A brief account of how an esteemed art and science came to be what it is today.
Surgery (from the χειρουργική cheirourgikē, via chirurgiae, meaning "hand work") is a medical specialty that uses operative manual and instrumental techniques on a patient to investigate and/or treat a pathological condition such as disease or injury, to help improve bodily function ... Ambrose Pare, a 16th century French surgeon stated that there were five reasons to perform surgery: "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 man first learned to make and handle tools, they have employed their talents to develop surgical techniques, 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, namely 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.
I intend to delve into what is known about the theory and practice of surgery in ancient India, Egypt, Greece, Alexandria and Rome, after which progress froze until the end of the Middle Ages and then follow its modernization into the 21st century.
Earliest Times
The oldest surgery for which we have evidence is trepanation , in which a hole is drilled or scraped into the skull thus exposing the duramater in order to treat health problems related to intracranial pressure and other diseases. Evidence has been found in prehistoric human remains from Neothilic times, in cave paintings, and the procedure continued in use well into recorded history (being described by ancient Greeks writers such as Hippocrates among others). Out of 120 prehistoric skulls found at one burial site in France dated to 6500 BC, 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 Mesothilic time dated to approximately 12000 BC. The remains suggest a belief that trepanning could cureepilepsy, seizures and mental disorders.
Surprisingly, 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. Indeed, in some studies the rate of survival surpassed 50%
Amulets
It was employed around the world – in Neolithic Gaul (now France), Bohemia (Czech Republic), north Africa, Asia, Tahiti, New Zealand and South America. It was particularly popular in ancient Peru, where sharp knives of obsidian, stone and bronze were used.
Skulls have been found with as many as five trepanned holes. People who survived the operation (and some did, as healed skulls attest) had their wounds covered with a piece of gourd, stone, shell or even silver and gold. In Europe, the excised rounds of skull bone were worn as amulets.
Setting bones
Among some treatments used by the Aztecs, according to Spanish texts during the conquest of Mexico, was the setting of broken 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 medula..." Modern medicine developed a technique similar to this in the 20th century know as medulary fixation.
Anesthesia
Evidence shows that one surgical technique that has existed for thousands of years is anesthesia . Alcohol is possibly one of the oldest forms of anesthesia, and it has been for thousands of years before our time Along with alcohol, opium is known to have been used for millenia, both for recreation and as an anesthetic. Some Babylonian cylinders and Mesopatamiam beliefs show heads of poppy. Other substances used from antiguity for anesthetic purposes are the extract of cannabis sativa etc
India
Varanasi on the banks of the Ganges is one of the holiest places in India. It is both the city of Buddha and a destination of pilgrimage for millions of Hindus who come to bathe in the holy river. It is also the home of Ayurveda, one of the oldest medical disciplines.
Ayurveda means ‘science of life’, and its approach to the body is philosophical and holistic. Among the greatest of its ancient writings is the Sushruta Samhita, which describes the tradition of surgery in Indian medicine.
Its author is believed to have been the scholar Sushruta, who lived over 3,000 years ago. Sushruta is said to have been given his knowledge by an incarnation of the god Vishnu. However, it is also suspected that he was simply reporting medical wisdom that had been passed down by word of mouth for centuries.
Illnesses and instruments
In the book’s 184 chapters, 1,120 conditions are listed, including injuries and illnesses relating to ageing and mental illness. For instance, there are accounts of 76 eye conditions, 51 of which were treated surgically. The book also describes 101 blunt and 20 sharp surgical instruments, many of which are surprisingly similar to instruments used today.
Other treatments are also discussed, comprising 700 healing plants, 57 preparations derived from animal sources and 64 preparations from minerals. One of the plants was used to produce suturing thread that had immunity-boosting properties. Others provided pain relief and still others were natural antiseptics.
Leeches
Sushruta also recommended using leeches to keep wounds free of blood clots. This has only recently been rediscovered and is now used, especially in plastic surgery, to help reduce congestion in tissues, especially in wounds and in flaps used for reconstructing body parts.
Sushruta’s general advice to physicians would certainly apply to doctors anywhere and in any age:
"A physician who has set out on this path should have witnessed operations. He must be licensed by the king. He should be clean and keep his nails and hair short. He should be cheerful, well-spoken and honest"
The first nose jobs
The compendium goes on to describe some extraordinary surgical techniques, including a revolutionary nose reconstruction, or rhinoplasty. It was common practice in ancient India to punish criminals by amputating the nose. As a result, Ayurvedic surgeons had plenty of opportunities to practise this.
They would cut a leaf-shaped flap of skin from the forehead, making sure that the end nearest the bridge of the nose remained attached. The flap would be brought down over where the nose should be. Then it would be twisted skin-side-out and sewn into place. Finally, to keep the air passages open during healing, two polished wooden tubes would be inserted into the ‘nostrils’.
In a few weeks, when the graft had bonded and blood vessels had formed, connecting the graft to the person’s face, the place where the graft was still attached would be cut. The secret was to keep the blood flowing. The brilliance of Sushruta’s method was his understanding of the function of blood in the largest organ, the skin.
The Gentleman’s Magazine of Calcutta carried an etching of an Indian bullock driver who had had this operation as late as October 1794.
Egypt
In November 2001, in the shadow of the first royal pyramid at Saqqara (built c. 2630 BC), about 19 miles south of Cairo, archaeologists made an extraordinary discovery. Buried under 5 metres (16.4 feet) of sand was a tomb that had been hidden since 2000 BC. In the writing on its walls was a hint that surgery had actually been practised in ancient Egypt – the first hard evidence of it being performed as early as this. Chief physician
This was the tomb of Skar, the chief physician of one of Egypt’s rulers of the 5th dynasty. It contained about 30 bronze medical implements, the oldest ever found, including scalpels, needles and a spoon.
Archaeologists also found an alabaster altar and 22 statues of different gods and goddesses inside the tomb. As was usual in ancient times, when science and religion were inseparable, Skar would also have been a priest, mixing ritual and magic with his medicine. But what kind of medicine and what kind of surgery?
Free-wheeling
It was in the Egyptian city of Luxor in 1862 that the first proof was found that surgery was being carried out in ancient times.
The free-wheeling American trader Edwin Smith spent much of his time trawling the Luxor markets hoping to discover ancient artefacts he could sell for an easy profit. Smith even described himself as ‘an American farmer of Luxor’. According to Dr Richard Sullivan of University College London, ‘most Egyptologists regard him as a bit of a bounder and a cad.’
Ancient medical treatise
Usually, Smith was quite happy to buy a well-made fake, which he had few scruples about selling on as the genuine article. But he knew his business, and he treated one papyrus, which looked genuine, very differently. Able to read hieroglyphs, he could see that this was an ancient medical treatise and therefore highly unusual.
Although he could have got a good price for the papyrus, for unknown reasons Smith decided to keep it, and it remained in his family for more than 70 years. It was only when it was fully translated in the 1930s that its full significance was recognised.
Acacia thorns and flax
The Edwin Smith Surgical Papyrus – as it is now known – is a detailed (if incomplete) compendium of surgical treatments for wounds, starting with head injuries and working down the body. Surprisingly, of the 48 case studies in it, only one mentions magic, and a modern surgeon would be familiar with the way each case is set out.
The papyrus goes into great detail describing each individual trauma: how you would look at it, how you would diagnose it, how you would examine it and then how you would treat it. It describes how to stitch a gaping wound with acacia thorns as needles and pieces of flax as suturing material. For pus-filled tumours, it recommends cauterisation, in which a very hot copper instrument would be used not only to cut away the damaged tissue but also to seal all the blood vessels. Today, a similar technique called diathermy is used, with an electric current taking the place of heat.
Unfinished
Even more important are the neurological insights that the Edwin Smith papyrus gives. It contains the first descriptions of the meninges (the membranes covering the brain), the external surface of the brain and the cerebrospinal fluid. It also notes that brain injuries are associated with changes in the function of other parts of the body, especially the lower limbs.
The papyrus was actually copied in about 1700 BC from an ancient composite manuscript that contained – in addition to the original author's text, written in 3000-2500 BC – a commentary added a few hundred years later in the form of 69 explanatory notes. The scribe who copied it made many errors, some of which he corrected in the margins. He had copied at least 18 columns of it, when, having reached the bottom of a column, he paused in the middle of a word and laid down his pen, leaving the papyrus unfinished for all time.
Nose jobs for the dead
Other clues that tell us that the Egyptians had discovered the principles of surgery can be found in the way they prepared their dead. For instance, the mummy of the great pharaoh Rameses II, now in Cairo Museum, was surgically altered by having a small bone and a quantity of seeds inserted into his nose. In life, this had been his most prominent feature. The Egyptian surgeons ensured that, in death, it remained just as prominent.
The mummy of Queen Nunjmet was also enhanced. Her cheeks and belly were stuffed with bandages, resin and a cheesy substance. Today, plastic surgeons would use materials such as silicon.
So the Egyptians used surgery on the dead. And, as the Edwin Smith papyrus shows, they had the skills to perform such operations on the living. But did they? The mummies don’t reveal any evidence that proves this one way or the other.
Alexander the Great
Horrible wounds forced the surgeons of Alexander the Great (356–323 BC) to find new ways of keeping him and his men alive and on the march.
As civilisations developed, wars became much more extensive than before, and thousands were killed or wounded on ancient battlefields. It was the campaigns of Alexander the Great in the 4th century BC that gave military surgeons (whom Alexander had introduced to the battlefield) new insights into anatomy.
An expensive investment
The Macedonian king’s empire eventually stretched from Italy to India. It was the result of 50,000 intensively trained soldiers marching across Europe, Africa and Asia, forcibly uniting the known world and reaping the wisdom of the civilisations they encountered.
Alexander saw each soldier as an expensive investment, and he protected them by providing dedicated medical teams. He invented the field hospital, and it was the doctors in these who helped lay the foundations of modern Western surgery.
Untried techniques
‘War surgery always moves knowledge on in the field of medicine, not just in surgery, the whole of medicine. And that’s been true since the beginning of time and was just as true in Alexander’s day,’ says Jim Ryan, former professor of military surgery at the Royal Army Medical College, who served as a surgeon during the Falklands War.
‘Faced with large numbers of wounded, the war surgeon’s got nothing to lose – there are no lawyers around. I don’t mean to be glib, but if a guy’s dying in front of you and there are some untried techniques that they’ve picked up by word of mouth, they’re going to try them – a better means of haemorrhage control, application of tourniquets, packing new wounds, whatever. Most of these would not have been thought of in civilian practice. They’ll have come off the battlefield.’
Invincible?
Alexander was a product of the Greek tradition of reason and scientific study. A century earlier, Hippocrates had separated medicine from magic and cults of healing and turned it into an empirical practice. From then on, doctors looked at the physical reality of illness and injury rather than invoking the gods as cause and cure.
So, just as rational thinking made Alexander’s battlefield strategy a success, this new scientific approach helped his battlefield surgeons keep his soldiers fighting fit.
Alexander himself was wounded many times, but he always survived and never lost a battle. As his victories accumulated, his men began to believe he was invincible, as did his enemies. But invincibility had nothing to do with it. His secret weapon was his surgeon Kritodemos of Kos, whose greatest challenge would come in India, near the end of Alexander’s campaign.
Operating with a spoon
While Alexander had his surgeon Kritodemos, his father Philip of Macedon had his surgeon Kritoboulos. In 354 BC, during the siege of Methone, Philip was hit in the eye by an arrow. According to the Roman writer Pliny the Elder, ‘Kritoboulos achieved great renown for having removed the arrow from Philip’s eye, and having treated the loss of the eyeball without disfiguring his face.’
To achieve such impressive results, the surgeon probably used a specialised surgical instrument designed to remove arrows. It was known as the ‘spoon of Diokles’ after its inventor Diokles of Karystos, a contemporary of Aristotle.
Inefficient ventilation
During the siege of the capital of the Mallians (modern Multan in Pakistan), Alexander was seriously wounded by an arrow in the chest. His faithful general Ptolemy, later king of Egypt, said: ‘His breath as well as his blood spouted from the wound.’ According to Professor Ryan, that is a very clear description of a penetrating injury into the lung: ‘This is what is now called an open chest wound or sucking chest wound. When you have this wound and you try to breathe in, only some of the air goes down there. So you have extremely inefficient ventilation and that’s one of the ways you die.’
The Macedonian leader was carefully placed on a shield and carried out of the citadel to his tent. The arrow in his chest was heavy, with a large barbed head. It was the most lethal kind and the hardest to remove. His men thought that, this time, Alexander really was going to die.
Unnerved
Kritodemos ordered Alexander stripped naked and the shaft of the arrow cut off. The doctor decided that the only way to extract it without the barbs doing greater damage was to enlarge the wound.
He was extraordinarily skilful, but the prospect of Alexander dying at his hands evidently unnerved him. Even the young commander, who had regained consciousness, was aware of his fear. ‘Why are you waiting?’ he asked. ‘If I have to die, why do you not at least free me from this agony as soon as possible? Or are you afraid of being held responsible?’
First principles
Told that he would have to be held down during the operation, Alexander said there was no need and, it is said, went through the ordeal unflinching. However, when the barbed head was finally removed and blood spurted from the wound, he finally fainted.
At first, the haemorrhage could not be stopped, and onlookers began to wail as if Alexander had died. ‘Without really knowing why, just applying his basic good first principles,’ says Professor Ryan, ‘Kritodemos would have covered the wound, probably to control the haemorrhage. But in so doing, he stopped the open chest wound sucking further – and saved Alexander’s life.’
Act of will
For the wound to heal, Kritodemos would have had to stitch muscle, tissue and skin separately. These are the basic skills of the modern surgeon, and they were brought back home from the battlefields.
Barely a week after being injured, and with his wound incompletely closed, Alexander arranged to be carried by ship down the river Hydraotes to the main camp. As the ship docked, his guard brought out a litter, but Alexander refused it. Instead, he walked down the gangplank and, in an act of extraordinary will, mounted his horse to ride to his tent.
Alexandria
With Alexander the Great’s new empire, the West was connected to the East and the South for the first time. The enquiring minds of the Greeks now had access to the rich medical traditions of Egypt and India, of the great physician Skar and of Sushruta, India’s first surgeon. Precisely what Alexander’s armies brought back from India isn’t certain, but all learning, including surgical knowledge, advanced rapidly at about this time.
Twenty-three centuries ago, on virgin land on the Mediterranean coast of Egypt, Alexander established his Egyptian capital: Alexandria. After his death in 323 BC, his successor as ruler of Egypt, Ptolemy, was determined to make the city the most important in the Greek world. And as part of this, it became a great centre of science where medicine could flourish.
The library and the museum
Ptolemy sent agents all over the Greek world to acquire new texts, and visiting ships were obliged by law to leave their manuscripts to be copied. As Alexander himself had wished, a great library was built to house them all. Over half a millennium, it gathered together some 700,000 volumes, including the most comprehensive body of medical texts in ancient history.
In addition, the Ptolemy family established a museum – ‘house of the Muses’ – a publicly funded research institute. Thanks to this and the great library, the development and teaching of scientific knowledge flourished as never before.
Research and anatomy
‘Hippocratic medicine is very interesting,’ says Lawrence Bliquez, professor of classics at the University of Washington, ‘but with the appearance of On Medicine by the Roman writerCelsus [ 25 BC-AD 45], we have much more developed medicine and much more developed surgery.
‘What’s happened in the meantime? Alexandria has happened. The museum has opened, and the ruling Ptolemy family is very liberal in their support of all sorts of research endeavours – medicine, literature, everything.
‘For a good 50-year period, we have people such as Herophilus of Chalcedon and Erasistratus of Iulis permitted to perform not only anatomical operations on corpses but also, if we’re to believe Galen, vivisection.’
Dissection
Physicians came to Alexandria from all over the Mediterranean world to teach and to study. Recently the remains of the original Ptolemaic university were uncovered. It’s an enormous site and, over 2,000 years ago, would have offered thousands of scholars the opportunity to learn in its oval lecture rooms where the great physicians of the day would have come to teach anatomy.
The key to anatomy was dissection, which in most early cultures was taboo. However, attitudes began to change when the philosophers Plato and Aristotle decided that the body was worthless after the soul left it at death. As a result, in liberal Alexandria sometime in the 3rd century BC, a young physician named Herophilus was given permission to dissect human bodies.Often called the father of anatomy, Herophilus was born in Chalcedon, Asia Minor. Little is known about his life; the date and place of his death have been completely lost, as have all his writings. Herophilus studied medicine under Praxagoras of Cos and then at Alexandria, where he later taught and practiced medicine. In Alexandria, Herophilus had the unique opportunityto practice human dissection, a research technique not allowed elsewhere. Herophilus even performed public dissections. His work was highly regarded, andthe medical school he founded at Alexandria attracted scores of students.
Herophilus made many anatomical studies of the brain. He distinguished the cerebrum (larger portion) from the cerebellum (smaller portion),pronounced the brain to be the seat of intelligence, and identified several structures of the brain, several of which still carry his name. He discoveredthat the nerves originate in the brain, was the first to distinguish nerves from tendons, and noted the difference between motor nerves (those concerned with motion) and sensory nerves (those related to sensation). Hetraced the optic nerve and described the retina. He studied the liver extensively and described and named the duodenum, the first part of the small intestine.
Drawing a distinction between arteries and veins, Herophilus noted the arterial pulse and developed standards for its measurement and use in diagnosis. Hethought that arterial pulsation was involuntary, rising from dilation and contraction of arteries due to impulses sent from the heart. He corrected the idea that arteries carry air rather than blood. Herophilus also wrote a treatise on midwifery and accurately described the ovaries, the uterus, and the tubes leading from the ovaries to the uterus (later named the Fallopian tubes).In the field of medical treatment, Herophilus sensibly recommended good dietand exercise, but was also an enthusiastic advocate of bleeding and frequentdrug therapy.
Although his medical school languished after his death, Herophilus (and his younger successor Erasistratus) established the disciplines of anatomy and physiology, which did not significantly advance before Galen in the second century and then the early modern anatomists of the thirteenth century. His findings revolutionised all kinds of surgery.
Anatomical distinctions
According to Heinrich von Staden, professor of classics and the history of science at Princeton University, ‘Prior to Herophilus, no one had ever done systematic dissection of human cadavers. Herophilus achieved a remarkably detailed knowledge of the entire human body.
‘For example, he demonstrated the anatomical distinction between arteries and veins, and perhaps most important, he discovered the nerves. In addition, he made the distinction between motor and sensory nerves, distinguished between four coats of the eye, discovered the ventricles of the brain and described them quite accurately.’
Most of today’s understanding of the body comes straight from Herophilus and the discoveries he made 2,000 years ago. ‘After him,’ says Professor von Staden, ‘the dissection of humans was not done again for another 15 centuries in any culture in any part of the world.’
A bigger taboo
But it wasn’t just the dissection of cadavers. Herophilus was allowed to break an even bigger taboo: carving up living humans – condemned criminals.
‘Systematic experimentation by vivisection is the cutting open of living human beings to observe the functions of the internal parts in a living being,’ explains Professor von Staden. ‘The justification for this was said to be that, no matter how well one gets to know the dead body, it is different from the living body.’
Natural causes
As horrific as these experiments were, they did give Herophilus and his students an unprecedented understanding of the human body – of the nerves, for instance, and the brain. The brain’s importance was recognised for the first time, again greatly reducing the dominant beliefs in spirits and magic.
‘Herophilus did not base his practice on the belief that diseases are sent to humans by gods as punishment or as rectification of some kind of moral or political disorder,’ says Professor von Staden. ‘Rather he based it on the belief that diseases have natural causes, which most of the Hippocratic doctors believed as well, and therefore diseases had to be addressed by secular, scientific means. His discoveries may have been the largest single step forward ever taken in medicine.’
Plotting the stars
At the beginning of the 3rd century AD, surgery was enjoying a golden age. While Rome, the cultural and political capital, benefited most from these advances, Alexandria remained the seat of medical learning.
All that science revolved around the museum and the great library with its 700,000 scrolls. Here was where the circumference of the earth was measured, where the stars were plotted, where Herophilus recorded that the brain, not the heart, was the centre of thought. But fast approaching was the end of both this golden age and the library itself.
The end
It is likely that Alexandria’s museum was destroyed during a revolt in AD 295. There is a growing consensus among historians that the library suffered from several destructive events, but the deliberate burning of the city’s pagan temples by Christians in the late 4th century was probably the most severe and final one.
Today, near where the old library once stood, there’s a new one, the largest in Africa – the $230 million Bibliotheca Alexandria. In it, you will find the only remaining papyrus from the ancient library. Written in ancient Greek, this fragment is part of an index of some of the scrolls that were once held by the library.
Rome
Alexander the Great had encouraged his physicians to expand the limits of their science, and from the time of Hippocrates, Greek doctors were recognised as the best in the world. The Romans admired them, too, and when they conquered the Greeks in about 100 BC, the physicians were allowed to continue to practise, now as Roman subjects.
The Executioner
However, the first Greek doctor/surgeon that the Romans encountered was almost their last. According to the naturalist Pliny the Elder, Arcagathus arrived from Greece in 219 BC. He was made a citizen, and a medical shop was set up for him at state expense. Because he was an expert wound surgeon (uulnerarius), he immediately became popular, but this did not last.
His enthusiastic use of the knife and cautery – that is, cutting and sealing tissue with high heat – soon earned him the title ‘Executioner’ (Carnifex). More than 100 years elapsed before another Greek physician, Asclepiades of Bithynia, took up residence in Rome.
Sophisticated
In 46 BC, Julius Caesar granted citizenship to all foreigners teaching a liberal art in Rome. This included the Greek doctors, most of whom were slaves or freed men. When, in 23 BC, Antonius Musa, once Mark Antony’s slave, cured the emperor Augustus of a serious illness, he was richly rewarded and won immunity from taxation for all doctors. Later, during the reign of Vespasian (AD 69-79), physicians were also freed from military service.
‘It’s not at all surprising that the Romans used Greek physicians,’ says Andrew Wallace-Hadrill, director of the British School at Rome and professor of classics at Reading University. ‘Greek medicine was incredibly sophisticated.’
The demand for Greek physicians continued to grow, and many Roman cities devised tax incentives to get them to stay. But this was strictly private medicine, with no set pay scale. Only reputation determined prosperity.
‘In general, Romans are very superstitious,’ continues Wallace-Hadrill, ‘and to them the borderline between medicine and magic was very unclear. So powerful Romans paid a lot of money to the great Greek physicians, they gave them a lot of respect, but at the same time, they wanted to distance themselves from them.’
Surgical instruments
In the ruins of Pompeii, turned into a time capsule by a volcanic eruption in AD 79, is a house that belonged to a Greek surgeon. It was identified, in 1887, by its large stores of surgical equipment – more than 100 instruments. Since there was relatively little innovation in these tools from the time of Hippocrates in the 5th century BC, instruments like these remained typical of surgical practice for nearly a millennium. In fact, some of them, such as the vaginal speculum, did not change significantly until the 20th century.
The instruments found at Pompeii represent the normal range that a surgeon of the time would have needed. They were mostly bronze, brass or copper, but blades and needles were almost invariably made of iron or steel. Most of the instruments could be heated up and used for cautery. By heating the instruments, the surgeons were, without realising it, sterilising them.
Circumcision, scars and brands
What sorts of things would these instruments have been asked to do?
The Romans distrusted most of the foreigners they had conquered, and foreigners who wanted to fit in would try to hide telltale differences. That wasn’t always easy, especially in the public baths that every respectable Roman visited every day.
The Romans, who celebrated the nude body in art and sport, viewed any abnormal appearance of the genitals with distaste, even amusement. The Jews were well known for their insistence on male circumcision, but they were not the only circumcised men known to the Romans. Egyptian priests also practised it, as did Arabs, Ethiopians and Phoenicians.
Certain scars were despised. The manly thing was to have battle scars on the front. To have scars on your back was a mark of shame – it showed that you had turned your back in battle and run away or, worse, that you had been whipped – only slaves were whipped. Brands were also hated, as they, too, revealed that you had once been (or still were) a slave, someone who could never enjoy respect.
So it was very important to these residents of Rome – foreigners who wanted to fit in and former slaves on the make – to find ways of abolishing these signs. And they turned to the Greek surgeons for solutions.
Removing the marks
There is some evidence from the poet Martial (AD 40-c. 104) – himself a foreigner, a Spaniard – that some slaves at that time had their brands removed by surgeons. Unfortunately he gives no details of exactly how it was done.
The area of branded skin might have been cut out and the edges sewn back together, so that the ex-slave would have been left with a long linear scar. Alternatively, the top layer of skin might simply have been shaved off to remove the brand. This would have left the poor ex-slave with a wide scar that he could then have said was caused by having accidentally burned his arm. Both these procedures (which could equally have been used for removing tell-tale scars) would have been excruciating, so the reasons have them done would have had to be extremely important.
Reversal and reduction
Celsus, writing during the reign of the emperor Tiberius (AD 14-37), must have witnessed a lot of experimental operations. This is his rather detached report of the reversal of a circumcision.
The prepuce [foreskin] is to be raised from the underlying penis mound the circumference of the glans by means of a scalpel. This is not so very painful, for once the margin has been freed, it can be stripped up by hand as far back as the pubes ... The prepuce, thus freed, is again stretched forwards beyond the glans ... For the following days the patient is to fast until nearly overcome by hunger, less satiety excite that part ...
Celsus also describes a procedure to reduce the breasts of an obese man because, he says, ‘they looked unsightly and shameful’. In Roman society, being fat was, apparently, as bad as being an ex-slave or a Jew and well worth the pain to have the stigma erased.
Cheerful countenance and entertaining talk
The physician himself, of course, had to be sympathetic and considerate. It was part of a code of conduct dating from Hippocrates. As Celsus wrote:
A practitioner of experience does not seize the patient’s forearm with his hand as soon as he come in but first sits down and, with a cheerful countenance, asks how the patient finds himself. And if the patient has any fear he calms him down with entertaining talk, and only after that moves his hand to touch the patient.
All eight volumes of Celsus’s work De Medicina (On Medicine) have survived intact. In them, he shows that he knew the difference between fresh wounds and ulcers that were slow to heal, and about clamping blood vessels to prevent haemorrhage. He describes complex surgical operations, including goitre and cataract removal, as well as plastic surgical procedures such as ‘counter-circumcision’ and gynaemastia (breast reduction).
Pain relief
These types of surgery were very sophisticated but quite invasive. How did surgeons help their patients cope with the pain?
They wouldn’t have had anaesthetics in the modern sense, but various plant extracts with analgesic (painkilling) properties would have helped. The healers probably grew some of these plants in their own gardens, as the surgeon did in Pompeii. For pain relief, there were four important plants: opium, poppy, white mandrake and henbane. Pliny the Elder (who died near Pompeii as it disappeared under the ash of Vesuvius) said of white mandrake that you only need a sniff of it before an operation to send you to sleep. But it was probably more like ‘pre-medication’ – a drug that would make patients drowsy but not completely asleep.
If they weren’t completely asleep, they could move around, and so the surgeons must have been quite skilled and fast. They needed a small number of instruments that covered most eventualities. And to help them, these tools were double-ended so that they could be turned round and used very quickly before the patients died of surgical shock.
Deceit and cunning
Like surgery, drugs were a speciality of the Greeks. The flourishing of their medicine had coincided with the expansion of their civilisation throughout Asia Minor and beyond, and they had access to narcotic plants from all over the known world. And now, under the Romans, they were careful to keep their formulae secret.
Then as now, there was a lot of money to be made in the drugs trade. Pliny the Elder complained:
The deceit of men and cunning profiteering led to the invention of quack laboratories. A small sore is charged with the cost of medicine from the Red Sea, although the genuine remedies form the daily dinner of even the very poorest.
The ancients had a huge range of pharmacopoeia to help with pain relief and use as anaesthetics in the operations. Much of our pain relief nowadays, such as aspirin and opiate-based medicines such as codeine, is based on herbs and the knowledge of them that was gained in the past.
Galen
In vain and violent Rome, a new medical revolution was about to begin. The demand for Greek physicians was greater than ever, and one in particular rose to the top. Claudius Galen (c. AD 130-c. 200), the greatest surgeon of antiquity, would be responsible for huge leaps in virtually every medical discipline.
Gladiators
Whenever the Romans conquered a territory, coliseums would soon spring up. One of the largest was at Pergamum in Asia Minor (now Bergama, Turkey). Here, every week, a crowd of 20,000 would come to watch paired-off slaves try to kill each other.
These gladiators were valuable and their owners wanted to protect their investments. Since even the winners could be terribly injured, doctors were in great demand, and the best were almost always Greek. For a young Alexandria-educated, ambitious Greek physician in AD 157, few jobs could have been better than resident surgeon at the Pergamum coliseum. That position was filled by Claudius Galen. Galen was born in Pergamos in Asia Minor in the year 131 C.E. After receiving medical training in Smyrna and Alexandria, he gained fame as a surgeon to the gladiators of Pergamos. He was eventually summoned to Rome to be the physician of the Emperor Marcus Aurelius. Galen spent the rest of his life at the Court writing an enormous corpus of medical works until his death in 201 C.E.
Taking Hippocrates’ notions of the humors and pathology, Galen incorporated the anatomical knowledge of noted Alexandrians such as Herophilus of Chalcedon (335-280 B.C.E.). A supporter of observation and reasoning, he was one of the first experimental physiologists, researching the function of the kidneys and the spinal cord in controlled experiments.
Galen’s works in many ways came to symbolize Greek medicine to the medical scholars of Europe and the Middle East for the next fifteen centuries. His message of observation and experimentation were largely lost, however, and his theories became dogma throughout the West. In the mid-16th century, however, his message that observation and investigation were required for through medical research began to emerge, and modern methods of such research finally arose.
Galen’s gladiator period was crucial to what he would accomplish later. It was as close as he could get to vivisection – dissection of the living. Galen would certainly have been able to see and feel, through the gladiators’ wounds, parts of the internal human anatomy to which others did not have access.
The surgeon and the emperor
According to Galen, not one of the gladiators died during his time as surgeon to them, and from his descriptions of the operations he undertook on their behalf, it is likely that this statement is true. But besides being an excellent physician, Galen was a great showman and self-promoter. It didn’t take long for his name to become known in the highest circles. In AD 161, at the age of 32, he felt it was time to move on.
There was only one place Galen could move on to. When he got to Rome, he became nothing less than resident surgeon in the great Colosseum. But he aspired to even higher things – and soon became doctor to the philosopher emperor Marcus Aurelius.
Marcus Aurelius wanted to wean his subjects away from superstition. He encouraged Galen to disseminate his scientific approach to surgery through public lectures and anatomical demonstrations (using animals). The Greek was as eager as the emperor to spread his scientific way of thinking. He became an extraordinarily prolific medical writer, producing perhaps as many as 600 books on every aspect of medical theory and practice that then existed.
Galen was, however, also extremely arrogant and unpleasant, using his learning and verbal skills to bludgeon opponents into submission. When he abruptly left Rome in 166 to spend three years in Pergamum, he claimed it was because he feared assassination. Oddly enough it was only his contempt for Herophilus and especially Erasistratus that led him to write at length about them, so that they have been able to take their rightful places in medical history.
Changing fashion
Despite his personality defects, Galen almost single-handedly created a golden age of medicine and surgery. During his time, cosmetic and reconstructive surgery became ever more daring.
The eye is incredibly difficult to operate on even today. Before Galen, the only operations that would be attempted on it were cataract removals. However, after Galen, surgeons would try to cure squints, droopy eyelids and eye infections.
And eyes were only part of it. Fashions were changing. Under Marcus Aurelius, wars had been banished to the empire’s frontiers, while in Rome itself, there were new obsessions, including the human body. This led to an increasing amount of cosmetic surgery. ‘It’s interesting that a number of these so-called plastic surgeries have got something to do with the genitalia,’ remarks Lawrence Bliquez, professor of classics at the University of Washington.
Ripples through the empire
The destruction of the library at Alexandria coincided with the end of the Roman empire. One of the reasons for Rome’s decline and fall was a lack of central authority – the long-distance networks simply fell apart. And the same thing happened with medicine. It was not that medicine wasn’t still practised, but there was no longer a great centre.
And when the centre of medical knowledge disappeared, the loss rippled through the empire. Everywhere great medical works disappeared, either deliberately destroyed or simply lost to time.
‘We shouldn’t forget,’ says Heinrich von Staden, professor of classics and the history of science at Princeton University, ‘that, despite the enormous wealth of medical literature that we have from antiquity, and the enormous wealth of archaeological finds, we have only a tiny fragment of what was written, what was buried by time. So we know very little, given what once was there.’
Saved by the Arabs
Of Galen’s 600 books, for instance, just 20 survive, and those are with us only because they were rescued by Arab physicians. As they conquered the Middle East, the Arabs captured and preserved some ancient medical texts, and from the 9th century, Galen was translated into Arabic on a massive scale.
Unfortunately translations of Galen’s revolutionary work on anatomy did not reach the Western world until the late Middle Ages. Even more unfortunately, many of his other theories (none of which had any medical validity) and his huge number of remedies (none especially useful) were used by doctors for centuries, becoming the medical equivalent of holy writ. In fact, they later became part of Church dogma. The egotistical Galen would probably have been pleased to know that he effectively held back the advancement of medicine for centuries.
The Arab physicians became famed for their skill, and their own writings entered the medical canon. However, they rarely practised invasive surgery. As for the Western Christians, they abolished surgery in both knowledge and practice: it was pagan and it was a sin.
An end and a beginning
So the end of the great library at Alexandria and of the Roman empire marked the end of progress in Western medicine and, in particular, surgery, for hundreds of years.
It wouldn’t be until the end of the Middle Ages, with the coming of the Renaissance, that the knowledge of the ancients would be rediscovered. Anatomy would gradually be accepted, new discoveries in wound treatment would be made on the battlefield and, finally, the doors to new surgical techniques and practices would swing open.
