a medical and obstetric station. A paramedic-midwife station is a primary pre-hospital medical institution that provides health care to the rural population within the competence and rights of a paramedic and midwife under the guidance of a local doctor. In this case, the paramedic provides the main assistance to the population. He provides outpatient services to the population; provides medical assistance in case of acute illnesses and accidents; deals with early detection of diseases and timely referral for consultation and hospitalization; conducts an examination of temporary disability and issues sick leave certificates; organizes and conducts preventive examinations; selects patients for clinical observation.
Work as a paramedic in a clinic. Planned patients are admitted to the hospital partially or fully examined, with an established clinical or preliminary diagnosis. For planned hospitalization, it is necessary to perform a standard minimum examination. The paramedic writes out directions to the patient for a general blood test, a general urinalysis, a test to determine blood clotting time, blood tests for bilirubin, urea, glucose, to determine the blood group and Rh factor, for antibodies to HIV infection, and HBs antigen. The paramedic also refers the patient to a large-frame fluorography (if it has not been performed within a year), an ECG with interpretation, a consultation with a therapist (if necessary, also other specialists) and for women - a gynecologist.
After making a diagnosis, assessing the operational risk, completing all the necessary examinations and making sure that the patient needs to be hospitalized, the clinic surgeon writes a referral for hospitalization, which must indicate the name of the insurance company and all the necessary details.
After discharge from the hospital, the patient is sent for follow-up treatment to the clinic at the place of residence, and working patients after a series of surgical interventions (cholecystectomy, gastrectomy, etc.) are sent directly from the hospital to a sanatorium (dispensary) to undergo a course of rehabilitation treatment. In the postoperative period, the main tasks of the paramedic are the prevention of postoperative complications, acceleration of regeneration processes, and restoration of working capacity.
Control questions
1. Define surgery. Name the main features of modern surgery.
2. What main types of surgical diseases do you know?
3. Name the most famous foreign surgeons in the history of medicine, what are their merits?
4. Who is the founder of Russian surgery? List the ionic services of this scientist to world and domestic surgery.
5. Name the outstanding Russian surgeons of our time.
6. List the medical institutions that provide care to surgical patients.
7. Name the types of surgical care. Where is emergency surgical care provided?
8. Formulate the basic principles of organizing inpatient surgical care.
9.What should a paramedic be able to do when providing assistance to a patient with an acute surgical disease?
10. What are the features of the surgical work of a paramedic as part of an ambulance team, in a surgical hospital, at a paramedic-obstetric station, in a clinic?
CHAPTER 2
PREVENTION OF SURGICAL IN-HOSPITAL INFECTION
2.1 Brief history of the development of antisepsis and asepsis
The basis of the work of any modern health care facility is the mandatory observance of the rules of asepsis and antisepsis. The term “antiseptic” was first proposed in 1750 by the English physician I. Pringle to denote the antiputrefactive effect of inorganic acids. The fight against wound infection began long before our era and continues to this day. 500 BC In India, it was known that smooth healing of wounds is possible only after they are thoroughly cleaned of foreign bodies. In Ancient Greece, Hippocrates always covered the surgical field with a clean cloth and used only boiled water during the operation. In folk medicine for several centuries, myrrh, frankincense, chamomile, wormwood, aloe, rose hips, alcohol, honey, sugar, sulfur, kerosene, salt, etc. were used for antiseptic purposes.
Before the introduction of antiseptic methods into surgery, postoperative mortality reached 80%, as patients died from a variety of purulent-inflammatory complications. The nature of rotting and fermentation, discovered by L. Pasteur in 1863, became a stimulus for the development of practical surgery and allowed us to assert that the cause of many wound complications are also microorganisms.
The founder of asepsis and antisepsis is the English surgeon D. Lister, who in 1867 developed a number of methods for destroying microbes in the air, on the hands, in the wound, as well as on objects in contact with the wound. As an antimicrobial agent, D. Lister used carbolic acid (phenol solution), which he used to treat the wound, healthy skin around the wound, instruments, the surgeon’s hands, and sprayed the air in the operating room. The success exceeded all expectations - the number of purulent-inflammatory complications and mortality decreased significantly. Simultaneously with D. Lister, the Austrian obstetrician I. Semmelvsius, based on many years of observations, proved that puerperal fever, which is the main cause of death after childbirth, is transmitted in maternity hospitals through the hands of medical personnel. In Viennese hospitals, he introduced mandatory and thorough cleaning of the hands of medical personnel with a solution of bleach. Morbidity and mortality from puerperal fever were significantly reduced as a result of this measure.
Russian surgeon N.I. Pirogov wrote: “We can safely say that most of the wounded die not so much from the injuries themselves, but from hospital infection” (Pirogov N.I. Sevastopol letters and memoirs of N.I. Pirogov. - M., 1950. – P. 459). To prevent suppuration and treat wounds during the Crimean War (1853-1856), he widely used a solution of bleach, ethyl alcohol, and silver nitrate. At the same time, the German surgeon T. Billroth introduced a uniform for doctors in surgical departments in the form of a white coat and cap.
D. Lister's antiseptic method of prevention and treatment of purulent wounds quickly gained recognition and distribution. However, its disadvantages also emerged - the pronounced local and general toxic effect of carbolic acid on the body of the patient and the medical worker. The development of scientific ideas about the causative agents of suppuration, the ways of their spread, the sensitivity of microbes to various factors led to widespread criticism of septic tanks and the formation of a new medical doctrine of asepsis (R. Koch, 1878; E. Bergman, 1878; K. Schimmelbusch, 1КЧ2 G.). Initially, asepsis arose as an alternative to antisepsis, but subsequent development showed that asepsis and antisepsis do not contradict, but complement each other.
2.2. The concept of “nosocomial infection”
Nosocomial infection (hospital-acquired, nosocomial, nosomal). Any infectious disease that affects a patient being treated in a health care facility or seeking treatment there, or employees of this institution is called a nosocomial infection.
The main causative agents of nosocomial infections are:
· bacteria (staphylococcus, streptococcus, Escherichia coli, Proteus, Pseudomonas aeruginosa, spore-bearing non-clostridial and clostridial anaerobes, etc.);
· viruses (viral hepatitis, influenza, herpes, HIV, etc.);
· mushrooms (causative agents of candidiasis, aspergillosis, etc.);
mycoplasma;
Protozoa (Pneumocystis);
A monoculture infection caused by a single pathogen is rare; an association of microflora consisting of several microbes is more often detected. The most common (up to 98%) pathogen is staphylococcus.
The entrance gate of infection is any violation of the integrity of the skin and mucous membranes. Even minor damage to the skin (for example, a needle prick) or mucous membrane must be treated with an antiseptic. Healthy skin and mucous membranes reliably protect the body from microbial infection. A patient who is weakened by illness or surgery is more susceptible to infection.
There are two sources of surgical infection - exogenous (external) and endogenous (internal).
Endogenous infection is less common and comes from chronic, sluggish foci of infection in the human body. The source of this infection can be carious teeth, chronic inflammation in the gums, tonsils (tonsillitis), pustular skin lesions, and other chronic inflammatory processes in the body. Endogenous infection can spread through the blood (hematogenous route) and lymphatic vessels (lymphogenous route) and by contact (contact route) from organs or tissues affected by the infection. It is always necessary to remember about endogenous infection in the preoperative period and carefully prepare the patient - to identify and eliminate foci of chronic infection in his body before surgery.
There are four types of exogenous infection: contact, implantation, airborne and droplet.
Contact infection is of greatest practical importance, since in most cases wounds become contaminated by contact. Currently, the prevention of contact infection is the main task of operating nurses and surgeons. Even N.I. Pirogov, not knowing about the existence of microbes, expressed the idea that infection of wounds is caused by “miasmas” and is transmitted through the hands of surgeons, instruments, through linen, and bedding.
Implantation infection is introduced deep into tissues through injections or with foreign bodies, prostheses, and suture material. For prevention, it is necessary to carefully sterilize suture material, prostheses, and objects implanted into body tissues. An implantation infection can appear long after surgery or injury, occurring as a “dormant” infection.
Airborne infection is the infection of a wound by microbes from the operating room air. Such an infection is prevented by strict adherence to the operating room regimen.
Droplet infection is the contamination of a wound with infection from droplets of saliva entering it and flying through the air during conversation. Prevention consists of wearing a mask and limiting conversations in the operating room and dressing room.
Sanitary and anti-epidemiological regime. A set of organizational, sanitary, preventive and anti-epidemiological measures that prevent the occurrence of nosocomial infections is called a sanitary and anti-epidemiological regime. It is regulated by several regulatory documents: order of the USSR Ministry of Health dated July 31, 1")78 No. 720 “On improving medical care for patients with purulent surgical diseases and strengthening measures to combat nosocomial infections” (determines the placement, internal structure and sanitary-hygienic regime surgical departments and operating units), by order of the USSR Ministry of Health dated May 23, 1985 No. 770 "On the implementation of OST 42-21-2-85 "Sterilization and disinfection of medical devices. Methods, means, regimes" (defines disinfection regimes and sterilization of instruments, dressings, surgical linen).
Measures to prevent surgical infection include:
1) interruption of transmission routes of infection by strict adherence to the rules of asepsis and antisepsis: cleaning the hands of surgeons and the surgical field, sterilization of instruments, dressings, suture material, prostheses, surgical linen; compliance with the strict regime of the operating unit, effective control of sterilization and disinfection;
2) destruction of infectious agents: examination of patients and medical personnel, rational prescription of antibiotics, change of antiseptics;
3) reducing the length of time a patient stays in a hospital bed by shortening the pre- and postoperative periods. After 10 days of stay in the surgical department, more than 50% of patients are infected with nosocomial strains of microbes;
4) increasing the resistance of the human body (immunity) (vaccinations against influenza, diphtheria, tetanus, hepatitis; BCG, etc.);
5) performing special techniques to prevent contamination of the surgical wound with infected contents of internal organs.
The medical worker's robe must be clean and well ironed, all buttons neatly fastened, straps tied. A cap is put on the head or a scarf is tied under which the hair is hidden. When entering the room, you need to change your shoes and change from woolen clothes to cotton ones. When visiting the dressing room or operating room, you should cover your nose and mouth with a gauze mask. You should always remember that a medical worker not only protects the patient from infection, but also, in turn, protects himself from microbial infection.
Antiseptics
2.3 .1. Physical antisepsis
Antiseptics (from the Greek anti - against, septikos - causing decay, putrefactive) is a set of therapeutic and preventive measures aimed at destroying microbes on the skin, in a wound, pathological formation or the body as a whole.
There are physical, mechanical, chemical, biological and mixed antiseptics.
Physical antisepsis is the use of physical factors to fight infection. The main principle of physical antiseptics is to ensure drainage from an infected wound - the outflow of its discharge to the outside and thereby cleanse it of microbes, toxins and tissue decay products. For drainage, various means are used: hygroscopic gauze, plastic and rubber tubes, strips of rubber gloves, as well as synthetic material in the form of wicks. In addition, various devices are used that provide outflow by creating a discharged space. In addition to creating outflow from a wound or cavity, drains are also used to administer antibiotics and other drugs with an antiseptic effect and to rinse cavities. Drains can be inserted into cavities (abdominal, pleural), the lumen of internal organs (gallbladder, urinary bladder, etc.).
Drainage methods can be active, passive and flow-wash.
Active drainage. Active drainage is based on removing fluid from the cavity using a discharged (vacuum) space. It provides mechanical cleansing of the purulent focus and has a direct antibacterial effect on the wound microflora. Active drainage is only possible
