History of the Operating Room
BEFORE THE OPERATING ROOM: MAGICIANS, PRIESTS AND PHYSICIANS
The development of surgery occurred in different regions at different times, in China, India, South America, Mesopotamia, Persia, Arabia and finally Europe. The early surgeons were either priests, magicians, physicians or barber-tradesmen who understood anatomy and were comfortable with the common practices of amputation and trephination.
Trephination is perhaps the oldest of surgeries that we know of. Because it involved cutting or grinding a hole in the skull, remnants are plentiful, as human skull bones have lasted for as many as 12,000 years intact. Neolithic evidence of trephination has been found in many disparate civilizations, from the pre-Incas in South America (2000 BC), to the early Europeans in France (5100 BC), to the Egyptians extending back as far back as 8,000 BC. The practice was probably originally performed for spiritual and magical reasons, and was performed by kings, priests and magician-physicians. It later was used to relieve pressure for head injuries, seizures and mental disorders such as psychosis.
During these times, the most common practitioner was the battlefield surgeon, who removed arrows, applied bandages, performed amputations and dispensed rugged hope to both the wounded and those who continued to fight. He was, at times, highly valued by both the men and their officers. A surgeon “who knows how to cut out darts and relieve the smarting of wounds by soothing unguents was to armies more in value than many other heroes.” (Iliad, Book XI)
The word ‘physician’ was probably coined by Homer. The name derives from the Ionian dialect spoken in the Greek colonies of the eastern Aegean meaning “Extractor of arrows.”
Witch doctors (“ashipu”) worked seamlessly with physical healers (“asu”) in a mix of magic, religious imprecations, administration of salves and plasters, and surgical procedures. Practiced surgeons became revered teachers who drained infections, controlled bleeding, performed amputations and trephinations, and accepted liability for failed operations. The Law Code of Hammurabi (c. 1700 BC) called for a surgeon’s hand to be cut off if the life of a person of high social order was lost as a result. Many of them specialized in the knowledge and the magic of particular anatomic spirits and therefore surgical areas of interest. They were the skilled technicians of the art of surgery who established the practical traditions that were passed on to Greeks.
While the Babylonians were magicians and generalists, the Egyptian physician-surgeons became specialists, some concentrating on the head, others eyes, yet others on the abdomen. They had extensive knowledge of anatomy, and performed dissections as well as mummification. They performed trephinations as early as 8000 BC.
The word “brain” was first observed in Edwin Smith Papyrus in 1700 BC. The convolutions of the freshly dissected brain surface were compared to “molten copper” when they were seen shining in the hot Egyptian sun.
Egyptian surgical instruments were some of the most sophisticated to be found until well after the Middle Ages.
The phrase, “To cut of your nose to spite your face” is familiar to all of us. However, very few know where it came from. In India, a common punishment for such crimes as stealing a large animal, abetting a thief and fornication was to cut off the nose of the offender. The North Indian Hindu poem, “Epic of Rama Prince of India,” dating from 1200 – 1000 BC, was retold in the Ramayana, by Valmiki, around 400-200 BC. The hero Sri Rama’s brother Lakshmana, when confronted by the female demon Shrupanakka, who dared to make love to him, cut off the nose of his consort to spite her and not to kill her.
Buddha Ghosa, in the 4th Century, in the Dhammapada Athakata, tells the story of a husband who committed fornication with a woman-servant in his house. His wife bound that guilty servant’s hand and foot and cut off her nose. This practice continued for many centuries.
Indian physicians were thus confronted with a large number of patients with a problem. They learned the detailed anatomy and the surgical techniques that would lead to the development of both ENT (ear nose and throat) surgery and plastic surgery.
Sushruta Banaras, now referred to as the “Father of Surgery” in the Indian tradition, worked and taught along the Ganges River in India around 600 BC. His many volumes of surgical descriptions, known as the Susrutha Samhita, were the basis of Indian surgical practice for many centuries after. He was the first to establish a surgical practical laboratory, or workshop, using clay objects and various fruits to mimic human surgical situations.
Han, China 190 BC
Hua Tuo was the first to use anesthesia for surgical procedures, using a combination of wine and a form of cannibis. During the Han Dynasty, he became well known for his treatments and cure of the injured general Zhou Tai. He was the first to use the pulse as a diagnostic indicator, and he apparently developed surgical skills that included castration and brain surgery. For this, he lost his life, as recorded in the Records of the Three Kingdoms:
Huà Tuó told Cáo Cäo that to cure him, he would have to open up his skull to rid him of his severe, chronic headaches (most likely due to a tumor, from which he later died). Cáo Cäo thought Huà Tuó had the intention of killing him by opening his skull. This was due to his fear of surgeons after Ji Ping, a former royal surgeon, attempted to assassinate him. Huà Tuó was jailed and ordered to death by Cáo Cao. Upon his execution, Hua Tuo presented a scroll, Qing Nang Shu ( “medical practice book”), to the jailer saying “This can save lives”. But the jailer, did not accept it, whereupon Hua Tuo asked that a fire be built and proceeded to burn the invaluable scroll.
GREECE: THE FIRST SURGICAL TRAINING PROGRAM
“A physician is worth more than several other men put together, for he can cut out arrows and spread healing herbs.” (Iliad, Book XI)
Greek surgeons were trained in semi-formal schools called Asklpieia. The result of this training resulted in a uniformity of medical and surgical practices that laid the groundwork for the modern training programs that would follow many centuries later. The Asklepion on the Aegean island of Kos was the place of learning for Hippocrates, the most remembered of Greek physicians. Temple of Aesculapius of Kiparissios Apollo was located on the site. It was dedicated to Aesculapius, the son of Apollo, protector of health and medicine. The Asklepion served as a sanatorium, the spas received waters from the spring of King Halkon and the spring of Vournika on Mount Dikeo. It soon became the preferred sanctuary for the injured and sick. It was here that herbal remedies of all kinds (including anise, cassian, frankincense, cumin, opium and germander from the East), and unguents for plasters (olive oil, parsnip, myrrh, honey) were developed and enhanced. Physicians from the Levant were here as well, and lessons that were learned during the times of the Babylonians and the Egyptians were handed down to the Greeks on this crossroad that stood between the East and the Greek mainland.
Greek surgical techniques were mostly learned on the battlefield, where arrows were removed, wounds covered, tourniquets and vasculature ligatures applied and amputated limb wounds were closed.
There were surgical specialists in some areas of gynecology (abortions were preformed, children birthed, infections drained), but most other surgeries did not include opening any cavities in the body, a practice that would last until the 19th Century.
ROME: THE BIRTH OF THE OPERATING TENT
The modern operating room is descended from the Roman military tent and hospital system that was perfected to a degree not matched again until the time of Napoleon. The first Roman Medical Corps was formed by Emperor Augustus. Medical professionals were required to train at the new Army Medical School and could not practice unless they passed stringent examinations.
The Roman military surgeon was called the “medicus vulnerarius,” the “wound doctor.” Roman military surgeons and their counterparts, the specialist arena surgeons (who maintained the health of the valued gladiators) were extremely proficient not only with their surgical techniques, but also in the organization of their infrastructure. The military surgeon Pedanios Dioscorides (c. 65 AD) was not only well known as a field surgeon, but as an author whose text on herbal medicines set the standard for another 1,500 years.
The medicus vulnerarius was in the field with the soldiers during battle, and managed a system that included surgery in the field, an ambulance team, and 2 receiving battlefield hospital tent systems located on opposite sides of the field. The tent system moved with the army. If the Battle of Pharsalus was any example, it was quite elaborate. Immediately behind the field of the battle, there were 25 tents providing space for 200 men, at the standard 8 men to the tent. There were probably 3 tents for the medical staff and 22 tent spaces for patients. At that rate, the hospital unit would have space for 176 men. Since there is a hospital on each side, the 40,000-man army had hospital beds for 352 men.
Once the battle was over and the troops moved on, surviving patients were transported to military hospitals located within city walls. These hospitals were quite large, and were organized around a circumferential ward system that alternated with intervening corridors. In the center was an area that might have been used as an operating theater, called the “refectory.” An example of this was found at Novasium, on the lower Rhine near Dusseldorf, where many sophisticated surgical instruments were excavated within the hospital proper.
ISLAMIC MEDICINE: THE FIRST SURGICAL SUITES
Abu Bakr Muhammad ibn Zakariya al-Razi (865-925 AD), known as Rhazes, was one of the most prolific Muslim doctors and probably second only to Ibn Sina in his accomplishments. He was born at Ray, Iran and became a student of Hunayn ibn Ishaq and later a student of Ali ibn Rabban. He wrote over 200 books, including Kitab al-Mansuri, ten volumes on Greek medicine, and al-Hawi, an encyclopedia of medicine in 20 volumes. In al-Hawi, he included each medical subject’s information available from Greek and Arab sources and then added his own remarks based on his experience and views. He classified substances as vegetable, animal or mineral while other alchemists divided them into “bodies,” “souls” and “spirits.”
Al-Razi was first placed in charge of the first Royal Hospital at Ray, from where he soon moved to a similar position in Baghdad where he remained the head of its famous Muqtadari Hospital for a long time. He found a treatment for kidney and bladder stones, and explained the nature of various infectious diseases. He also conducted research on smallpox and measles and was the first to introduce the use of alcohol for medical purposes. A unique feature to his medical system was that he greatly favored cure through correct and regulated food intake. This was combined with his emphasis on the influence of psychological factors on health. He also tried proposed remedies first on animals in order to evaluate their effects and side effects. He was also an expert surgeon and the first to use opium for anesthesia.
Abu Ali al-Hussain Ibn Abdallah Ibn Sina alone wrote 246 books, including Kitab-al Shifa (The Book of Healing) consisting of 20 volumes and Al- Qanun fit Tibb (The Canons of Medicine). He approached philosophy, logic, mathematics, astronomy, psychology, medicine and surgery all as part of a whole. The Qanun was a predominant text for medicine in the West from the twelfth to the seventeenth century. Containing over one million words, it surveyed the entire medical knowledge available from ancient and Muslim sources, and preserved the knowledge of the Greeks and Levant for eventual transmission through the Middle Ages to the Renaissance. It continued to be a relied upon source of medical knowledge until the early 19th Century.
Ibn Sina determined that tuberculosis was infectious, and was the first to describe meningitis and to institute quarantine as a method for limiting the spread of infections by the air.
He had to escape to Isafan, in Persia. After having been vizier and having been forced into hiding by a change in the political landscape upon the death of the Buyadid prince who had appointed him. Once in Isafan, he wrote his many medical (approximately 40) works and had a school of medicine and philosophy. Here surgeries were set up and the sick came for diagnosis and surgery that was performed on site. Suites of surgeries were located together, and individual types of surgical procedures were regulated to each. No detailed description of these operating rooms is extant.
His surgical operations to remove cancers were among the first.
Abul Qasim Khalaf ibn al-Abbas al-Zahravi (known in the west as Abulcasis) was born in 936 C.E. in Moorish Spain near Cordoba. He became one of the most renowned surgeons of the era and was physician to King Al-Hakam-II of Spain. He is best known for his early and original breakthroughs in surgery as well as for his Medical Encyclopedia, called Al-Tasrif, a thirty-volume treatise, with three books dedicated to surgical techniques, cauterization, kidney stone removal, eye, ear, and throat surgery. His surgical books contained over 200 surgical illustrations.
Cauterization of wounds, tumors, bleeding and open infections became standard as a result of his methods.
He was the first to separate surgery as a separate area of concentration, and developed such advanced techniques as those for the division of the temporal artery to relieve headaches, diversion of urine into the rectum, reduction mammoplasty for excessively large breasts and the extraction of cataracts.
Translated into Latin, the books were an important link between Europe in the Middle Ages and past medical knowledge of the Greek, Indian and Egyptian traditions, becoming part of the established surgical curriculum for centuries thereafter.
MIDDLE AGES: THE BARBER SURGEON
The barber-surgeon was first and foremost, one who traveled with caravans, perused battlefields and put up shops in towns and cities, working outside in the field or street. When they were not treating patients, they often maintained other jobs, such as traveling road shows complete with entertainment, magic and liniments and potions and “cures” from “far away” places. They dispensed practical advice and treated various ailments at the end of these entertainments, gradually enhancing both their practical knowledge and stature among the people. Physicians, usually affluent and educated, were most often medical doctors, dispensing herbs and medications. Because of their perception of the limitations of surgery and the Church’s proscriptions against anatomic dissection, they more often than not left the difficult work of amputations and wound closures to the barber-surgeons. Thus was born the “Town-Gown” dichotomy that lives on today in the practices of modern physicians and surgeons.
As time went on, the barber-surgeon rose further in stature. A person of importance, a member of the upper classes needed not only his physician, but also his barber-surgeon.
The most common form of surgery was bloodletting, in an effort to restore the balance of the body’s four humors. Surgery for breast cancer, fistula, hemorrhoids, gangrene, and cataracts, as well as tuberculosis of the lymph glands in the neck (scrofula) was performed. Some of the potions used to relieve pain or induce sleep during the surgery were themselves potentially lethal. One of these consisted of lettuce, gall from a castrated boar, briony, opium, henbane, and hemlock juice, something that more often than not resulted in death of the patient.
During this time, the concept of the dispensary evolved, as the outdoor activities of the barber-surgeon moved indoors. There were no formal operating theaters, but bare rooms filled with shelves of herbs and poultices, along with a wooden table that could be used to perform surgery.
Barber surgeons became so proficient at surgery, while the academic surgeons fell behind (especially after their numbers were decimated during the plague) that the union of the two groups was inevitable. In England, King Henry VIII signed a decree merging the Fellowship of Surgeons with the Company of Barbers in 1540, into the Great Company of Barbers and Surgeons.
Ambrose Pare, a French surgeon, was apprenticed to a barber-surgeon before he went on to become the famous battlefield surgeon and aide to the chief of surgery at the Hotel Dieu in Paris.
Dominique Jean Larrey (1766-1842) was Napoleon’s army surgeon. He reintroduced the Roman-style hospital tent system to the battlefield. Injured soldiers were brought from the field by “flying ambulances” (ambulances volantes), horse-drawn carts that scoured the scene and rapidly brought the wounded to the tents situated in the rear. The hospital tents included a wooden table surrounded by billets. The wounded were brought in along a “corridor” that was made among the patients and the injured were carried onto the table. Once there, their bullets were removed (Larrey invented a porcelain-tipped probe to “hear the missiles”) or their limbs were amputated immediately. Larrey advocated early amputation as a preventative to infection. For example, during the Battle of Borodin, he performed around 200 amputations in a single day.
The Larrey ambulance system and battlefield tent system was retained by American surgeons, and the Roman military hospital system was reintroduced as well. Again, the primary operation was that of amputation. However, advancements in surgical techniques and the use of anesthetics allowed for improved closure of other wounds, such as abdominal injuries.
Overall, however, as witnessed by one soldier, the scene was one of great difficulty:
“In the operating tent, the amputation of a very bad looking leg was witnessed. The surgeons had been laboring since the battle to save the leg, but it was impossible. The patient, a delicate looking man, was put under the influence of chloroform, and the amputation was performed with great skill by a surgeon who appeared to be quite accustomed to the use of his instruments. After the arteries were tied, the amputator scraped the end and edge of the bone until they were quite smooth. While the scraping was going on, an attendant asked: ‘How do you feel, Thompson?’ ‘Awful!’ was the distinct and emphatic reply. This answer was returned, although the man was far more sensible of the effects of the chloroform than he was of the amputation.”
GERMANY, FRANCE, AUSTRIA, ENGLAND, AMERICA 1800 – 1900
Large, city-based charitable hospitals arose out of the medieval monetary medical care system in Europe during the late 1700’s to care for the poor and indigent. Leading cities in Europe developed the operating theater as the venue for both operating and teaching. These theaters were modeled after the dissection theaters that gained fame in Padua, Leiden and other largely Italian cities. In 1822 the St Thomas’ Hospital built its operating theater, and in 1824, in Boston, what was to become known as the Ether Dome was built.
These theaters remained the standard until the full acceptance of Semmelweis’ and Lister’s antisepsis regimens lead to the inclosure of the operating room and the introduction of sterile technique.
WORLD WAR I
By this time, antisepsis was accepted, and the wearing of gowns, gloves and masks, washing of hands and the use of antiseptics lead the army surgical team indoors whenever possible. Houses were commandeered and used as battlefield hospitals.
In the university setting, however, the operating theater concept persisted.
WORLD WAR II AND THE KOREAN WAR
By World War II, the military hospital tent system was expanded to include the peripheral-style design for operating rooms that allowed for multiple patients to be operated upon simultaneously. All necessary components could be powered and supported from any location within the tent, so that a single tent had the flexibility to allow for a variable number of casualties to be operated upon at any time.
This peripheral design reached its zenith during the Korean War, with the development of the MASH (mobile army surgical hospital) concept. This format was the basis of modern operating room design, with support systems coming into the room from the periphery.
Examples of modern operating rooms during the 20th Century are presented here visually: