(1)
Flinders University of South Australia School of Medicine, Adelaide, SA, Australia
General Surgery
Origins of Surgical Simulation
“To give efficiency in surgical operations (trainees) were asked to try their knives repeatedly on natural and artificial objects resembling diseased parts of the body before undertaking an actual operation.” Extract from an English translation of the Sushruta Samhita which was written over 1500 years ago [1]
For most of history surgery was performed without anaesthesia and pain was a limiting factor. When the patient could feel every cut the surgeon needed to be quick and over fifteen hundred years ago the authors of the Sushruta Samhita advised surgical trainees to practise their skills on simulators [1]. Whilst some of the simulators were simple items that could be easily found others required some preparation (see Table 6.1). According to the Sushruta Samhita a life-size patient simulator was used to practice bandaging of fractures [1].
The art (skill) | The simulator for demonstration and practice |
|---|---|
Specific forms of incision | Cuts in the body of a Pushpaphla a kind of gourd, Alávu, watermelon, cucumber, or Erváruka |
Cuts in the upward or downward direction | As above |
Excisions | Openings in the body of a full water bag, or in the bladder of a dead animal, or in the side of a leather pouch full of slime or water |
Scraping | A piece of skin on which the hair has been allowed to remain |
Venesection (Vedhya) | The vein of a dead animal or with the help of a lotus stem |
Probing and stuffing | Worm (Ghuna) eaten wood, or on the reed of a bamboo, or on the mouth of a dried Alávu (gourd) |
Extracting | Withdrawing the seeds from the kernel of a Vimbi, Vilva, or Jack fruit as well as by extracting teeth from the jaws of dead animal |
Secreting or evacuating | The surface of a Shálmali plank covered over with a coat of bee’s wax |
Suturing | Pieces of cloth, skin, or hide |
Bandaging or ligaturing | Tying bandages round the specific limbs and members of a full-sized doll made of stuffed linen |
Tying up a severed ear-lobe (Kama-sandhi) | Soft severed muscle or on flesh, or with the stem of a lotus lily |
Cauterizing, or applying alkaline preparations (caustics) | A piece of soft flesh |
Inserting syringes and injecting enemas into the region of the bladder or an ulcerated channel | Insert a tube into a lateral fissure of a pitcher full of water or into the mouth of a gourd (Alávu) |
In the section of the text on surgical training (Sutrasthanam) each part followed a standard format that included an “authorative verse.” The expert comment at the end of the part on practical instructions in surgical operations (Yogya-Sutra) identified a key performance outcome of simulation-based training.
An intelligent physician who has tried his prentice hand in surgery (on such articles of experiment as, gourds, etc., or has learnt the art with the help of the things stated above, or has been instructed in the art of cauterisation or blistering (application of alkali) by experimenting on things which are most akin, or similar to the parts or members of the human body they are usually applied, will never lose his presence of mind in his professional practice. [1, Authoritative verse for Chap. 9, Volume 1]
Simulation in Sixteenth Century Orthopaedics
Around a thousand years later a whole-body mannequin for demonstrating bandaging was acquired by the University of Salamanca in Spain. The country was involved in many conflicts and needed surgeons so the University created a chair of surgery and in 1567 appointed Andrés Alcazár a full professor. He developed a 4-year training course with what is now orthopaedics taught for the final year students. In 1568 Alcazár asked the University for an articulated wooden “maniqui” so that he could demonstrate the reduction of fractures and dislocations, splinting and bandaging [2]. The university agreed and one was made by Mateo de Vangorla in 1570 in time for the first cohort of students (see Fig. 6.1).
Fig. 6.1
Surgical simulator at the University of Salamanca, Spain. Made in 1570 it is in the style of Castilian religious statues of the time (Credit: University of Salamanca)
The general appearance of the mannequin reflects the local style of carved religious statues of the time and it has articulated joints, glass eyes, oral and anal holes and an articulated penis. In addition to student teaching for around 200 years1 the selection process for new professors of surgery included demonstrations of bandaging and application of ligatures on the mannequin [3]. The original anatomy theatre in Salamanca was built between 1552 and 1554 but after educational reforms in the middle of the eighteenth century it was replaced by a new one that was completed in 1780. Soon after this surgical teaching took a new direction and the mannequin was transferred to the anatomy department of the university [2].
Simulation in Early Neurosurgery
“I therefore would advise a young Artist to make some experience first upon a Calves head, or a sheepes head till he can well & easily take out a piece of bone; so shall he the more safely doe it to a man without errour when occasion is” [4].
Woodall (1617)
Many civilisations have used trepanation or trephining (i.e., drilled or cut holes in the skull) for the treatment of illnesses, head injuries, and possibly for rituals. Trepanation was undertaken thousands of years ago in Asia, South America, North Africa, and Europe [5, p. 6]. The procedure is described in the body of works associated with Hippocrates from around 500 years BCE and the term trepanation is derived from the Greek word for a borer [5, p. 6]. From around the same time there are accounts of the Buddhist physician and surgeon Jĩvaka Komãrabhacca learning trepanation as an apprentice and later performing it successfully to remove parasites from the brain [6, pp. 50–70].
Galen of Pergamum obtained much experience in trauma surgery, including trepanning, whilst he was surgeon to the gladiator school in Rome in the second century CE. Galen wrote about the indications for performing the operation and how it was done and recommended trainees perfect their technique on animals, ideally primates [5, 7]. Bailey reported that an old skull found by a French surgeon in Morocco had been used to teach the trepanning [8]. Studies of skulls from South America have revealed that trepanation was practised in south-central Peru around a thousand years ago during the Early Late Intermediate Period (c. 1000–1250 CE) [9]. Several of the skulls have rows of holes and partially and completed procedures that were made post-mortem (See Fig. 6.2) and Kurin has suggested these holes were the result of early practitioners using simulation to improve their surgical skills [9].
Fig. 6.2
Peruvan skull showing many holes drilled to practice trepanation. The inset shows that the original owner of the skull had previously survived another trepanation (Credit: Danielle Kurin © 2013)
A specialist text on skull fractures, De Fractura Calvae sive Cranei, by Jacopo Berengario da Carpi was published in Bologna in 1518. Berengario recommended that only a skilful surgeon who has practised for a long time should learn to operate on the head [10, p. 154]. A little over a hundred years later John Woodall (1570–1643) recommended in his book The surgeon’s mate or military and domestique surgery first published in 1617 that in the interests of patient safety young surgeons should practice “trephining” on animals before attempting the procedure on patients [11, pp. 72–73].
In a later edition of the Surgeon’s mate published in 1639 Woodall shows trepanation being practised on a human skull using a three-ended surgical instrument called a tres fines (see Fig. 6.3). Hieronymus Fabriciuis ab Aquapendente, had also developed a three-ended instrument for making holes in the skull called a tres fines and this name led to the term trephining [5, p. 6].
Fig. 6.3
Trepanning instruments from “The surgeons mate or military and domestique surgery” (1639). Woodall’s tres fine (trephine) shown in the collection of tools was more suited to use on a rolling ship than brace and bit trepans (Credit: Wellcome Library, London)
Simulation of trephining was mentioned in the Gentleman’s Magazine in 1907 in a Retrospective Review of the Vade Mecum by Thomas Brugis published in 1651 [12]. Brugis had written that “a man can never be too wary in such a business; otherwise may kill his patient ere he doth find or perceive he is through.” Brugis favored Woodall’s “trafine” and he mostly followed the method Woodall described in his book and readers were told “Mr. John Woodall adviseth the young Artist to make tryal on a calves head, or the like subject before he put in practice upon a man.”
The report of a successful Caesarean Operation in Florence in 1828 led the editor of the Medico-Chirurgical Review and Journal of Practical Medicine to comment on an important difference between surgical training in Great Britain and in Europe.
In this country students have few opportunities of putting the knife upon the living body till, in private practice they have the whole responsibility on their heads, and none to direct to their trembling hand. The continental rule of permitting students to operate under the direction of their masters, is assuredly better calculated for sending forth, into private life men capable of operating, than plans here prevailing. [13, p. 265]
Simulated Patients
When Louis XIV of France developed an anal fistula in 1868 he was reluctant to have surgery. Many alternative treatments were suggested and these were tested on peasants with the condition who acted as simulated patients for the king. After a year of trials none of the therapies had been successful and the king agreed to undergo surgery [14, pp. 99–103]. The nominated surgeon, Charles-François Félix de Tassy (1650–1703), then spent several months perfecting the technique and modifying the surgical instruments used, again on peasants [15, p. 902]. Fortunately for all concerned when the operation was finally performed it was completely successful.
Surgical Simulation on Cadavers
“the true question is, whether the surgeon shall be allowed to gain knowledge by operating on the bodies of the dead, or driven to obtain it by practising on the bodies of the living” [16, p. 52–53].
Mackenzie 1824
Dissection has been an important part of surgical training for hundreds of years. Dissection helped students appreciate the anatomical relationship of organs, nerves, blood vessels, etc., and in the process they became familiar with cutting. Cadavers were frequently used by students to practise surgical procedures and by surgeons to develop new operations. In seventeenth century France the final examination of surgical trainees included operations on cadavers [17, p. 190].
Europe
The availability of bodies from the large public hospitals in Paris in the eighteenth century attracted medical students from all over Europe . There were free lectures on anatomy and surgery but the aspiring surgeon sought out private teaching for, as Denis Diderot explained, “private schools [are] more instructive, where the student works by himself and practises operations” [18, p. 239].
Pier Paulo Mollinelli, professor of surgery in Bologna, introduced surgical training on cadavers which he had seen when he was a student in Paris. The bodies came from local hospitals including l’Ospedale della Santa Maria della Morte and l’Ospedale della Santa Maria della Vita and the surgical instruments used had been donated by Pope Louis XV [19, p. 115]. The aim of practice on cadavers was to develop confidence and speed which were particularly important when surgery was being performed without anaesthesia. Portal visited Italy in 1731 and noted that Molinelli gave public demonstrations of operations on cadavers [20, p. 62].
Cadavers were much used for surgical training in Germany. Guidelines for surgical exercises on the cadaver and their utilization on the living by Ernst Julius Gurlt was first published in 1881 [21] and The typical operations and their practice on the body by Emil Rotter was published in 1892 [22].
Britain
When Willam Hunter introduced individual dissection into private surgical training in London in the middle of the eighteenth century he advertised he would be teaching in “the same manner as Paris” [23]. Obtaining bodies for the mostly private anatomy schools in London and other cities could be profitable and led to a new occupation, that of the resurrectionist or body snatcher [24]. In 1824, William Mackenzie, then a professor of anatomy and surgery in Glasgow wrote An appeal to the Public and to the Legislature on the Neccessity of affording Dead Bodies to the Schools of Anatomy, by Legislative Enactment. In the Appeal Mackenzie asked what he called “the true question” which was,
whether the surgeon shall be allowed to gain knowledge by operating on the bodies of the dead, or driven to obtain it by practising on the bodies of the living. If the dead bodies of the poor are not appropriated to this use, their living bodies must be and will be. The rich will always have it in their power to select, for the performance of an operation the surgeon who has signalized himself by success: but that surgeon, if he have not obtained the dexterity which ensures success, by dissecting and operating on the dead, must have acquired it by making experiments on the living bodies of the poor. [16]
In Edinburgh William Burke and William Hare committed several murders in 1828 to obtain bodies which they sold to a surgeon-anatomist who didn’t ask too many questions. The Government’s response to this scandal was the Anatomy Act of 1832 which was not the legislation that Mackenzie and other anatomists wanted and it would have an adverse impact on private schools of anatomy and medicine in Britain.
The Grosvenor Place School of Anatomy and Medicine in London provided students with corpses to practise sutures, ligatures, amputations, and the disarticulation and resection of bones; to insert catheters into various tubes and ducts; to perform tracheotomies and the operation of lithotomy, repair fistulas, and remove cataracts [25]. A notice published by the Grosvenor Place School explained that students were divided into groups of eight and each group was provided with four subjects (cadavers). Each operation was demonstrated to a group and students were supplied with the appropriate surgical instruments.
Surgical procedures taught on cadavers at the Grosvenor Place School of Anatomy and Medicine c. 1835 [26]
Operative Surgery
1.
The various kinds of sutures.
2.
Subcutaneous ligatures.
3.
All the ligatures of arteries on both upper and lower limbs, and both sides of the neck.
4.
Such of the Amputations, Disarticulations, or Resections of the hand and foot, as the Pupils themselves may choose.
5.
All the Amputations and Disarticulations of the following bones and joints, or Resections should the Pupil prefer; wrist-joint, forearm, elbow-joint, arm, shoulder-joint, leg, knee-joint, thigh, hip-joint, leg, and inferior maxillary.
6.
The catheterism of the urethra, Nasal Duct, and Eustachian Tube.
7.
Lithotomy.
8.
Operation for lachrymal fistula.
9.
Autoplastic operations on the Nose, Eyelids, and Lips.
10.
Tracheotomy.
11.
Operations for Cataract, if the state of the eyes allow it.
Students worked in groups of eight and each group was provided with four subjects (cadavers). Each operation was demonstrated to a group and students were supplied with the appropriate surgical instruments. The fee for the course was £7 7s.
The United States
A nationwide audit of healthcare during the American Civil War (1861–1865) was undertaken by the US government and published in several volumes under the title “Medical and Surgical History of the War of the Rebellion” between 1870 and 1888. This series systematically detailed how illness and injury were managed during the conflict2 and drew lessons from the outcomes. Part 2 Volume 2, published in 1876, was on trauma of the abdomen, pelvis, back and upper extremities flesh wounds of the back, and wounds and injuries [27]. In the chapter on wounds penetrating the abdomen there was a recommendation that intestinal suturing “…should not be attempted on the living subject until the operator has acquired some experience by practicing, as M. Enno used to require his pupils to do, either using the fingers of a glove, or, better still, upon a recent subject, or on intestines placed in a manikin.”
John Allan Wyeth (1845–1922) had fought for the Confederates until he was captured. After the war he studied medicine and became aware of the limitations of medical schools in the United States. He became a successful surgeon in New York where he established the New York Polyclinic Medical School and Hospital, the first post-graduate medical institution in the United States. Wyeth recognized the value of simulation for surgical skill training and in a paper on intestinal surgery published in 1888, concluded,
Finally, the subject of intestinal suture is one of such vast importance that too much stress cannot be laid upon the necessity for a thorough preparation for the operation. In the careful application of this procedure to penetrating wounds of the intestines, to exsection of gangrenous portions of the canal as the result of hernia, volvulus, intussusception, and in the removal of malignant neoplasms and strictures, many lives may be saved which, under the teaching of former years, were left to die without surgical interference. The difficulties of the operation are great, and the time required in exsection dangerously long, unless the surgeon has had sufficient practice to enable him to work rapidly and safely. I would advise those who are willing to undertake this procedure to perfect themselves in the various sutures upon the cadaver, or preferably upon living animals. I was deeply impressed with the importance of this in my own case, for, notwithstanding that I had done this operation upon the cadaver about ten times, four hours were occupied in the case which forms the subject of this paper. [28]
More than fifty years later advertisements for courses at the New York Polyclinic still included references to use of the manikin and cadaver for training [29].
Cadavers were widely used in US medical schools in the second half of the nineteenth century and early twentieth century. Operative Surgery on the Cadaver by Jasper Jewett Garmany (1859–1947), professor of surgery at the Belleview Hospital Medical College in New York, published in 1887 described a complete course on cadavers. The first chapters of the book outlined how to perform what we now call clinical skills on bodies and later chapters included some complex surgical procedures [30]. In the book every orifice and duct was probed or catheterised, needles and tubes were inserted into cavities and the scalpel was used for incision and drainage. The chapters on surgery were arranged by body system and the last chapter was on amputations and disarticulations which ranged from fingers and toes to hips and shoulders. A review of this book described it a “very good manual to a course on operative surgery; succinct, clear, and comprehensive” [31].
The intended syllabus of surgery at medical schools in the United States was often outlined in the bulletins, catalogues, and annual announcements they published, for example:
The Columbian University, Washington DC 1897
SURGERY: Every effort is made to teach Surgery in accordance with the latest developments of scientific research. At the School operations are performed upon the cadaver, and the uses of all important surgical instruments and appliances are demonstrated in the same manner [32, p. 175].
Medical Department of the University of California, San Francisco, California 1892 (Annual announcement of lectures at Toland Hall
SURGERY: The more recent views on the management of surgical conditions, and the appliances devised for their relief, are particularly dwelt upon and illustrated with drawings and models when necessary. The course will include a series of lectures upon Operative Surgery, with demonstrations on the cadaver. The students will be drilled in the manipulation of instruments used in the various operations [33, p. 10].
College of Physicians and Surgeons, Baltimore MD 1900
SURGERY: The course in surgery extends over the third and fourth years. During the third year, by lectures, quizzes, and systematic reading, the ground of Surgical Pathology—wounds, burns, fractures, and dislocations is gone over. At the same time all of the various surgical operations are taught by description and then by direct work, either upon the lower animals or upon the cadaver. This work being done by the students and overlooked by the Professors and Demonstrators, carries with it the advantages of clinical work. [34]
Columbia University College of Physicians and Surgeons, 1901
MINOR SURGERY: Each course will consist of ten lessons, and include the application of bandages and the various dressings used for the treatment of Wounds, Fractures, Dislocations, etc. The number in each class will be limited to ten, so that each member may have ample opportunity of practising the various manipulations, and applying the different kinds of dressings on the manikin or cadaver [35, pp. 15–16]
Meharry Medical College of Walden University, Nashville TN, 1904
SURGERY: Students are required to perform amputations on the cadaver, and surgical operations are performed before the class [36, p. 9].
Georgetown University School of Medicine, Washington DC. 1910.
SURGERY: Students are instructed in the practical use and application of bandages, fracture dressings, and other surgical apparatus. The use of the principal surgical instruments is also demonstrated on the living subject or on the cadaver. Members of the Fourth Class are instructed in orthopedic and genitourinary surgery by lectures and clinical demonstrations, and are given a course in operative surgery on the cadaver, in which nearly every operation, minor and capital, classic and modern, is done by the student under the direction of the professor and his assistants [37, pp. 144–145].
Victor C. Vaughan provided some memories of teaching at the Michigan University Medical School in Ann Arbor in the January 1927 issue of the Alumi magazine [38].
As a student I saw more than one surgical operation performed on a cadaver, or illustrated on a manikin, or figured in detail on charts, the day before I saw the operation on the patient. More frequently I saw these demonstrations the day after the operation. These procedures were highly helpful to the student.
Australia
In the late nineteenth and early twentieth centuries the bodies of those who had died in public institutions in Adelaide, South Australia became “Government corpses” if they were not claimed by family within 12 h and were used by medical students to practice operations.
Some insight into the use of cadavers for teaching surgery in medical schools in Australia at the end of the nineteenth century can be obtained from the report of a scandal over improper use of bodies in Adelaide, South Australia [25]. In 1884 the province (colony) of South Australia had passed an act to regulate schools of anatomy which like similar acts in other colonies was modelled on the British anatomy act of 1832 but there were some significant changes. In the British act the bodies of those who died in government institutions could be transferred to an authorized school of anatomy unless claimed within 48 h. In the South Australian legislation, family and friends were given just 12 h because, according to the Attorney General at the time, if a dissection needed to be performed quickly it would be “inconvenient” to have to find a relative to give consent. The anatomy acts of the time mostly referred to the procedure the corpse would undergo as an “anatomical examination.” The South Australian act did have a redeeming feature, a “decency clause” that required students to be well behaved when examining corpses and not mutilate them.
At the beginning of the twentieth century William Ramsay Smith was both the coroner in South Australia and, conveniently the South Australian anatomy inspector. In 1903 Smith held a coronial inquest into the death of Eugene Green and afterwards invited the medical students present to use the body to practice procedures, which was not unusual by the standards of the time. The students were note closely supervised and later the constable assisting the coroner found fingers and toes strewn around and a kidney was on the floor. Also, the skull had been removed and the liver had been used to hold the face in shape. Smith was charged with misconduct and suspended from duty and a Board of Inquiry was established. Wisely, Smith employed the best counsel in Adelaide to represent him.
The inquiry discovered there was little respect for “government corpses.” Smith used the bodies that passed through his jurisdiction for experiments such as the effect of different bullets on the skull. He also collected body parts, particularly skulls, and had bodies filleted for their skeletons. He kept some material for his own collection but much was sent overseas and it was later found that Smith had been the biggest single donor of Australian Aboriginal material to British museums. Also, it was not unusual for students to go to the morgue to practise operative anatomy and the hospital porter who collected specimens for Smith routinely cut the heads off corpses and sold them to students for five shillings each. Smith’s counsel was able to persuade the Board that all the procedures performed on Green’s body were part of an anatomical examination and everything that Smith had done was lawful.
Hernia Surgery Simulation
“Dr Howard’s Hernia Manikin, for demonstrating Surgical Anatomy, and treatment of Hernia, and for illustrating its descent and protrusion. Price $12” [39].
Advertisement in the New York Medical Journal (1870)
Even when there was a good supply of cadavers it was only by chance that students would see a particular condition. The surgeon Ameline recognised that anatomical models could be used to demonstrate disease or condition and different stages of the same condition [40]. To demonstrate this concept Ameline made a series of models of the development of different hernias that he presented in 1822 [41]. The models received positive reviews from other surgeons [40] but they were expensive to produce at a time when cadavers were readily available in France [42, pp. 112–117]
Phantom des Schenkelringes und Leistenkanales (Phantom of the femoral ring and inguinal canal) was a small book by G.E. Matthes published in 1862 [43]. The book had three tables of the area showing different stages of dissection. Matthes’s Table 1 showed a superficial dissection and Tables 2 and 3 showed progressively deeper dissections. Tables 2 and 3 had several flaps that opened to show the relationships between structures (see Fig. 6.4).
Fig. 6.4
Table 2 from Phantom des Schenkelringes und Leistenkanales by G.E. Mathes showing the superficial anatomy (a) and with flaps lifted (b) to show deeper structures [43]
Dr. Benjamin Howard demonstrated a hernia manikin (see Fig. 6.5) at a meeting of the Medical Society of New York in 1869 [44] and a paper on the simulator was published later in the year [45, p. 46] Howard explained a simulator was necessary because current teaching methods placed “undue reliance upon didactic description” and “obscurity of demonstration” meant students didn’t understand the anatomy of inguinal hernia. Howard’s manikin was also a skill trainer on which students could practice reducing a hernia. The simulated intestines had the correct shape and feel for this and they even made an authentic gurgle when the loop was returned to the abdomen.
Fig. 6.5
The back (a) and front (b) of Howard’s hernia manikin used to explain the development and treatment of inguinal hernia [45, p. 46]
Jules Regnault, a French surgeon, also made a hernia simulator from canvas early in the twentieth century. Regnault developed this simulator so he could practice performing a hernia repair operation on himself [46].
Urology
“I will not cut persons labouring under the stone….but will leave this to be done by men who are practitioners of this work.” From “the Oath” attributed to Hippocrates who lived around 400 BCE. [47]
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