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Evolution of Modern Surgery:
Historical Overview
K.M.N. KunzruMS FRCS DHMSA
Emeritus Consultant Orthopaedic Surgeon1
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SCOPE
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INTRODUCTION• Overview• Details of Instrumentation and Technique
excluded• Some Specialties only• EVOLUTION –
Dead Ends Hypertension-Sympathectomy Dinosaurs Duodenal Ulcers-Gastrectomy
VagotomyMyths! “Visceroptosis” (“dropped” organs)
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ETYMOLOGY1
Greek EnglishΧέίροϋργη (cheirourgy) “Treatment by Hand”
Surgeryχέίρ (cheir) hand Έργον (ergon) work, or activityΧέίροϋργος (cheirourgos) Surgeon
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ETYMOLOGY 2
Latin Older Modern English English
Chirurgia Chirurgery Surgery
Chirurgos Chirurgeon Surgeon
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STONE AGE ‘SCENE’“Life without injury can hardly be
imagined” Wells, 1964
Kirkup6
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The Best Instrument
Wells Cathedral
Sculpture
“Thorn Extraction”
after Kirkup
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INDIA 1 Suśruta• Suśruta:
Mid 1st. Millenium BCE ;
• Kāśī (Varanasi)
• Compendium of Surgery Suśrutasam hitā (probably written by his students)
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Kāśī
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SUŚRUTA 1a• Taught Anatomy: human and animal
dissection • Physician: Practised and taught Surgery:
precept , practice (on cadavers, animals) • Triaged patients: Incurable(“leave alone”),
Relievable( “treat, with caution”), Curable (“treat with confidence”)
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SUŚRUTA 1b• Treated the whole patient, on tri-humoral
basis, systemically and locally • Described a fracture bed for immobilisation of
limbs and trunk• 120+ Instruments ,including details of
construction, metallurgy and usage. • Described a variety of pharmacological and
surgical therapies (Laparotomy/enterotomy)
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SUŚRUTA’S OPERATIONSREPRODUCED
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SURGICAL INSTRUMENTS(NAQVI)
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TAXILA
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INDIA 2 Vāgbhatt
• Vāgbhatt : Mid 1st. Millenium CE;
• Fled from Sindh to Mālwā (Central India)• Two Compendia • Author: ?homonymous grandson
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SindhMālwā
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Greece and Rome• HIPPOCRATES (?460-370 BCE)
• CELSUS (25BCE-50CE) ? Encyclopaedist
• GALEN(90-138CE) Large corpus of work (in Greek)
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1st. MILLENIUM CE 1• European
stagnation• Christian legends
Ss. Cosmas and Damian “transplanting a leg” (Emery)
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1st. MILLENIUM CE 2• “Dark Ages” in Europe
BUT• ENLIGHTENMENT in MIDDLE EAST• Byzantium: (preserved old writings)
• India: Surgery delgated to artisans in the latter part of the 1st.Millenium.
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ARABIC TRANSLATIONS
• Hunayn-ibn-Ishāq (Joannitus): Baghdadi Eye Surgeon ; Prolific translator (> 40 books)-- Christian
• Kitāb-l-Sushrud (Sanskrit Old Persian Syriac in Gundishapur, Iran Arabic)
• Mamoun (Baghdad): Bait-l-Hikmā (House of Wisdom)
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SURGERY• Hunayn-ibn-Ishāq (Joannitus):
Ophthalmic Surgery(Couching for Cataract)
• Al-Rhāzi (Rhazes): Rayy Baghdad• Ibn Sinna (Avicenna): Bukhara B’dad• Al-Zahrāwī(Albucasis):Cordoba,Spain
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ALBUCASIS (al-Zahārāwī) 1• ALBUCASIS ‘On Surgery
& Instruments’ • circa 1,000 CE in
Cordoba• Known from 1188
illustrated manuscript
• This translation 1973
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“ISLAMIC” EUROPEEuropean “Re-Education” by contacts with Arab/Turkish scholars and surgeons :
• Crusades • Christian Re-conquest of Iberian Peninsula• Islamic Conquest of Byzantium
• Translation of Ancient Manuscripts from Arabic to Latin
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SURGEONS & EUROPEAN UNIVERSITIES
• ITALY : Salerno Xc, Bologna XIc, Padua XIIc• FRANCE : Paris XIc, Montpellier XIIc• Only the literate surgeons wrote: the only
recorded knowledge of European Surgery.
Little knowledge of the artisan surgeon, who treated the majority
(e.g.Jacques de Beaulieu, “Frére Jacques”, the 17th. C. lithotomist)
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WOUND MAN
STUDENT LEAFLET wounds weaponry treatment notes
(de KETHAM, circa 1400)
after Kirkup
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SURGEONS INSTRUMENTS
BRUNSCHWIG’S ARMAMENTARIUM,
1497 One of the first printed
books on surgery. Mostly artisanal tools -
modified
after Kirkup
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GUNPOWDER XIIIC
• More serious wounds with greater tissue trauma and foreign bodies
• Greater risk of Sepsis• Jean de Vigo ( and others): “Poison of
Gunpowder to be neutralised by boiling oil”
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AMBROISE PARÉ(1510-1590) 1
• Born Laval, France • Apprentice barber-surgeon Paris1532• Compagnon-chirurgien Hotel Dieu de
Paris• Military Surgeon --Duc de Montjean,
Colonel General of the French Army
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AMBROISE PARÉ 2
1537 siege of Turin: momentous discovery in wound healing. Due to lack of boiling oil used egg yolk, rose oil and turpentine, with superior result: much less pain, little pus, and no fever; healing earlier.
?First controlled trial(Ellis)
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AMBROISE PARÉ 3• 1541(post campaign) passed examination
“Community of Barber-Surgeons” • 17 campaigns• Surgeon to four Kings • 1583 First to ligate (not cauterise) blood
vessels in amputation (Amputation through gangrenous tissue); Amputation Prostheses
• Left mark on European Surgery
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PARÉ’S PROSTHESES
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KIRKUP
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AMBROISE PARE “The Workes”
FIRST ENGLISH TRANSLATION, 1634
after Kirkup
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Companies of Barber-Surgeons
• Ireland : Henry VI 1499
• Edinburgh: James IV 1505
• London :HenryVIII 1540
• Glasgow:James VI 1599
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JOHN WOODALL(1569-1643)
• Surgeon to East India Company (ashore and on board)
• Treated Scurvy with Lemon Juice (long before James Lind)
• “ The Surgion’s Mate” 1617
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WOODALLSEA SURGEON’S HANDBOOK
JOHN WOODALL’S “SURGIONS MATE” 1617
COMPULSORY PURCHASE FOR ALL SHIPS SURGEONS OF THE EAST INDIA COMPANY
after Kirkup
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WOODALL’S INSTRUMENT CHEST
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Woodall censured for profiteering from sale of chest: compulsory for surgeons of East India Company
AFTER KIRKUP
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THE ‘FATHER’ OF EARLY ENGLISH SURGERY
RICHARD WISEMAN (c.1620-1676)Royalist Surgeon Civil War: battle wounds
Published failures as well as successes
after Kirkup
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WISEMAN’S MAJOR WORK
• Eight Chirurgical Treatises’ (1676)
660 case histories: Tumours, ulcers,
diseases of the anus, scrofula, wounds (including tendon repair), gunshot wounds, fractures & dislocations, Syphilis after Kirkup 35
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SURGEONS IN PARIS
• College St Côme (1210)• Louis XIV’s fistula cured by Félix(1687) Collége Royale de Chirurgie formed: The physicians’ objections were overruled! • Surgeons of “the Long Robe”-University
trained status, as at St. Come• Barber- Surgeons of “the Short Robe”; lower
status and only permitted some operations
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WILLIAM CHESELDEN (1688-1752), Anatomist & Lithotomist
London Company of Surgeons-1745 after Kirkup
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XVIII C “THE ENLIGHTENMENT”
• Questioning of “received wisdom”• Advance of Natural Philosophy by
Royal Society (late 17th.C.) and similar continental bodies
• The Hunter Brothers- London, Smellie - Edinburgh
• The Lunar Society in the Midlands38
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JOHN HUNTER (1728- 1793) 1
• Cheselden’s pupil • The “Father”ofModern
Scientific SurgeryHuman & Comparative Anatomist, Physiologist,PathologistSurgeon (Exptl.)
• Collector (Museum)• Teacher (after Kirkup)
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JOHN HUNTER (1728- 1793) 2
• Dyslexic. Nervous lecturer.• Surgeon General and Royal Sergeant Surgeon• Conservative surgeon Aneurysm Operation• Large part of earnings into anatomical,
physiological and surgical research, and Collection:
Bought by Government London Surgeon’s Company RCS LONDON
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ROYAL COLEGE OF SURGEONS OF LONDON(1800)
• Hunter’s Museum given to Company on condition: To be housed in a new building in Lincoln’s Inn Fields
• Independent Trustees• College: Education & Training of
Surgeons; not just examining body• Museum to be open to the public 41
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ROYAL COLEGE OF SURGEONS OF ENGLAND(1844)
• Anatomy Act 1832 (College support)• Conversion to English College, with a
higher diploma by examination : Fellowship (pre-requisite for senior appointment)
• Many Fellows continued General Practice,e.g.Penny Brooks (Olympics)
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ROYAL COLEGE OF SURGEONS OF EDINBURGH
• “INCORPORATED” 1505 James IV- 15 members
• “Surgeon-Apothecaries” (included Barbers )1657
• 1722 Dissatisfaction with Barbers led to litigation; separation of Surgeons from Barbers
• 1817 diplomates became “Licentiates”
• 1884 Fellowship by exam.43
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HUNTER’S PUPILS 1• Jenner: Cow-Pox Vaccination, Hibernation• Everard Home: (Brother-in-law: St.George’s)
Probably plagiarised Hunter’s work, but got the Museum for Surgeon’s Company; Master of Surgeons’ Company (twice); President RCS England (once); Aneurysm
• Astley Cooper: Surgeon Guy’s; Surgical and Anatomical Innovator (Aortic Aneurysm); Anatomy Act; President RCS England (twice)
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HUNTER’S PUPILS 2• PHILIP SYNG PHYSICK
(1768-1837)Surgeon to Pennsylvania Hospital and Medical School, Philadelphia (USA)
• School helped by British doctors (Fothergill, Lettsom), despite the War
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GEORGE GUTHRIE 1(1785-1856)
• Wellington’s Surgeon Peninsular War; Dy. DG
• Ophthalmic Surgery (first to make artificial pupil for adherent iris)
• Treatment of Chest Wounds
• President RCS Eng.(X3)• Anatomy Act proponent
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GEORGE GUTHRIE 2(1785-1856)
• Popularised Flap Amputations
• High Hospital Mortality (56%) as opposed to Field Mortality(19%)Probably due to dirty instruments with cross infection , and other hospital acquired diseases (e.g.Typhus)
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CONTINENTAL GIANTS SURGEONS 1
• Larrey (1766-1842): Napoleon’s Surgeon General: Principle of Débridement;
Hypothermia for battlefield amputations; Ambulance Volante Field Hospital
• Bichat(1771-1842): Delineation of Tissues (Traites des Membranes)
Excision of pathological tissues
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CONTINENTAL GIANTS: SURGEONS 2
• Dupuytren (Paris) (1777-1835): Finger Contracture; Ankle fracture dislocation; Eye Surgery; Hernia Surgery
• Dieffenbach (Berlin) (1792-1847): “The most skilled surgeon in Europe, in
most fields” • Stromeyer (Hanover-1804-76): Tenotomy
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MID-XIXC BARRIERS TO SURGERY
• PAINANAESTHESIA
• INFECTION ANTI/ ASEPSIS
• PHYSIOLOGY: EXPERIMENT, OBSERVATION 50
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CONTINENTAL GIANTS : NON SURGEONS
• G. MORGAGNI(1761) Seats ofDisease• CLAUDE BERNARD (1813-1878) Milieu Interieur• LOUIS PASTEUR(1822-1895)
Germ Theory• ROBERT KOCH(1843-1910)
Evidential Bacteriology
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MID XIX C. WATERSHED
• Anaesthesia• Physiology, Microbiology Anti(A)sepsis• Unhurried exploration and
reconstruction• Body Cavity Surgery (for the first time)• Experimental Surgery pre-operation
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LISTER-ANTISEPSIS(1827-1912) JOSEPH LISTER :UCL graduate(Robert
Liston).Appointed Glasgow Royal Infirmary.Carbolic Acid (Phenol) soaks for wounds, for instruments, and hands greatly reduced infection in open fractures:1 deathin11. (Lancet 1865-66)
Transferred to Edinburgh: Closed patellar fractures internally fixed NO INFECTIONS OR DEATHS
Prof.Surgery, King’s College, London
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THEODOR BILLROTH(1829-1894)
• Prof.Vienna University (formerly Zürich): Training - School of Surgery; 46 Gastrectomies and reconstruction,both benign gastric ulcers and malignant (21)
• Animal experiments pre-operation
• Musical:Brahms’s friend54
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Prevention of Infection• Steam Sterilisation to eliminate microbes:
von Neuber (Kiel 1850-1923), Schimmelbusch (1889) and von Bergmann(Berlin)
• Halsted (Baltimore): Scrub nurse (fianceé) allergic to carbolic: rubber surgical gloves (1889), which became routine
• Macewen (Glasgow 1848-1924): Surgical Gown and Scrubbing ; boiling instruments(all steel) First to remove intracranial tumour
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XX C 1• Moynihan,Godlee,Lane:GeneralSurgeon;
“Specialism” suspect ( ?charlatans)• Robert Jones : Orthopaedic Surgery;
Organisation of fracture service• WWI-Evacuation, Understanding Shock,
Blood Transfusion donor to recipient• Gillies: Reconstruction Faces and Hands
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SKIN GRAFTS and FLAPS
• SKIN GRAFTS (Free of fat):THIERSCH(1822-1895): Partial ThicknessWOLFE (1824-1904): Full thickness BURNS _ large areas: motorised blades;
animal skin(xenograft)• FLAPS: Attached to skin at one end or side for
blood supply. Include fat; could have other tissue (e.g. bone/ muscle for complex reconstruction)
• Pedicle Flap (Gillies): Flap’s edges sewn together to reduce raw area (prevents infection)
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XXC 2• WWII: Worse trauma incidence; Shock
lessons re-learnt; functional restoration • McIndoe at E.Grinsted: Burnt Faces • Antibiotics• Fixation of fractures to allow early
mobility-Küntscher Femoral Rod• Lung Resection for Cancer and TB• Cardiac surgery: correct physiology
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TAUSSIG & BLALOCK (&Thomas)
VIVIAN THOMAS
HELEN TAUSSIG
ALFRED BLALOCK
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Blalock and Taussig 2
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Blalock’s Subclavian Shunt
61 VIVIAN THOMAS
ALFRED BLALOCK
• Blalock’s Diagram
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OPEN CARDIAC SURGEY
• Pump Oxygenator: Gibbon (Philadelphia), Melrose(Hammersmith and Stanford),Lillhei (Minnessota), Kirklin(Mayo Clinic)
• Open Correction Congenital Defects• Prosthetic and Animal Valves (Xenografts)• Myocardial Ischaemia• Transplant• Intensive-care, Nursing , Rehabilitation
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XXC 3a
• ExternalProstheses: Artificial limbs transformed by material science, engineering, biomechanics
• Internal Prostheses: Joints; Blood Vessels; Heart Valves
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XXC ENDOSCOPY • RIGID FLEXIBLE TUBES• BULBS ROD LENS +
FIBRELIGHT(Hopkins)• SAFE DISTENSION:CO2;
Modified Ringer; Glycine
• OPERATIVE EQUIPMENT
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MICRO-SURGERY(Operating Microscope & Instruments)
• ENT: Stapes& Cochlear implants, Larynx• OPHTHALMOLOGY: Cataract(lens), Glaucoma• NEURO–SURGERY: Brain- tumours, aneurisms
Spinal Cord, Nerve Roots (micro-discectomy)• PERIPHERAL VESSELS & NERVES-Micro-Neural
& Vascular Suture/ graft ; Replantation limbs/digits; Brachial Plexus Nerve Graft
• FREE FLAP RECONSTRUCTION
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ORGAN TRANSPLANT 1(Live and Cadaver)
• CORNEA: Free Allograft (like skin)• CARREL (1873-1944): Vascular Anastomosis • MEDAWAR; IMMUNITY
BURNETT : (SELF/NON-SELF)• MURRAY (Harvard) : KIDNEYtrnsplnt.
(TWINS)• CALNE (Harvard,R.Free): 6MP- poor results• STARZL (Colorado): AZATHIOPRINE+STEROIDS
27/33 survived
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ORGAN TRANSPLANT 2
• CYCLOSPORINE(Calne1978) NEED FOR HIGH DOSE STEROIDS (and side-effects) ABOLISHED; partial preservation of immune reponse
• DONOR MATCHING: increasing sophistication• OTHER ORGANS: liver, heart, lungs, pancreas• DONOR SHORTAGE : Reduced RTA mortality
?“Presumed Consent”; ?animal organ ?temp.
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TUMOURS 1
• WIDER AND DEEPER EXCISION (Halsted’s Radical Mastectomy)– HIGH FAILURE
• LOCAL EXCISION +- radiation (Patey’s Local Mastectomy)—NO WORSE
• LOCAL IMPLANTATION of RADIATION SOURCE ---Radium; Radio-Isotopes
(Iodine, Yttrium, Radon) SOME SUCCESS
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TUMOURS 2
• EXTERNAL RADIOTHERAPY-Deep Xrays,Cobalt, etc. -- Metastateses and some primary tumours
• CHEMO & HORMONAL THERAPY • IMMUNOTHERAPY/Tumour Biology
• COMBINED THERAPY Superior results
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XX C Last Decade
• Basic Sciences , Engineering , Material Science, and Diagnostic Modalities have shaped Surgery_ TEAM WORK
• Surgery at extremes of age• Cost/Benefit Ratio; NICE; “Rationing” • Ethics: “Patient’s Welfare paramount”
Hippocrates_ Helsinki(1964)_Tokyo(1975)• External Regulation--- Government, Insurers• “FIRST DO NO HARM”- RiskTaking v/sLitigation
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