History of surgery
Surgery (cheirourgia, from cheir hand + ergon work) is the branch of medicine that deals with the physical manipulation of a bodily structure to diagnose, prevent, or cure an ailment. Ambroise Paré, a 16th-century French surgeon, stated that to perform surgery is: "To eliminate that which is superfluous, restore that which has been dislocated, separate that which has been united, join that which has been divided and repair the defects of nature."
Since humans first learned to make and handle tools, they have employed their talents to develop surgical techniques, each time more sophisticated than the last; however, 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 risky "art" into a scientific discipline capable of treating many diseases and conditions.
The first surgical techniques were developed to treat injuries and traumas. A combination of archaeological and anthropological studies offer insight into man's early techniques for suturing lacerations, amputating insalvageable limbs, and draining and cauterizing open wounds. Many examples exist: some Asian tribes used a mix of saltpeter and sulfur that was placed onto wounds and lit on fire to cauterize wounds; the Dakota Indians used the quill of a feather attached to an animal bladder to suck out purulent material; the discovery of needles from the stone age seem to suggest they were used in the suturing of cuts (the Maasai used needles of acacia for the same purpose); and tribes in India and South America developed an ingenious method of sealing minor injuries by applying termites or scarabs who ate around the edges of the wound and then twisted the insects neck leaving their heads rigidly attached like staples.
The oldest operation for which evidence exists is trepanation (also known as trepanning, trephination, trephining or burr hole from Greek τρύπανον and τρυπανισμός), in which a hole is drilled or scraped into the skull for exposing the dura mater to treat health problems related to intracranial pressure and other diseases. In the case of head wounds, surgical intervention was implemented for investigating and diagnosing the nature of the wound and the extent 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. Evidence has been found in prehistoric human remains from Proto-Neolithic and Neolithic times, in cave paintings, and the procedure continued in use well into recorded history (being described by ancient Greek writers such as Hippocrates among others). Out of 120 prehistoric skulls found at one burial site in France dated to 6500 BCE, 40 had trepanation holes. Folke Henschen, a Swedish doctor and historian, asserts that Soviet excavations of the banks of the Dnieper River in the 1970s show the existence of trepanation in Mesolithic times dated to approximately 12000 BCE. The remains suggest a belief that trepanning could cure epileptic seizures, migraines, and mental disorders.
Many prehistoric and premodern patients had signs of their skull structure healing, suggesting that many of those that proceeded with the surgery survived their operation. In some studies, the rate of survival surpassed 50%.
Setting bones 
Examples of healed fractures in prehistoric human bones, suggesting setting and splinting have be found in the archeological record. Among some treatments used by the Aztecs, according to Spanish texts during the conquest of Mexico, was the reduction of fractured bones: "...the broken bone had to be splinted, extended and adjusted, 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..." Modern medicine developed a technique similar to this in the 20th century known as medullary fixation.
Bloodletting is one of the oldest medical practices, having been practiced among diverse ancient peoples, including the Mesopotamians, the Egyptians, the Greeks, the Mayans, and the Aztecs. In Greece, bloodletting was in use around the time of Hippocrates, who mentions bloodletting but in general relied on dietary techniques. Erasistratus, however, theorized that many diseases were caused by plethoras, or overabundances, in the blood, and advised that these plethoras be treated, initially, by exercise, sweating, reduced food intake, and vomiting. Herophilus advocated bloodletting. Archagathus, one of the first Greek physicians to practice in Rome, practiced bloodletting extensively and gained a most sanguinary reputation. The art of bloodletting became very popular in the West, and during the Renaissance one could find bloodletting calendars that recommended appropriate times to bloodlet during the year and books that claimed bloodletting would cure inflammation, infections, strokes, manic psychosis and more.
Berossus, a 3rd-century BCE Assyrian philosopher wrote considerably about the traditional Babylonian medical techniques (principally in the archives of Borsippa) and went on to assert that the god Oannes taught the Sumerian people all that was to be known about civilization and that nothing new had been invented. This assertion seemed hyperbolic until analysis of Sumerian tablets showed that the Mesopotamian civilization had developed or invented numerous medical techniques thousands of years before they were re-developed or re-invented by the Europeans.
Some 4000 BCE the Sumerian civilization was established in Mesopotamia between the Tigris and Euphrates rivers, creating the oldest form of writing, cuneiform. Of the 30,000 or so cuneiform tablets that have been discovered, about 800 of them deal with medical themes (one of these being the first prescription known to have been written). The name of the first surgeon is Urlugaledin, from the 4000 BCE, whose personal seal depicts two knives encircled by medicinal plants. This seal is now housed in the Louvre.
The Sumerians saw sickness as a divine punishment imposed by different demons when an individual broke a rule. For this reason, to be a physician, one had to learn to identify approximately 6,000 possible demons that might cause health problems. To do this, the Sumerians employed divining techniques based on the flight of birds, position of the stars and the livers of certain animals. In this way, medicine was intimately linked to priests, relegating surgery to a second-class medical specialty.
Nevertheless, the Sumerians developed several important medical techniques: in Ninevah archaeologists have discovered bronze instruments with sharpened obsidian resembling modern day scalpels, knives, trephines, etc. Hammurabi's Code itself contains specific legislation regulating surgeons and medical compensation as well as malpractice and victim's compensation:
215. If a physician make a large incision with an operating knife and cure it, or if he open a tumor (over the eye) with an operating knife, and saves the eye, he shall receive ten shekels in money. 217. If he be the slave of some one, his owner shall give the physician two shekels. 218. If a physician make a large incision with the operating knife, and kill him, or open a tumor with the operating knife, and cut
out the eye, his hands shall be cut off. 220. If he had opened a tumor with the operating knife, and put out his eye, he shall pay half his value.
Archaeologists made the discovery that the people of Indus Valley Civilization, even from the early Harappan periods (c. 3300 BCE), had knowledge of medicine and dentistry. The physical anthropologist that carried out the examinations, Professor Andrea Cucina from the University of Missouri-Columbia, made the discovery when he was cleaning the teeth from one of the men. Later research in the same area found evidence of teeth having been drilled, dating back 9,000 years to 7000 BCE.
Sushruta (c. 600 BCE other dates range from 1000BCE to 900CE) known as "Father of Sugery" taught and practiced surgery on the banks of the Ganges in the area that corresponds to the present day city of Benares in Northern India. He is also considered as the father of platic surgery and ophthalmology. His method of plastic surgery was copied by George Screw from Germany and 2 others in 1614 in marthawada in central India was taken to England and from there to Germany and from there it spread to rest of Europe. Much of what is known about Sushruta is in Sanskrit contained in a series of volumes he authored, which are collectively known as the Susrutha Samhita. It is the oldest known surgical text and it describes in detail the examination, diagnosis, treatment, and prognosis of numerous ailments, as well as procedures on performing various forms of cosmetic surgery, plastic surgery and rhinoplasty.
Around 3100 BCE Egyptian civilization began to flourish when Narmer, the first Pharaoh of Egypt, established the capital of Memphis. Just as cuneiform tablets preserved the knowledge of the ancient Sumerians, hieroglyphics preserved the Egyptian's.
In the first monarchic age (2700 BCE) the first treaty on surgery was written by Imhotep, the vizier of Pharaoh Djoser, priest, astronomer, physician and first notable architect. So much was he famed for his medical skill that he was deified, becoming the Egyptian god of medicine. Other famous physicians from the Ancient Empire (from 2500 to 2100 BCE) were Sachmet, the physician of Pharaoh Sahure and Nesmenau, whose office resembled that of a medical director.
On one of the doorjambs of the entrance to the Temple of Memphis there is the oldest recorded engraving of a medical procedure: circumcision and engravings in Kom Ombo, Egypt depict surgical tools. Still of all the discoveries made in ancient Egypt, the most important discovery relating to ancient Egyptian knowledge of medicine is the Ebers Papyrus, named after its discoverer Georg Ebers. The Ebers Papyrus, conserved at the University of Leipzig, is considered one of the oldest treaties on medicine and the most important medical papyri. The text is dated to about 1550 BCE and measures 20 meters in length. The text includes recipes, a pharmacopoeia and descriptions of numerous diseases as well as cosmetic treatments. It mentions how to surgically treat crocodile bites and serious burns, recommending the drainage of pus-filled inflammation but warns against certain diseased skin.
Edwin Smith Papyrus 
The Edwin Smith Papyrus is a lesser known papyrus dating from the 1600 BCE and only 5 meters in length. It is a manual for performing traumatic surgery and gives 48 case histories. For example, it gives instructions for dealing with dislocated vertabra:
Thou shouldst bind it with fresh meat the first day. Thou shouldst loose his bandages and apply grease to his head as far as his neck, (and) thou shouldst bind it with ymrw . Thou shouldst treat it afterwards with honey every day, (and) his relief is sitting until he recovers.
Greece and the Hellenized world 
Surgeons are now considered to be specialized physicians, whereas in the early ancient Greek world a trained general physician had to use his hands (χείρ in Greek) to carry out all medical and medicinal processes including for example the treating of wounds sustained in the battle field, or the treatment of broken bones (a process called in Greek: χειρουργείν).
In The Iliad Homer names two doctors, “the two sons of Asklepios, the admirable physicians Podaleirius and Machaon and one acting doctor, Patroclus. Because Machaon is wounded and Podaleirius is in combat Eurypylus asks Patroclus “to cut out this arrow from my thigh, wash off the blood with warm water and spread soothing ointment on the wound."
The Hippocratic Oath, written in the 5th century BC 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. The multiple volumes of the Hippocratic corpus and the Hippocratic Oath elevated and separated the standards of proper Hippocratic medical conduct and its fundamental medical and surgical principles from other practitioners of folk medicine often laden with superstitious constructs, and/or of specialists of sorts some of whom would endeavor to carry out invasive body procedures with dubious consequences, such as lithotomy. Works from the Hippocartic corpus include; On the Articulations or On Joints, On Fractures, On the Instruments of Reduction, The Physician's Establishment or Surgery, On Injuries of the Head, On Ulcers, On Fistulae, and On Hemorrhoids.
Celsus and Alexandria 
Two great Alexandrians laid the foundations for the scientific study of anatomy and physiology, Herophilus of Chalcedon and Erasistratus of Ceos. Other Alexandrian surgeons gave us; ligature (hemostasis), lithotomy, hernia operations, ophthalmic surgery, plastic surgery, methods of reduction of dislocations and fractures,tracheotomy, and mandrake as anesthesia. Most of what we know of them comes from Celsus and Galen of Pergamum (Greek: Γαληνός)
Galen, On the Natural Faculties, Books I, II, and III, is an excellent paradigm of a very accomplished Greek surgeon and physician of the Roman period (2nd century), who carried out very complex surgical operations and added significantly to the corpus of animal and human physiology and the art of surgery.
Hua Tuo was a famous Chinese physician during the Eastern Han and Three Kingdoms era. He was the first person to perform surgery with the aid of anesthesia, some 1600 years before the practice was adopted by Europeans. Bian Que (Pien Ch'iao) was a "miracle doctor" described by the Chinese historian Qima Nan in Shi Ji who was credited with many skills. Another book, Liezi (Lieh Tzu) describes that Bian Que conducted a two way exchange of hearts between people. This account also credited Bian Que with using general anaesthesia which would place it far before Hua Tuo, but the source in Liezi is questioned and the author may have been compiling stories from other works. Nonetheless, it establishes the concept of heart transplantation back to around 300 CE.
Middle Ages 
Paul of Aegina 
Abulcasis (Abu al-Qasim Khalaf ibn al-Abbas Al-Zahrawi) was an Andalusian-Arab physician and scientist who practised in the Zahra suburb of Cordoba. He is considered a great medieval surgeon, whose comprehensive medical texts, combining Islamic medicine with Greco-Roman, shaped European surgical procedures until the Renaissance. He is often regarded as the father of surgery. Patients and students from all parts of Europe came to him for treatment and advice. According to Will Durant, Cordoba was in this period the favorite resort of Europeans for surgical operations.
School of Salerno 
Based on oral tradition from Calabri, the translation by Constantine the African of Haly Abbas, and the Bamberg Surgery, which draws on Paul of Aegina and Abulcasis as well as the notes and observations of Salerno surgens, surgery reached new heights in Salerno. Rogerius Salernitanus composed his Chirurgia also known as The Surgery of Roger 1170, which laid the foundation for the species of the occidental surgical manuals, influencing them up to modern times. Roger seems to have been influenced more by the 6th-century Aëtius and Alexander of Tralles, and the 7th-century Paul of Aegina, than by the Arabs. Roland of Parma and Surgery of the Four Masters were responsible for spreading Rogers work to Italy, France, and England.
13th-19th Century 
By the 13th century, many European towns were demanding that physicians have several years of study or training before they could practice. Montpellier, Padua and Bologna Universities were particularly interested in the academic side to Surgery, and by the 15th century at the latest, Surgery was a separate university subject to Physic (Medicine).
- William of Saliceto also known as Guilielmus de Saliceto c.1210-1277
- Henri de Mondeville (c. 1260 – 1316)
- Mondino de Luzzi (1275-1326) "Mundinus" carried out the first systematic human dissections since Herophilus of Chalcedon and Erasistratus of Ceos 1500 years earlier.
- Guy de Chauliac d.1368
- John of Arderne 1306-1390
- Heinrich von Pfolspeundt f.1460
- Antonio Benivieni 1443-1502 Pathological anatomy
- Paracelsus 1493-1541 On the relationship between medicine and surgery surgery book
- Ambroise Pare 1510-1590 pioneered the treatment of gunshot wounds.
- Bartholomeo Maggi at Bologna, Felix Wurtz of Zurich, Léonard Botal in Paris, and the Englishman Thomas Gale (surgeon), (the diversity of their geographical origins attests to the widespread interest of surgeons in the problem), all published works urging similar treatment to Paré’s. But it was Paré’s writings which were the most influential.
- Pierre Franco 1500?-1561
- Caspar Stromayr or Stromayer Sixteenth Century
- Hieronymus Fabricius His "Surgery" is mostly that of Celsus, Paul of Aegina, and Abulcasis citeing them by name.
- William Clowes 1540-1604 Surgical chest for military surgeons
- Peter Lowe 1550-1612
- Richard Wiseman 1621-1676
- William Cheselden 1688-1752
- Lorenz Heister 1683-1758
- Percivall Pott 1714-1789
- John Hunter 1728-1793
- Pierre-Joseph Desault 1744-1795 First surgical periodical
- Dominique Jean Larrey 1766-1842 Surgeon to Napoleon
- Antonio Scarpa 1752-1832
- Astley Cooper 1768-1843 lectures principles and practice
- The Bells of Scotland
- Baron Guillaume Dupuytren 1777-1835 Head surgeon at Hôtel-Dieu de Paris, The age Dupuytren
- James Marion Sims 1813-1883 Vesico-vaganial surgery Father of surgical genocology Biography
- Joseph Lister 1827-1912 Anti-septic surgery Father of modern surgery
Foundations of modern surgery 
To make the transition to the modern era, the art of surgery had to solve three major problems — bleeding, infection, and pain — that effectively prevented surgery from progressing into modern science.
Hemostasis (Bleeding) 
- Direct pressure/digital compression thought to be the oldest recorded by Homer probably older
- Torsion/tourniquet also thought to be pre-recorded history
- Early cultures realized they could close wounds using a procedure called cauterizing. The early cauterization was successful, but only usable in a limited fashion, highly destructive, and painful, with very poor long term outcomes.
- ligatures. A ligature is a piece of material used to tie closed the end of a severed blood vessel to prevent further bleeding. Ligatures form the basis of modern bleeding control, but prior to the development of germ theory, they were more of a hazard than a help because the surgeons using them had no concept of infection control. Ligatures were used by Galen in his experiments on animals. Galen is also known as "The king of the catgut suture" Abulcasis used the technique in the 10th century although the ligature has commonly been attributed to Ambroise Paré in the 16th century, Paré cites his sources (Hippocrates, Galen, and Avicenna). It is for the rejection of cautery that he is most remembered.
Another barrier to be overcome was the problem of replacing blood lost. Limiting bleeding is important, but ultimately, a surgeon is fighting a losing battle if blood cannot be replaced, and this final barrier was only conquered when early 20th century research into blood groups allowed the first effective blood transfusions.
The ultimate problem, however, was for the medical profession to recognize that blood loss was a major threat to the survival of the patient. In fact, doctors would typically bleed patients. Bloodletting was used to treat almost every disease and it was thought to prevent infection. Before surgery blood was removed to prevent inflammation. Before amputation it was customary to remove a quantity of blood equal to the amount believed to circulate in the limb that was to be removed. The practice was abandoned only in the late 19th century.
Attempts at reducing pain and at producing a state of general anesthesia were made in ancient times. Opium was used by a number of ancient cultures for pain reduction, and various herbal concoctions were also used for this purpose.
In the early 1800s, Humphry Davy discovered the anesthetic properties of nitrous oxide, and wrote on the gas's potential benefits in relieving pain during surgery. In Japan, Hanaoka Seishū developed a plant-derived anesthesia drug. Friedrich Sertürner first isolated morphine from opium in 1804.
Beginning in the 1840s, surgery began to change dramatically with the discovery of effective and practical anesthetic chemicals such as ether and chloroform. Pioneers in the use of ether and chloroform in surgery include British physician John Snow, Scottish obstetrician James Young Simpson, and American dentists Horace Wells, William T. G. Morton, and Gardner Quincy Colton.
In The 20th century, tracheotomy, endoscopy, and non-surgical tracheal intubation became essential components of the practices of anesthesia, and a number of highly effective chemical local and general anesthetics were developed.
The gradual development of germ theory has allowed the final step to be taken to create the highest quality of aseptic conditions in modern hospitals, allowing modern surgeons to perform nearly infection-free surgery.
William of Saliceto (AD ca 1210-1280) held that wounds should heal by first intention opposing the Galenic theory of "laudable pus". Girolamo Fracastoro (1478-1553), thought infection was due to the passage of minute bodies from person to another as opposed to miasma theory. The work of Louis Pasteur (1822-1895) started the association between bacteria and infection but it was slow to be accepted. Ignaz Semmelweis (1818-1865) noted a connection between bacterial infection and puerperal fever. Joseph Lister (1827-1912) began the modern movement to control infection with his work in antiseptic surgery. Ernst von Bergmann 1836-1907; steam sterilization of instruments and William Stewart Halstead (1852-1922; rubber gloves for surgeons). John Charnley (1911-1982; the laminar flow enclosure). The development of antibacterial drugs Gerhard Domagk (1895-1964; sulfonamides) and was followed by Alexander Fleming (1881-1955), Howard Walter Florey (1898-1968) and Ernest Boris Chain (1906-1979; penicillin and Selman Waksman 1888-1973; actinomycin.
Modern surgery 
Timeline of surgical procedures 
|This section requires expansion. (June 2008)|
- archeological record Trepanation, broken bones, wounds.
- ca 2613 to 2494 BCE a jaw found in a Fourth Dynasty tomb shows the marks of an operation to drain a pus-filled abscess under the first molar.
- 2580 BCE Khufu heard stories of Dedi's feats of surgery Dedi re-attaches the severed head of a goose with magic.
- 1772 BCE Code of Hammurabi
- 1550 BCE Ebers Papyrus
- 1250 BCE ? Asklepios his sons Podaleirius and Machaon reported by Homer as battlefield surgeons.
- 8th century BCE Homer reports; arrowheads cut out; styptics; administers sedatives and cuts bandaged with wool.
- 5th century BCE Medical schools at Cnidos and Cos
- 460 BCE Hippocrates insisted on the use of scientific methods in medicine. He "taught that wounds should be washed in water that had been boiled or filtered, and that a doctor's hands should be kept clean, his nails clipped short"
- (?-c.1258)Hugh of Lucca (BIorgognoni, Ugo) . An Italian physician. He served as a military surgeon during the crusade to Syria and Egypt. His experience on the battlefield led him to believe that a large part of the brain could be removed without much functional loss.
- c. 1900 Cargile membrane employed by surgeons.
- 1967: First successful heart transplant.
Notable individuals in the development of surgery 
- Harvey Cushing, neurosurgeon, often called the "father of modern neurosurgery."
- William Williams Keen, first brain surgeon in the United States.
- William Stewart Halsted, American surgeon and one of the "Big Four" founding professors at Johns Hopkins Hospital.
See also 
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- (Capasso 2001)
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- A. Agelarakis, “Artful Surgery: Greek Archaeologists Discover Evidence of a Skilled Surgeon Who Practiced Centuries Before Hippocrates”, Archaeology, Vol. 59/2: 26-29, 2006
- Ralph Solecki, Rose Solecki and Anagnostis Agelarakis, “The Proto-Neolithic Cemetery in Shanidar Cave”,Texas: A&M University Press, College Station, 2004
- Restak (2000)
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- Brothwell, D.R. Digging up Bones. 1963:126
- La tribu Yanto en el Perú. Manuel Antonio Muñiz y W. J. Mc. Gree. In this study, 250 of 400 skulls showed evidence of surviving trepanation.
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Further reading 
- F. Gonzalez-Crussi, The Rise of Surgery, in: A Short History of Medicine, New York: The Modern Library 2008
- Gawande, A. (2012). "Two Hundred Years of Surgery". New England Journal of Medicine 366 (18): 1716–1723. doi:10.1056/NEJMra1202392. PMID 22551130.
- The portrayal of surgery by various artists throughout history
- A Manual of Military Surgery, by Samuel D. Gross, MD (1861)