A history of surgery

storia della medicina

We are now confronted with amazing scientific ideas that offer themselves as new models interpretation of disease and that make us think of already having been in another revolutionary phase of medicine. The century that has just closed, especially in his later years, he offered scientific and technological tools deeply innovative opening up interesting prospects intervention, previously unimaginable. If it is true that, in almost two hundred years of history, certain extraordinary changes in life expectancy have come from the correct application of the criteria estimates protection, it is equally undeniable that in recent decades, medicine and surgery were presented to the sick with tools finally able to really ensure effective action in cure and heal. The surgery, which had already caught in the path of his extraordinary success more recent history, was found to be among the main protagonists of this avventura.Tuttavia we know that, in the fight against suffering and the desire to dominate illnesses, medicine men have yet to overcome other stages to achieve a greater clarity about biological phenomena that still resist to our ability to explain. The reflection on the past is one of the essential elements of the body of knowledge man even in the age of technology and this book aims to respect the good tradition of a Introductory chapter, act to present the main lines along which took place on the path surgery from antiquity until today. In these pages we will try to dwell briefly on some aspect of a long history, not so much to please us of the journey undertaken in the changing and nell'aggiornarsi doctrines and medical clinic, but to look forward and get closer with more adequate awareness examination of the changes that are now marking the way of understanding health problems, understand the ideas and methods of the present, to face the contradictions and lingering insecurities doctrinaire, critically orientate in open questions and master the tools and the same language of medicine. The brief review we give today, necessarily Synthetic, try not to neglect the stages of Italian history, also hoping to be able to stimulate the reader to further reading. The doctor and the surgeon, intertwining their skills in varied manner, were the protagonists of a commitment of care that in the past could count on very limited means and that only a little over a century, with the extraordinary progress of science and technology, has seen substantial say solving capacity. Until antiquity had raised the question whether it was appropriate to distinguish diseases of medical interest from diseases of surgical interest, be faced with skills and care means different. The unitary concept was already expressed in the Hippocratic literature, which extolled the power of surgery that can intervene which was beyond the help of Medicine: quaecumque not sanant medicamenta, and ferrum sanat; quae ferrum not sanat, and the nis sanat; quae the nis not sanat, and the InCura ia utare or Ortet. In his same etymological meaning, Ceirourgi goes indicates the care with manual arts and the surgeon has always been the one who is to heal availed itself of the use of the hand, naked or having only tools, but always following the instructions of His rational intellect. We know that the Hippocratic Oath puts us in this regard, a problem not easily interpretazione.Vi we read, in fact, the recommendation to the doctor not to perform surgical procedures, but we also know that the distance between medicine and surgery at that age was not so strong and other works of Hippocrates surgery was deemed one of the normal duties of the physician. Circumstances and complex factors determined in the past and disjunctions ricongiunzioni practice of medicine and surgery, in different cultural and historical moments, but in the Western world the move away from the direct activities of the surgery the doctor seems rather the result of a medieval atmosphere, in which they determined the differences in roles that lasted several centuries, until the final overcoming of a subordinate condition of the surgeon, took place less than two hundred years ago. The history of surgery taken beginning in the earliest forms of human life. an organization rational theoretical knowledge and practical procedures could be seen already in the first civilization of the remote past and the evolutionary line then progressed along different paths in different areas of the world. For many centuries, the changes of the surgery, his theories, his methods and of his instruments had occurred very slowly. The ideas of science, generally, employed a long time to get into the baggage of medical treatment. in recent two hundred years, however, the eruption of the most mature and solid biological knowledge in the world of Medicine has determined true profound revolutions and a constant renewal of discoveries and progress. The speed of many new incentives to upgrade now requires a connection incessant and punctual between the laboratories of research and hospital wards and also within time in the life of a doctor is seeing substantial renovations of ideas and resources. Along these paths, even recent, there have been incidents of ephemeral successes or misleading, but surgery has gained stages of great importance, not even imaginable before, and not slows his journey along this road. The distant sources of our culture are sought in the ancient peoples of the basin Mediterranean. The scientific thought of classical greek-roman lasted in the rich culture the Arabs, in the school of the Christian Middle Ages, in the centers of particular interest as the Salerno school, to be accepted then in the nascent University of European nations. Moreover we know that the path of the driving forces of medicine shifted always following, gradually, the transfers of economic and political power. If in the Renaissance and in the early days of age Modern flourished Italian centers, in the centuries following the major stimuli were present in more rich countries of central and northern Europe, up to the appearance of new worlds and Americans Asian.

From the beginnings to classical Greek and Latin

The first surgical procedures were certainly those made by men inexperienced and without education meet the needs of traumatic events. From the first steps remotest empirical path then led the establishment of regular doctrines and every ancient civilization has handed down evidence of a surgical operation governed by specific knowledge, practiced by people able to soothe suffering, healing wounds, abscesses affect, with different roles and positions in the companies in which appartenevano.Tanti aspects of the ancient exercise of medicine and surgery there were clarified literary sources, those artistic and archaeological. The extraordinary chapter of palaeopathology, which explores with modern methods of investigation bones and other biological remains joints down to us in non-negligible quantity, provides direct information on the diseases they were suffering the oldest populations and helps to understand how they were treated failures organism. It gives us the proof the action of the hand of the man who intervened in distant times and in primitive peoples on the body injured or sick who suffered. We find traces of bone fractures of the limbs and vertebrae, undoubtedly dealt with healing abilities, with good outcomes in healings and cures bad. The cranial trepanation on living - which was already coded accurately the texts of Greek physicians Hippocratic age, illustrating the technique of opening and bone drilling with drill perforator or crown, possible complications to the bone or the meninges and the appropriate precautions to prevent them - was famously performed by many primitive peoples who showed knowledgeable master well. The directions were restricted mostly to the fractures of the skull and sometimes to mental illness, but the archaeological and anthropological data suggest also think origins broader, who did not reside only in the surgery rational, but perhaps were connected to remote bases interventions rituals, performed on both the living, both on the corpse. In the cultural traces of ancient populations from different regions of the world can be found remote testimonies of a passage from the surgery and medicine exercised instinctively, by men educated only through traditions and empirical experiences, to a body of regular codified knowledge. In the establishment of the doctrines and techniques taught with the authority of a specific literature, are the elements that led to the formation of the first schools. From ancient Egyptian world there were broadcast testimonies of knowledge surgical relatively advanced and also the archaeological excavations in the regions of the fertile crescent, which flourished Mesopotamian civilizations, still provide archives of clay tablets with texts of wealth extraordinary for our studies. The richest literary source on the medicine of antiquity is made sure by the Greek texts of the so-called Hippocratic Corpus, which encompasses many medical treatises, traditionally attributed to Hippocrates, the physician born in the island of Cos, but probably composed at different times and in generally does not predate the middle of the fifth century before Christ. However, even outside of the texts their medicine, valuable information to learn about the ancient practice of surgery there can come from reading other great works of ancient literature. The same Homeric poems are rich in specific references to the intervention healing the wounds of the epic heroes. We know that surgery of ancient Greece was not supported by a good knowledge of anatomy, but was already able to suggest techniques useful in many pathological conditions. Between the civilizations of pre-Roman, the Etruscans left evidence of their ability with the refined gold workings on the teeth. Of ancient Rome then poured around the vast store of knowledge Greek, enriched by the experience gained in Egypt and shining in the era of medicine Alexandrian. The recognized quality of the Greeks and their medical schools made them protagonists main art of curing in Roman society, where exercised either medicine and surgery. Even Galen (ca. 129-210), the greatest of the doctors of that time, and authorities undisputed for many centuries, was born in Pergamum in Asia Minor, and was trained in medicine Greek. He was capable of deep processing of thought. On the basis of experiences and observations personal, came to build a system in which anatomical and physiological was systematization the ancient doctrine of humors, understood as constituting the body and the imbalance which were made descend disease states. The work of Galen, which was accepted as dogma and ruled each pathophysiological interpretation, not neglected fields of surgical interest and certain technical aspects surgical procedures, such as ligatures vessel and the risk of nerve injury. His anatomy, as is known, was largely imperfect, because elaborate on the section of the animals rather than man, but spent resisting every criticism through the processing of many authors later, the Arabs and the Christian Middle Ages, remaining firmly text obligated education medical and surgical care to the modern age. Several authors of the Roman left other writings surgical interest, on which we can not entertain here. Simply, to title example, remember that two of the books of De re medica, by Aulus Cornelius Celsus, treated exclusively by surgery, describing the historical background, instrumentations, paintings pathological and methods of intervention. In the power of imperial Rome had a significant role in the Surgery applied to the military. The soldiers were treated in valetudinaria, large complexes hospital perfectly organized and spread even in outlying provinces of the Empire. Army operated people capable of treating wounds, reduce fractures and dislocations, extract foreign objects, use the meticulous craftsmanship of bandages. A special category of doctors was represented by vulnerari, those treating the gladiators. Those surgeons, alongside more practical municipalities how to hack abscesses, cauterize wounds, extracting teeth, knew also face interventions of greater complexity: the amputation of limbs, vessel ligation purposes hemostatic, sutures to approximate the edges of the wounds, the operation for bladder stones and cataract, hernias with resection of the bag, tracheotomy, caesarean section. They were very extensive knowledge of which fed the exercise of the surgery until the modern age.

Medicines transition and the Middle Ages

A text long held as authoritative source of knowledge for surgery is the work of Paul of Aegina (625-690) which provides precise information on the techniques used in the ancient world. The high Middle Ages, as is known, was considered a period of stagnation in the sciences. The thought of classical greek-roman struggled to survive in that time and went back through the ages of strands in which was preserved and was passed down much of the ancient texts. The main rails transmission of medicine were on the one hand to the Islamic world, he knew then its most important phase of expansion, and the other the so-called native, environments Christian monastic and the School of Salerno. In passing through the Islamic culture and Arabic translation of the masters of medicine of antiquity, being examined in the acute and reworkings of his scholars, surgery certainly got ideas that helped to enrich it. Albucasis, Rhazes, Avicenna and other minor writers left relevant descriptions of surgical series. Their manual confided much in cauterization, but proved to know and be able to apply precise techniques as hemostasis for compression, the section of the vessels between ligatures, sutures bowel with catgut or silk. The organization of the places of medicine and surgery in Islam showed care centers and medical education inspired to complex models, real hospitals with salt hospitalization, differentiation of diseases, libraries. Monasticism, popular both in the East and in the West, represented the other binary transmission heritage classic, but between the ninth and twelfth centuries was important especially medicine Salerno, considered the first example of a secular school in the Christian Middle Ages. in that environmentanimated by many figures of value did not lack works of some interest for surgery. Roger from Frugardo gave a systematic codification of surgical standards, with significant points for originality, as drains with torches elder in deep wounds, the sutures of intestinal lesions with silk and fine needle, or the use of the seton in interventions for goiter. His Rogerina, which also contained a detailed description of instruments, became the text of surgery more adopted in European schools. Towards 1250, Rolando da Parma gave one processing commented, introducing new ideas, such as the inclined position of the patient in the operation of hernia. Those teachers showed to consider surgery an act of the doctor, knew moving in the wounds of the brain, as in those of the lung or bowel, treat pots and tackle difficulty midwives. When was setting the luck of the School of Salerno, in many European cities were born the University, who imposed themselves as the headquarters authoritative regular education in medicine. There Surgery will immediately found place in the wide range of disciplines that were taught and reached its best expression in the work of some authors who left signs of value. From a famous family of surgeons were born Ugo Lucca Burgundian (d. 1252) and his son Theodoric (1205-1298) who demonstrated uncommon intuition. Remember that, opposing the traditional belief, he claimed that the pus in the wounds was a fact that could hinder and not encourage guarigione.Aveva also proposed the use of sponges soaked in soporific substances to decrease the sensitivity of the patient. Lanfranc of Milan, moved to Paris, helped give birth to the French surgery. Guido da Vigevano, in the fourteenth century, picked in Liber Notabilium the fruit of his good anatomical observations. Belonged to the same era and at the same cultural environment Henri de Mondeville, professor at Montpellier, and Guy de Chauliac, who was perhaps the most famous of French surgeons of the Middle Ages. Special consideration deserves William of Saliceto, active in Bologna in the thirteenth century. There His work, which showed some originality also opposing the wide use of cauteries suggested Arabs, he proved capable of proclaiming the need to keep the surgery combined with medicine, at a time when you were settling in practice, however, certain distances.

Surgery of the empirical

Just at that time strengthened the distinction between the medical graduate, able to interpret the operation hidden body healthy or sick, and the performer practical acts surgical parts patently malate.Mentre medicine was tied closely to the rank and culture university, surgery was performed by people with lower levels of education. Yes affirmed and prospered forms of exercise uneducated, entrusted to surgeons "minor" and barbers, who dedicated themselves to the exercise of bloodletting, on the advice of the doctor, care of abscesses, fistulas, fractures, dislocations in general, but they could also face the more difficult jobs. Sometimes they stood together in guilds that regulated the exercise of the art of its own statutes, accentuating their separation from medicine. Along several centuries, from the Middle Ages to modern, all surgery, including operations more demanding challenges such lithotomy, hernia or cataracts, was also practiced by empirical individuals the irregular formation, with no school education, trained to manual in which were capable of skilled successes. They were mostly itinerant figures, carrying their service from one country to another, where it was necessary. Often belonged to the same family that handed down from generation to generation tools and techniques, as jealous protected secrets. The Norcia and Preci, Umbria, were the recognized home of an ancient tradition who went on to form bands of skilled surgeons until the modern age, also renowned for singular distinction of being the most experienced in the practice of castrating the putti destined to become the voices so requests for singing. We know that could be found in every part of butchers of Italy, and in many states of Europe, walked on the paths along which there was always need their capable hands. In southern Italy flourished other actual celebrities, as the families of Vianeo to Tropea Branca or in Sicily, the only ones who knew how to repair faults or wounds of the nose with the original rhinoplasty techniques. Leonardo Fioravanti described the ruse used to intrude home of Vianeo and learn their secrets of the operation in 1549 in Tropea. Moreover, it is known that often the Regular surgeons preferred to leave the empirical fields of intervention more difficult and no doubted that they were capable of bits of real value and craftsmanship. In some modern France litotomisti reached deserving successes, like the Provencal Pierre Franco (1505-1570) or the two monks Jacques de Beaulieu (1651-1719) and Jean de Saint Come (1703-1781). In Milan, a butcher was on duty in the wards of the Ospedale Maggiore again in the second half of the eighteenth century.

The surgeons and rehabilitation of the anatomy

At the end of the Middle Ages medicine, which was beginning to escape the empire of tradition and to the text Galen, undertook a profound transformation of his knowledge. The rehabilitation of the anatomy, who departed from the studio directly performed on the corpse, it was the first engine. The text so innovative Vesal Andreas (1514-1564), De humani corporis fabrica, had seen the light in In 1543, but had been preceded by the work of other surgeons and anatomists who knew sagacious publish works already oriented modern observation, based on visual acuity et tactus, as did Berengar Carpi (1460 ca.-1530). In 1511, Giovanni da Vigo (1450-1525) had published a valuable collection of rational norms for wound dressings, ligation of the arteries, directions and techniques of operations, including the cranial trepanation. Constituted a separate chapter the work sum of Leonardo da Vinci (1452-1519), who also was in anatomy capable of very deep new observations, but in general the great contributions anatomical sixteenth century, before and after Vesal, were given by authors who were also skilled chirurghi.Gabriele fallopian (1523-1562) collected great merits for its anatomical demonstrations; Realdo Colombo (m. 1599) argued in Padua the doctrine of the pulmonary circulation and in 1559 described it with experimental observations. Andrea Cesalpino (1519-1603) proposed a scheme that included the great circle and the movement of blood in the veins, directed from the periphery to the center of the human body. Although not had recognized the exact functions, Gerolamo Fabrizi d'Acquapendente (1537-1619) had, by For his part, described as early as 1603 the venous valves and their distribution in the tree vessel. Leonardo Botallo (d. Ca. 1587) studied the gunshot wounds, Giulio Cesare Aranzio (1530-1589) approached the study of the fetus. The Venetian Biondo Michelangelo (1497-1565), who worked in Naples, is remembered for having recommended the application of cold water in the dressing of wounds. Giovan Andrea Della Croce (d. 1575) was the author in 1573 of a treaty that was classic text of instruction for more than a century. Gaspare Tagliacozzi (1545-1599), author in 1597 of De surgery curtorum for insitionem, was able to illustrate the technique of rhinoplasty, which was previously known only to empirical. His work is also demonstrative of the frequent connections between the fields of medicine and morals and their effects. Could correct the defects of the nose, understood as an act capable of change the nature, met strict religious criticism. Rhinoplasty was condemned and not returned to use that at the end of the eighteenth century. In Germany he worked Wilhelm Fabry von Hilden, known as Hildanus Fabricius (1564-1634), one of the greatest surgeons of the time. The name most authoritative of the surgery of the sixteenth century was undoubtedly that of Ambroise Paré (1510-1590). Born into a modest family in the North of France, was launched the AR-te surgery, according to a widespread custom at the time, starting from the lower steps, as a student of barber-surgeons in the army and began that career wandering and dangerous part in the great war campaign in northern Italy, where he made his first experiences with the wounded in battle. The quality of his work and genius of his observations led him to reach the higher ranks of the profession, to the title of the first surgeon in the crown, and the most famous which, established over time, it suggests one of the most famous surgeons in history. In his work had had to deal with the new effectiveness detrimental artillery and firearms, introduced recently as tools of war, who got serious injury. acted developing genial quality of clinical intuition, renewing substantially different aspects of the practice, with a considerable influence among his contemporaries and a lasting trace in time. He invented and prostheses new instruments. In the treatment of wounds in fact abandoned the traditional methods of oil boiling and cautery preferred vessel ligation. Between 1545 and 1584 had published a fifteen works, in which there were expressions of unquestionable priority in different fields surgical, including obstetricians, as the description in detail of the technique of upheaval breech. Padua and the environment at the school of Fabrizi, had gained his scientific training William Harvey (1578-1657) who, with the anatomical Exercitatio de Motu Cordis et sanguinis in animalibus, in 1628, solved the problem of blood circulation. It erased the ancient doctrine Galen, who believed in a reciprocating motion of the blood, seen as a coming and going between the center and the periphery, similar to the movement of the tides and postulant a transit of blood from the heart to the right left by the porosity of the interventricular septum. For a long time, however, the application of these findings had no effectiveness in therapeutic practice. Diseases and health status of the populations had not changed with the sprouting of revolutionary scientific ideas. The knowledge of the mechanisms of body function intended as the machine did not offer real benefits to the needs of medicine and surgery, which ranged from the stimuli of a culture renewed and the needs of the practice always struggling with the old evils. In the seventeenth century, sensitive to Galileo's ideas and study deep minute machines body, observable with the new tools of optical magnification, it was stated inclination to attempts to experiment brought Also in the domain of surgery. We can remember Zambeccari Joseph (1655-1728) with works sull'ablazione gallbladder, the spleen, the liver resection and nephrectomy, or first fallacious tests for blood transfusion from animals to humans, given in Cambridge and Paris in 1667.

The view in the modern surgery

The effectiveness of the traditional surgical was limited by the problems always unchanged, which impeding his progress. Surgical wounds were followed by the phenomena of suppuration. Lacked any notion on the pathogenesis of the infection and was not even suspected of action microorganisms. It was seen that a thorough cleaning of the wound healing process allowed without strong suppurations, but the surgeon usually considered positively the formation of pus, as an inevitable fact that was explained by the theory of humors. Was interpreted in belief in the concoction, that is a kind of cooking moods discrasici, necessary for their elimination and for healing. In the eighteenth century, compared with a significant spread of pathological complications with lethal effects in wounded in the operated and postpartum women, feared infections and fevers putrid, especially in large hospitals with a high concentration of patients. The pain and shock were among the major obstacles to action operative. Opposite the first there arose, however, with the strong belief that a good surgeon does not give in to certain attitudes of pity because for save suffering it ran the risk of not treating the patient well. The states of shock that struck the subjects operated escaped at every possible theoretical understanding, and sometimes even the loss of consciousness of the patient was welcomed, eliminating the drawbacks of reactions to pain. The instruction of Paré, in the sixteenth century, had set the use of boiling oil or the hot iron on the wounds, which prevent the effect of "poisonous" bullets. He ran to the use of balms and formed several different trends, methods to "dry" or "wet" dressing. Sutures with needle and thread of linen, silk and metal, is often preferred to the suture "dry" with fasciature.Vi were those who supported the usefulness of washing with cold water, those who preferred to leave the wounds discoveries, who preached to protect them from the air. Even on the bandages there was agreement among those who wanted changed frequently and those who advocated the opposite. Cesare Magati (1579- 1647) achieved a certain notoriety for the proposed treatment "simple" and rationally wounds, bandaging only with a light cloth to protect from the air. Were not known in their real issues, even the risk of bleeding. The technique of tying, known since antiquity, had always remained little practiced. In some ways it also feared negative effects, because could be a harbinger of infection and suppuration. Moreover, requiring good knowledge anatomical that the surgeon does not always possedeva.Ancora era in the seventeenth and eighteenth centuries ligation is preferred to the twist of the vessels, the compression or even the application of substances astringents or cauterizzanti. Between the seventeenth and eighteenth centuries, alongside the many tools resulting from ancient tradition, they saw appear new irons for specialist applications, saws and drills perfected, tongs for teeth, pliers cavapalle for gunshot wounds, probes, siringotomi for anal fistula, syringes and also trocarre or foratoio triangulated, known to us as the frontline, proposed by Sanctorius (1561-1636) for the drainage of the cavity. The daily operation of the surgeon was accomplished in the practice of bloodletting, certainly the act more discussed between the therapeutic means used by medicine in its history, praised or discredited by hosts of doctors until the nineteenth century did not stop to debate, even violently, on his utility or abuse of its applicazioni.Tra interventions more frequent in the case studies surgeon, was the amputation of limbs, widely practiced on the wounded in battle. Some recommended immediate amputation, to avoid the frequent and lethal septic complications, others preferred to adopt strategies attendistiche and this debate remained substantially lit up our century. A very known and practiced since ancient times was the lithotomy, as bladder stones were always a disease spread widely. The incision of the perineum and bladder with instruments directed to the calculation, detected by touch from the finger that probed the wall bladder through the rectum, had traditional surgery. In the sixteenth century, Mariano Santo (n. 1488) had proposed his new method, called the "big machine", with the cut side that was then widely practiced by many litotomisti. Was performed with some confidence also Surgical treatment of inguinal and scrotal, compressing the sac in the channel inguinal and practicing ligation occlusive. The discussion lasted long concerned the conservation or less of the testis, as many surgeons showed a preference for castration, others considered unnecessary. The Calabrian Marco Aurelio Severino (1580-1656), creator of interesting surgical techniques, was celebrated as one of the leading surgeons of his time. But even among minor figures are of some interest, as Anton Filippo Pacifiers who published observations case studies, along with recommendations and suggestions of a medical-legal for many chirurgo.Tra who achieved considerable fame can remember the French Pierre Dionis (m. 1718) and, England, Richard Wiseman (1625-1686).

In the century of the Enlightenment and of Morgagni

The eighteenth century, the path from the deep stimuli Enlightenment, opened with the publication of De morbis artificum (1700) by Bernardino Ramazzini (1633-1714), the first manifesto of the disease workers, and closed in the consolidation of the ideas of a medicine should protect the health of populations according to the teachings of the System einer vollstaendigen medizinischen Polizey (1779), Johann Peter Frank (1745-1821). Flourished lush interpretations organism according to the construction of the "systems" in an ideological-vitalistic. The positions of Georg Ernst Stahl (1660-1734), Friedrich Hoffmann (1660-1742), William Cullen (1712-1790) and John Brown (1735-1788), were accepted by large sections of the medical profession and found supporters until Eight hundred forwarded, even though they were now becoming more and more incompatible with the luggage rich natural sciences. Excelled in surgery environments of Paris, where the foundation of a Royal Academy had marked the beginning of the century, an important moment of promotion of culture surgical. We worked prominent figures, as Pierre Joseph Desault (1744-1795), a pupil of Jean Louis Petit (1674-1750), who was the founder of the clinic surgical Hôtel Dieu, or François Chopart (1743- 1795) who proposed an original method amputation piede.Si differed also true specialist areas, such as obstetrics and ophthalmology, which have long enjoyed a certain autonomous dimension. Nicolas Andry (1658-1742), by publishing The orthopedie ou l'art de prevenir et de les enfants dans les corriger difformités du corps, in Paris in 1741, gave the new definition of orthopedics. From the eighteenth century began to develop different schools of surgery established in major universities Europe. England had wide fame Percival Pott (1714-1788), who gave his name to tuberculous spondylitis and two brothers John (1728-1793) and William Hunter (1718-1783). However the practice of traditional medicine, largely ineffective, justified still a kind distrust which conditioned the doctor-paziente.Anche people more educated could feed mixed feelings of confidence and fear of therapies. An intellectual Lombard First plan as Pietro Verri (1728-1797) could write: "Little by little we can hope ajuto ' doctors, and assaissimo there is to fear [...] If I go a bone out of place, or I will break, certainly I can not help but to resort or to a famous sculptor, or a surgeon, unless I do not I remain content with deformed or crippled, after many dangers and spasms. So it is that the surgery we have a real need, where we can reasonably make medicine no. "But it was not unanimous chorus of trusting adherence to realizing chirurgia.Possiamo reading a letter written by Charles Castelli, Canon and Professor of Mathematics and Physics at Milan, the Earl of Carpenè of Turin, in December 1771: "[...] aggravated fluxion eye and the surgeon Moscati, impostor like everyone else in this pro-profession, continues the vineyard of visits. "The same Verri we suggested an explanation, when he said that surgery was divided "in two parts, since they are two very different trades that actually does the surgeon. A craft is dependent on the medical faculty, and is fallacissimo; other craft is to operator, and has standard principles and safe. The surgeon, as regards tumors, skin ills, the plasters, the predictions and giudizj origin, quality and remedies; for this part, I say, is like the ciurmatore doctor [...] The other trade that makes the surgeon, namely that of the operator with the hand, has certain principles. Who knows the organization of the bones and the mechanism by which they are combined [...] who knows the anatomy, as knowing the needs a surgeon, can save his life by tying an artery torn from a wound; it can inocuamente remove a foreign body intruder in the human body can restore sight, freeing the axis of the eye by an opaque body; here there is no doubt, that the art of the surgeon did not principles safe, and is not of benefit. " The work destined to have major influences on the new medicine was to Giovan Battista Morgagni (1682-1771) that gave lodging to the anatomical-clinical method. His De sedibus et causis morborum for anatomen indagatis, published in 1761, taught that the phenomenology clinical disease could be explained in the lesions identified at autopsy and is considered the founding act of the "organ disease". The instruction of Morgagni did not immediately practical application, because for several decades, medicine and surgery were ruled by visions systemic and vitalistic who survived in the ambiguities of a period transition while a harbinger of great news. But at the beginning of the nineteenth century, in the embrace with acquisitions of chemistry and physics, medicine came from the uncertainties fueled by survival of different visions and surrendered to the new lesson of the clinic. The disease was not more views in the imbalance of humors or vital forces, as for centuries before, but localized and gave more strength also the workings of those who could intervene with surgical means to repair or rectify faults visible organism. Stethoscope, proposed in 1819 by René Laennec Théopile (1781-1826) to auscultate the chest, was not just a new tool, but was a revolutionary transition to a different way of think the disease. To use it, the doctor had to get rid of all the ideas in stratified medicine over the centuries, and adhere to the new visions of the clinic. Educated in this new culture, he was finally able to understand and explain on objective grounds alterations and body the very concept of disease localized riavvicinava culture of the physician and the surgeon.

Towards the safety of surgery

Between the end of the eighteenth century and the mid-nineteenth century, the interweaving of intellectual ferment, political and social, were renewed many aspects of society. Many scientific and technical innovations made possible companies that were not even imaginable, fueling a optimism confident in the achievements of progress, he touched the needs and expectations of medicine. The new climate changed his training, practice and also the social role and Professional surgeon. Gone are the days of the two surgeries, "major" and "minor", and their historical differences -although some ancient guilds of barbers and surgeons were late set - in the late eighteenth and early nineteenth century, the training profession is moved permanently in universities and intimately tied to that of medicine. The great surgeons identified themselves even with the masters of anatomy and universities in Italy were the highest caliber. Antonio Scarpa (1752-1832), in Pavia, represented a tip excellent expression of thought morgagnano, with works of paramount importance on hernias, aneurysm, cataract. Among the major Roman surgeons can remember Flajani Joseph (1741-1808) and Charles Guattani (1707-1773). The school of the Ospedale Maggiore Milan was illustrated by Giovan Battista Palletta (1748-1832) and Giovan Battista Monteggia (1762- 1815), author of a treatise that was widespread until the mid-nineteenth century. Giuseppe Baronio (1759 ca.-1811) performed experiments grafts autoplastic animals, valuable for rise of plastic surgery, if not anticipatory ideas on transplants. Michael Troy (1747- 1828) was the author of acute observations on the periosteum and diseases of the urinary bladder. If the role of doctors and surgeons had been always the one dictated by the limits of their knowledge and their instruments largely fallacious, the transformations of biological knowledge and technological renewal century were harbingers of true, deep and substantial achievements. A mid-nineteenth century, medicine finally embraced its status of biological science from which was not to be removed and on which he would build the main successive discoveries. The physiological phenomena were investigated on bases extensively renovated in schemes physical and chemical doctors of previous generations would not have even been able to understand. The knowledge of the cells and tissues, the unveiling of cellular pathology, physiology and experimental medicine, able to base his practice on certainties objective, convincing affirmation of the doctrine microbial opened unexpected paths that led to the culmination of the victorious fight disease infectious and rapid way of surgical techniques. At the beginning of the century, M.F. Xavier Bichat (1771-1802) introduced the term of the fabric, while the cell theory stated above Matias Jacob Schleiden (1804-1881) and Theodor Schwann (1810-1882), who in 1839 had published his treatise of microscopic observations. Given the cell as the basic element of life, passed to study the changes in structure and function to search of perceived signs of the disease, as did Rudolph Virchow (1821-1902) in 1859. Claude Bernard (1813-1878) in 1865 he dictated the precise directives of the new address in the experimental research, with the Introduction à l'étude de la médecine expérimentale. Pharmacology, with its parallel growth, abandoned the streets of materia medica and became a scientific discipline experimental, firmly attached to the physiology, so that at the end of the century it came to be used in therapy substances taken in the laboratory without the use of models of nature, capable of respond to the changing needs of medical therapy and the surgical. In practical applications of the healing, during the nineteenth century, it was mainly in surgery take immediate concrete profits from new science and extensive overhaul its instruments, obtaining, before the end of the century, exciting successes. A surgeon who was born the late eighteenth century and had been trained at his craft toward the beginning of the nineteenth century, would learned the manual skills of the profession according to rules derived from the heritage antiche.Avrebbe had good knowledge useful to affron-ing operations demanding: hernia, lithotomy for bladder stones, cutting of anal fistulas, plastic reconstruction of injured parties, the reduction fractures, amputations, vessel ligation and specialized fields of interest, such as the sinking of the lens opacato cataracts and obstetric maneuvers. His skill was linked to the ability to conduct operations as rapidly as possible to reduce the pain, which had little or no controlled by the few remedies known anesthetics. Was not obliged to operate in hospital operating rooms, indeed intervened mostly at home, or in any environment equipped extemporaneously, with his bare hands, and blood stains on his jacket were testimony of his commitment. The perfect quality of the acts and conduct of his hand then had to deal with the fate postoperative always uncertain, often undermined the onset of serious and very serious facts septic vanificavano general surgery. His motto the patient must always be the same: "I will have worked, God can heal." purgatives and hydration, bandages and leeches accompanied and followed the operation. The patient was immobilized by strong helpers and narrow straps to reduce the contortions that could prevent action. The field was cleaned with sponges of ice water, the wound was treated with the silver nitrate as caustic and flaps approached with patches. The surgeon was operating with its arsenal of tools manufactured by a skilled gunsmith. Pain, bleeding, shock and infection were risk factors fundamental that hindered the advance of the surgery. There wound was followed by what was defined as irritative fever and healing occurred rarely by first intention. Already at the beginning of the century passed clinical stages of great significance. In 1809, in the United States, Ephraim MacDowell (1771-1830) executed a ovariectomy on a woman of forty. The driving force of the new surgery was, however, in France, where Guillaume Dupuytren (1777-1835) was a master of vast numbers of students. Among the French cut off the name Jean Civiale (1792- 1867), who was able to start the lithotripter original method to extract the calculations from the bladder  in other European nations were flourishing centers of renewal of the surgery, with figures such as Johann Friedrich Dieffenbach (1792-1847) or Vincenz von Kern (1760-1829) in the German-speaking countries, John Bell (1763-1820) and Astley Paston Cooper (1768-1841) in Inghilterra.Tra the many Italian names can limit ourselves to remember Luigi Porta (1800-1875), who had picked up the teaching of Antonio Scarpa University of Pavia; Andrea Vaccà Berlinghieri (1773-1826) taught at Pisa; Charles Cousins (1814-1883) was clinical in Parma; Francesco Rizzoli (1809-1880), surgeon in Bologna, played a role fundamental in orthopedics Italian; Tito Vanzetti (1809-1888), taught in Padua.