THE HISTORY OF SURGERY

Surgery is the branch of medicine that deals with the physical manipulation of a bodily structure
to diagnose, prevent, or cure an ailment. Ambroise Par, a 16th century French surgeon, stated
that there were to perform surgery !"o eliminate that which is superfluous, restore that which
has been dislocated, separate that which has been united, #oin that which has been divided and
repair the defects of nature.!
Since humans first learned to ma$e and handle tools, they have employed their talents to develop
surgical techni%ues, each time more sophisticated than the last& however, up until the industrial
revolution, surgeons were incapable of overcoming the three principal obstacles which had
plagued the medical profession from its infancy ' bleeding, pain and infection. Advances in
these fields have transformed surgery from a ris$y !art! into a scientific discipline capable of
treating many diseases and conditions.
Generalities
"he surgical profession has suffered numerous brea$throughs and setbac$s throughout history. (n
general, the surgeon has been considered the technician while the physician )more historically
related to the priest and shaman* was the true healer. +uring the development of modern
medicine, both disciplines were taught together and one could obtain the %ualifications to
practice medicine and surgery. A good bit of history, in any case, is intimately related with the
history of general medicine. ,ew archaeological technologies confirm that the origin of
medicine coincides with the appearance of modern humans.
[edit]Origins
"he first surgical techni%ues were developed to treat in#uries and traumas. A combination of
archaeological and anthropological studies offer insight into man-s early techni%ues for suturing
lacerations, amputating insalvageable limbs, and draining and cauteri.ing open wounds. /any
e0amples e0ist some Asian tribes used a mi0 of saltpeter and sulfur that was placed onto wounds
and lit on fire to cauteri.e wounds& the +a$ota (ndians used the %uill of a feather attached to an
animal bladder to suc$ out purulent material& the discovery of needles from the stone age seem to
suggest they were used in the suturing of cuts )the /aasai used needles of acacia for the same
purpose*& and tribes in (ndia and South America developed an ingenious method of sealing minor
in#uries by applying termites or scarabs who ate around the edges of the wound and then twisted
the insects nec$ leaving their heads rigidly attached li$e staples.
112
[edit]Trepanation
"he oldest operation for which evidence e0ists is trepanation
132
)also $nown as trepanning,
trephination, trephining or burr hole from 4ree$ and *, in which a hole
isdrilled or scraped into the s$ull for e0posing the dura mater to treat health problems related to
intracranial pressure and other diseases. (n the case of head wounds surgical intervention was
implemented for investigating and diagnosing the nature of the wound and the e0tend of the
impact while bone splinters were removed preferably by scraping followed by post operation
procedures and treatments for avoiding infection and aiding in the healing process.
152162
7vidence
has been found in prehistoric human remains from Proto8,eolithic
192
and,eolithic times, in cave
paintings, and the procedure continued in use well into recorded history )being described
by ancient 4ree$ writers such as :ippocrates among others*. ;ut of 13< prehistoric s$ulls found
at one burial site in France dated to 69<< =>7, 6< had trepanation holes.
162
Fol$e :enschen, a
Swedish doctor and historian, asserts that Soviet e0cavations of the ban$s of the +nieper ?iver in
the 1@A<s show the e0istence of trepanation in /esolithic times dated to appro0imately 13<<<
=>7.
1A2
"he remains suggest a belief that trepanning could cure epileptic sei.ures, migraines,
and mental disorders.
1B2
/any prehistoric and premodern patients had signs of their s$ull structure healing, suggesting
that many of those that proceeded with the surgery survived their operation. (n some studies the
rate of survival surpassed 9<C.
1@2
[edit]Setting bones
Among some treatments used by the A.tecs, according to Spanish te0ts during the con%uest of
/e0ico, was the reduction of fractured bones !...the bro$en bone had to be splinted, e0tended
and ad#usted, and if this was not sufficient an incision was made at the end of the bone, and a
branch of fir was inserted into the cavity of the medulla...!
11<2
/odern medicine developed a
techni%ue similar to this in the 3<th century $nown as medullary fi0ation.
[edit]Anesthesia
Main articles: History of general anesthesia an History of tracheal int!"ation
[edit]Bloodletting
Hir!o #eicinalis. Deeches for bloodletting
=loodletting is one of the oldest medical practices, having been practiced among diverse ancient
peoples, including the /esopotamians, the7gyptians, the 4ree$s, the /ayans, and the A.tecs. (n
4reece, bloodletting was in use around the time of :ippocrates, who mentions bloodletting but
in general relied on dietary techni%ues. 7rasistratus, however, theori.ed that many diseases were
caused by plethoras, or overabundances, in the blood, and advised that these plethoras be treated,
initially, by e0ercise, sweating, reduced food inta$e, and vomiting.:erophilus advocated
bloodletting. Archagathus, one of the first 4ree$ physicians to practice in ?ome, practiced
bloodletting e0tensively and gained a most sanguinary reputation. "he art of bloodletting became
very popular in the Eest, and during the ?enaissance one could find bloodletting calendars that
recommended appropriate times to bloodlet during the year and boo$s that claimed bloodletting
would cureinflammation, infections, stro$es, manic psychosis and more.
1112
[edit]Antiqit!
[edit]"esopota#ia
Ha##!ra"i$s %oe itself contains s&ecific legislation reg!lating s!rgeons an #eical
co#&ensation as 'ell as #al&ractice an (icti#$s co#&ensation)
=erossus, a 5rd century =>7 >haldean philosopher wrote considerably about the traditional
=abylonian medical techni%ues )principally in the archives of =orsippa* and went on to assert
that the god ;annes taught the Sumerian people all that was to be $nown about civili.ation and
that nothing new had been invented. "his assertion seemed hyperbolic until analysis of Sumerian
tablets showed that the /esopotamian civili.ation had developed or invented numerous medical
techni%ues thousands of years before they were re8developed or re8invented by the 7uropeans.
1citation neee2
Some 6<<< =>7 the Sumerian civili.ation was established in /esopotamia between
the "igris and 7uphrates rivers, creating the oldest form of writing, cuneiform. ;f the 5<,<<< or
so cuneiform tablets that have been discovered, about B<< of them deal with medical themes )one
of these being the first prescription $nown to have been written*. "he name of the first surgeon
is Frlugaledin, from the 6<<< =>7, whose personal seal depicts two $nives encircled by
medicinal plants. "his seal is now housed in the Douvre.
"he Sumerians saw sic$ness as a divine punishment imposed by different demons when an
individual bro$e a rule. For this reason, to be a physician, one had to learn to identify
appro0imately 6,<<< possible demons that might cause health problems. "o do this, the
Sumerians employed divining techni%ues based on the flight of birds, position of the stars and
the livers of certain animals. (n this way, medicine was intimately lin$ed to priests, relegating
surgery to a second8class medical specialty.
1132
,evertheless, the Sumerians developed several important medical techni%ues
in ,inevah archaeologists have discovered bron.e instruments with sharpened obsidian
resembling modern day scalpels, $nives, trephines, etc. :ammurabi-s >ode itself contains
specific legislation regulating surgeons and medical compensation as well as malpractice and
victim-s compensation
1152
319. (f a physician ma$e a large incision with an operating $nife and cure it, or if he open a
tumor )over the eye* with an operating $nife, and saves the eye, he shall receive ten she$els in
money. 316. (f the patient be a freed man, he receives five she$els. 31A. (f he be the slave of
some one, his owner shall give the physician two she$els. 31B. (f a physician ma$e a large
incision with the operating $nife, and $ill him, or open a tumor with the operating $nife, and cut
out the eye, his hands shall be cut off. 31@. (f a physician ma$e a large incision in the slave of a
freed man, and $ill him, he shall replace the slave with another slave. 33<. (f he had opened a
tumor with the operating $nife, and put out his eye, he shall pay half his value.
[edit]India
Archaeologists made the discovery that the people of (ndus Galley >ivili.ation, even from the
early :arappan periods )c. 55<< =>7*, had $nowledge of medicine and dentistry. "he physical
anthropologist that carried out the e0aminations, Professor Andrea >ucina from the Fniversity of
/issouri8>olumbia, made the discovery when he was cleaning the teeth from one of the men.
Dater research in the same area found evidence of teeth having been drilled, dating bac$ @,<<<
years to A<<< =>7.152
Sushruta )c. 6<< =>7* taught and practiced surgery on the ban$s of the 4anges in the area that
corresponds to the present day city of =enares in ,orthern (ndia. /uch of what is $nown about
Sushruta is in Sans$rit contained in a series of volumes he authored, which are collectively
$nown as the *!sr!tha *a#hita. (t is the oldest $nown surgical te0t and it describes in e0%uisite
detail the e0amination, diagnosis, treatment, and prognosis of numerous ailments, as well as
procedures on performing various forms of plastic surgery, such as cosmetic surgery
and rhinoplasty.
1162
(n the Sushruta school, the first person to e0pound Hyurvedic $nowledge was +hanvantari who
then taught it to +ivodasa who, in turn, taught it to Sushruta, Aupadhenava, Aurabhra,
Pausha$alIvata, 4opurara$shita, and =ho#a.
=ecause of his seminal and numerous contributions to the science and art of surgery, Sushruta is
also $nown by the title !Father of Surgery!. "he Samhita has some writings that date as late as
the 1st century, and some scholars believe that there were contributions and additions to his
teachings from generations of his students and disciples. Susrutha is also the father of Plastic
Surgery and >osmetic Surgery since his techni%ue of forehead flap rhinoplasty )repairing the
disfigured nose with a flap of s$in from the forehead*,that he used to reconstruct noses that were
amputated as a punishment for crimes, is practiced almost unchanged in techni%ue to this day.
1citation neee2
"his $nowledge of plastic surgery e0isted in (ndia up to the late 1Bth century as can be
seen from the reports published in 4entleman-s /aga.ine );ctober 1A@6*.
"he Sushruta Samhita contains the first $nown description of several operations, including the
uniting of bowel, the removal of the prostate gland, the removal of cataract lenses and the
draining of abscesses. Susrutha was also the first surgeon to advocate the practice of operations
on inanimate ob#ects such as watermelons, clay plots and reeds& thus predating the modern
practice of the surgical wor$shop by half a millennium.
[edit]Eg!pt
*ee also: +gy&tian #eical &a&yri
Pictures of surgery tools at Jom ;mbo, 7gypt
Around 51<< =>7 7gyptian civili.ation began to flourish when ,armer, the first Pharaoh of
7gypt, established the capital of /emphis. Kust as cuneiform tablets preserved the $nowledge of
the ancient Sumerians, hieroglyphics preserved the 7gyptian-s.
(n the first monarchic age )3A<< =>7* the first treaty on surgery was written by (mhotep, the
vi.ier of Pharaoh +#oser, priest, astronomer, physician and first notable architect. So much was
he famed for his medical s$ill that he was deified, becoming the 7gyptian god of medicine.
1192
;ther famous physicians from the Ancient 7mpire )from 39<< to 31<< =>7* were Sachmet,
the physician of Pharaoh Sahure and,esmenau, whose office resembled that of a medical
director.
;n one of the door#ambs of the entrance to the "emple of /emphis there is the oldest recorded
engraving of a medical procedure circumcisionand engravings in Jom ;mbo, 7gypt depict
surgical tools. Still of all the discoveries made in ancient 7gypt, the most important discovery
relating to ancient 7gyptian $nowledge of medicine is the 7bers Papyrus, named after its
discoverer 4eorg 7bers.
"he 7bers Papyrus, conserved at the Fniversity of Deip.ig, is considered one of the oldest
treaties on medicine and the most importantmedical papyri. "he te0t is dated to about 199< =>7
and measures 3< meters in length. "he te0t includes recipes, a pharmacopoeia and descriptions of
numerous diseases as well as cosmetic treatments. (t mentions how to surgically treat crocodile
bites and serious burns, recommending the drainage of pus8filled inflammation but warns against
certain diseased s$in.
"he 7dwin Smith Papyrus is a lesser $nown papyrus dating from the 16<< =>7 and only 9
meters in length. (t is a manual for performing traumatic surgery and gives surprisingly accurate
advice given the time. For e0ample, it gives instructions for dealing with dislocated vertabra
"hou shouldst bind it with fresh meat the first day. "hou shouldst loose his bandages and apply
grease to his head as far as his nec$, )and* thou shouldst bind it with ymrw . "hou shouldst treat
it afterwards with honey every day, )and* his relief is sitting until he recovers.
[edit]Gree$e
*ee also: ,ncient -ree. #eicine
Surgeons are now considered to be speciali.ed physicians, whereas in the early ancient 4ree$
world a trained general physician had to use his hands )/01 in 4ree$* to carry out all medical
and medicinal processes including for e0ample the treating of wounds sustained in the battle
field, or the treatment of bro$en bones )a process called in 4ree$ /0201*. "he:ippocratic
;ath,
1162
written in the 9th century => provides the earliest protocol for professional conduct and
ethical behavior a young physician needed to abide by in life and in treating and managing the
health and privacy of his patients. "he multiple volumes of the :ippocratic corpus
11A2
and
the :ippocratic ;ath elevated and separated the standards of proper :ippocratic medical conduct
and its fundamental medical and surgical principles from other practitioners of fol$ medicine
often laden with superstitious constructs, andLor of specialists of sorts some of whom would
endeavor to carry out invasive body procedures with dubious conse%uences, such
as lithotomy. 4alen of Pergamum )4ree$ 345*
11B2
is an e0cellent paradigm of a very
accomplished 4ree$ surgeon and physician of the ?oman period )3nd century*, who carried out
very comple0 surgical operations and added significantly to the corpus of animal and human
physiology and the art of surgery.
[edit]%hina
:ua "uo was a famous >hinese physician during the 7astern :an and "hree Jingdoms era. :e
was the first person to perform surgery with the aid of anesthesia, some 16<< years before the
practice was adopted by 7uropeans.
11@2
=ian Mue )Pien >h-iao* was a !miracle doctor! described
by the >hinese historian Mima ,an in Shi Ki who was credited with many s$ills. Another
boo$, Die.i )Dieh ".u* describes that =ian Mue conducted a two way e0change of hearts between
people.
13<2
"his account also credited =ian Mue with using general anaesthesia which would place
it far before :ua "uo, but the source in Die.i is %uestioned and the author may have been
compiling stories from other wor$s.
1312
,onetheless, it establishes the concept of heart
transplantation bac$ to around 5<< >7.
[edit]"iddle Ages
[edit]Eastern he#isphere
Surgery in :olland )ca. 16@<*
"he surgeon-s consultation room, a painting by =althasar van den =ossche
Abulcasis )Abu al8Masim Jhalaf ibn al8Abbas Al8Nahrawi* was an Andalusian8Arab physician
and scientist who practised in the Nahra suburb of>ordoba. :e is considered a great medieval
surgeon, whose comprehensive medical te0ts, combining (slamic medicine with 4reco8
?oman and (ndian teachings, shaped 7uropean surgical procedures up until the ?enaissance. :e
is often regarded as the Father ;f Surgery.
1332
Patients and students from all parts of 7urope came
to him for treatment and advice. According to Eill +urant, >ordoba was in this period the
favorite resort of 7uropeans for surgical operations.
[edit]&estern he#isphere
=y the 15th century, many 7uropean towns were demanding that physicians have several years
of study or training before they could practice./ontpellier, Padua and =ologna Fniversities were
particularly interested in the academic side to Surgery, and by the 19th century at the latest,
Surgery was a separate university sub#ect to Physic )/edicine*. Surgery had a lower status than
pure medicine, beginning as a craft tradition until ?ogerius Salernitanus composed
his %hir!rgia, which laid the foundation for the species of the occidental surgical manuals,
influencing them up to modern times.
Ambroise Par pioneered the treatment of gunshot wounds. Among the first modern surgeons
were battlefield doctors in the ,apoleonic Earswho were primarily concerned with amputation.
,aval surgeons were often barber surgeons, who combined surgery with their main #obs as
barbers.
(n Dondon, an operating theatre or operating room from the days before
modern anaesthesia or antiseptic surgery still e0ists, and is open to the public. (t is found in the
roof space of St "homas >hurch, Southwar$, Dondon and is called the ;ld ;perating "heatre.
[edit]Fondations o' #odern srger!
"o ma$e the transition to the modern era, the art of surgery had to solve three ma#or problems
' bleeding, infection, and pain ' that effectively prevented surgery from progressing into
modern science.
[edit]Bleeding
=efore modern surgical developments, there was a very real threat that a patient would bleed to
death on the table during an operation or while being attended after an accident or wound. "he
first real progress in combating bleeding had come when early cultures reali.ed they could close
wounds using a procedure called cauteri.ing. "he early cauteri.ation was successful, but only
usable in a limited fashion, highly destructive, and painful, with very poor long term outcomes.
1(erification neee2
"he ne0t real brea$through to come was the invention of ligatures, widely believed to have
originated with Abulcasis
1352
in the 1<th century and improved by Ambroise Par in the 16th
century. A ligature is a piece of material used to tie closed the end of a severed blood vessel to
prevent further bleeding. Digatures form the basis of modern bleeding control, but at the time,
they were more of a ha.ard than a help because the surgeons using them had no concept of
infection control.
Another barrier to be overcome was the problem of replacing blood lost. Dimiting bleeding is
important, but ultimately, a surgeon is fighting a losing battle if blood cannot be replaced, and
this final barrier was only con%uered when early 3<th century research into blood groups allowed
the first effective blood transfusions.
"he ultimate problem, however, was for the medical profession to recogni.e that blood loss was
a ma#or threat to the survival of the patient. (n fact, doctors would typically bleed
patients.=loodletting was used to treat almost every disease and it was thought to prevent
infection. =efore surgery blood was removed to prevent inflammation. =efore amputation it was
customary to remove a %uantity of blood e%ual to the amount believed to circulate in the limb
that was to be removed.
1362
"he practice was abandoned only in the late 1@th century.
[edit]In'e$tion
"he first progress in combating infection was made in 1B6A by the :ungarian doctor (gna.
Semmelweis who noticed that medical students fresh from the dissecting room at Gienna 4eneral
:ospital were causing e0cess maternal death compared to midwives. Semmelweis, despite
ridicule and opposition, introduced compulsory handwashing for everyone entering the maternal
wards and was rewarded with a plunge in maternal and fetal deaths. :is teachings were not
accepted during his lifetime, however, and after writing a boo$ denouncing the medical
establishment and sending increasingly furious letters to prominent 7uropean obstetricians, he
was dismissed as insane. :e was institutionali.ed and, in a cruel irony, died ofsepticaemia in a
mental hospital.
"he ne0t true progress came when, after reading a paper by (ois )aster, the =ritish
surgeon *oseph (ister began e0perimenting with using $arboli$ a$id during surgery to
prevent infections. Dister was able to %uic$ly reduce infection rates, a reduction that was
further helped by his subse%uent introduction of techni%ues to sterili+e e%uipment, have
rigorous hand ,ashing and a later implementation of rubber gloves. Dister published his
wor$ as a series of articles in The (an$et )/arch 1B6A* under the title Antiseptic
Principle of the Practice of Surgery. "he wor$ was groundbrea$ing and laid the
foundations for a rapid advance in infection control that saw modern asepti$ operating
theatres widely used within 9< years )Dister himself went on to ma$e further strides in
antisepsis and asepsis throughout his lifetime*. Abraham 4roves
[-.]
of Fergus, ;ntario,
>anada, was one of the first surgeons to used boiled water to wash his hands and the
patient-s incision site and to heat sterili.e surgical instruments and sponges in 1BA5.
[-/]
4roves developed his aseptic techni%ue because he considered surgical infections to
be transmitted by fluids as he $new typhoid was spread. "he gradual development
of ger# theor! has allowed the final step to be ta$en to create the highest %uality of
aseptic conditions in modern hospitals, )ain
Anesthesia was discovered by two American dentists, :orace Eells )1B19O6B* and Eilliam
/orton. =efore the advent of anesthesia, surgery was a traumatically painful procedure and
surgeons were encouraged to be as swift as possible to minimi.e patient suffering. "his also
meant that operations were largely restricted to amputations and e0ternal growth removals.
=eginning in the 1B6<s, surgery began to change dramatically in character with the discovery of
effective and practical anaesthetic chemicals such as ether and chloroform. (n =ritain,Kohn
Snow pioneered the use of these two anaesthetics. (n addition to relieving patient suffering,
anaesthesia allowed more intricate operations in the internal regions of the human body. "he
further discovery of muscle rela0ants such as curare also facilitated safer applications.