Timeline of Surgery in Antiquity
The ‘Timeline of Surgery’ is presented with an Index of the date and country that an operation was first carried out and by whom where this is known. If readers tap on an item of interest in the Index then the main article concerning the origin and times of the new operation will come up. Also listed are important technical advances that facilitated the development of novel operations. As the centuries have passed, innovative and more knowledgeable surgeons have improved the technique and safety of particular operations to the great advantage of their patients. These very significant advances have not been listed if that particular operation had been carried out successfully at an earlier date in more primitive conditions. For convenience, the Timeline is divided into three sections; the Timeline of Surgery in Antiquity, The Timeline of Medieval and Early Modern Surgery and the Timeline of Modern Surgery.
It is interesting that throughout history the flow of innovative surgery has passed from a declining civilisation to one in ascendancy and this is demonstrated in the ‘Analysis of the Timeline’ on this website. In most cases the knowledge established in an earlier civilisation was passed on to the next mainly through translation of the written word. The scholars who carried out these translations performed a great service as their work facilitated new advances. The author fully acknowledges his debt and reliance on the work of these scholars, ancient and modern, for without them this timeline could not have been produced. The sources of information used are referenced and there is also a separate bibliography.
INDEX of Timeline of Surgery in Antiquity. (Tap on a heading below to bring up the main article).
Abbreviations: BCE =Before the Common Era (Before the Christian Era). c. = circa (estimated dates). CE = Common Era (Christian Era).
c. 10,000 BCE. Peru. Trephination of the skull
Trephined skulls have been found in many countries and some date back thousands of years. The practice is known to have continued into the early twentieth-century in North Africa. The largest collection of ancient trephined skulls is in Peru. These trephines were almost all in men who had obvious fractures, mainly on the left side of the skull, thought to be caused by right handed blows from a club or stone. Observable evidence of osteomyelitis (post-surgery sepsis) around the trephine was rare as shown by the smooth healing of the bone round the edge of most of the trephines. It seems that nearly everyone who underwent trephination survived to fight another day. This is supported by the fact that some skulls had multiple fractures caused at different times with their associated trephines. These extraordinary results from ancient Peru can be contrasted with the introduction of trephination in the first half of the nineteenth century in Europe. In these latter operations, the unfortunate patients were nearly always infected and the mortality was nearly 100%. This lead to the abandonment of trephination until the introduction of aseptic surgery (see Timeline of Modern Surgery). Both groups of operations, millennia apart, were carried out before the cause of sepsis was known. In Peru, the population was small and rural and operations almost certainly infrequent giving small opportunity for the practitioners to transfer pathogenic bacteria between patients, this contrasts with the dirty crowded towns and cities of Europe where the surgeons wore the same pus be-splatted aprons, so guaranteeing the spread of sepsis and death.
Reference: The Healing Hand. Man and Wound in the Ancient World, by Guido Majno. Harvard University Press 1975.
c. 3000 BCE. Egypt. Catheterisation for retention of urine.
Catheterisation has been used since earliest times when straw or other tubes of vegetable origin were used. In Roman times catheters made of bronze have been found and by the middle ages silver was the most popular metal used. Regular catheterisation would often be necessary, so inevitably over time repeated catheterisation must have led to chronic infection of the urinary tract and often early death due to renal failure.
2423-2262 BCE. Egypt. Circumcision.
Two young men undergoing circumcision are Illustrated in a tomb drawing of a high-ranking royal-official in Sakkara in ancient Egypt dated as above. Circumcision was probably the first elective or planned operation, whether it was for religious reasons or to relieve sepsis in a male with a phimosis is not known. It appears that the operators knife is made of stone. Reference: Science and Secrets of Early Medicine by Jurgen Thorwald, translated from the German by Richard and Clara Winston. Published by Thames and Hudson, 1962. Page 53.
c. 1700 BCE. Babylon. Hammurabi’s laws governing surgery.
Hammurabi (c. 1810 – 1750 BCE), King of Babylon ordered a strict code of laws to be carved in stone, which can now to be seen in the Louvre in Paris. It prescribed on the one hand, high reward for medical or surgical success and on the other hand failure could result in the surgeon’s hands being cut off if he had treated a man’s wound with a bronze knife and the patient had died (1). In the ancient civilisations physicians would not operate or treat a patient who they thought was incurable or would die from their wounds. Therefore, the death of a patient at the hands of a surgeon was treated harshly.
Reference: (1). Wikipedia. (2). The Cambridge Illustrated History of Medicine edited by Roy Porter. Cambridge University Press, 1996. ISBN 0 521 44211. Page 204.
C. 1550 BCE. Egypt. Ebers Papyrus. The use of antiseptics.
Malachite is a green stone composed of copper carbonate and when it was suitably prepared was used over millennia by Egyptian women as a cosmetic for their eyes. It is now known that malachite has a powerful antibacterial effect and probably warded off the common eye diseases of the Near-East. Malachite was also prepared as Verdigris and was applied to wounds as a poultice. Unfortunately, the ancient Egyptians also had a habit of adding dung or ground flies to their mixtures. In the same document a salve of honey and grease was also in common use. There was no clear-cut distinction at that time between magic and empiricism. The use of antiseptics in Egypt has been studied, tested and described most elegantly by Dr Majno. (1).
Reference: (1). The healing Hand by Guido Majno. Harvard University Press. 1975, paperback edition 1991. Pages 111-120.
c. 1550 BCE. Egypt. Edwin Smith papyrus. Splinting of fractured bones.
This ancient Papyrus was discovered in Egypt in the 1860s. It documents 48 cases of generic trauma starting with injuries to the head and then in descending order down the body. Information of injuries below the chest are lost. The only surgical conditions treated were wounds, fractures, dislocations and abscesses. The first splinting of a fractured upper arm is described. ‘The patient is laid on his back in a position to spread apart the upper arm until the break falls into place. Then two splints of linen are made and applied to the inside and underside of the arm, it is then bound with a mineral substance until he recovers’. This is simple splinting of the fracture appeared to be successful and the unknown mineral substance must have stiffened the linen. Also, practical descriptions of physical examination, diagnosis and treatment are given with incantations. Failure of a treatment administered could result in punishment in Egypt, as in Babylon (1). Circa 400 BCE the Greek Hippocrates’ (c. 460-377 BCE) produced a masterly description of the management of fractures and dislocations in the ‘Hippocratic Writings’. This is well worth a read (2).
References: (1). A History of Surgery by Harold Ellis. Published by Greenwich Medical Media Ltd. 2001. ISBN 1 84110 023 4. (2). Hippocratic Writings in Penguin Classics. Edited by G.E.R. Lloyd, Translated by J. Chadwick and W.N. Mann, 1950 reprinted 1983.
c. 1550 BCE. Egypt. Edwin Smith papyrus. Reduction of a dislocated jaw.
In the papyrus is this description. ‘If you examine a man having a dislocation of his mandible, should you find his mouth open, and his mouth cannot close again, you should put your two thumbs upon the ends of the two rami of the mandible inside his mouth and your fingers under his chin and you should cause them to fall back so they rest in their places.
Reference: A History of Surgery by Harold Ellis. Published by Greenwich Medical Media Ltd. 2001. ISBN 1 84110 023 4.
c. 1550 BCE. Egypt. Edwin Smith papyrus. Use of sutures to close wounds.
Among the treatments mentioned are the closing of wounds with sutures (for wounds of the lip, throat, and shoulder). There is no information of what the suture material was made.
Reference: The Healing Hand by Guido Majno. Harvard University Press. 1975, paperback edition 1991.
c. 450 BCE. India. Sushruta. Snake bites, the first use of a tourniquet.
Sushruta (dates unknown) was a famous Hindu physician and author of a treatise on medicine, the date it was written is uncertain, possibly somewhere between 800 BCE and 100 CE. This difficulty with dates is due to the ancient oral tradition of passing on knowledge. The text of Sushruta’s work was translated into Arabic by Kitab Shah Shun al-Hindi in Baghdad early in the 8th century CE and reached Europe at the end of the Medieval period. Sushruta states that snake bites were (and still are) frequent in India. A person bitten in a limb had a tourniquet applied above the bite (1). An attempt was then made to suck the venom from the wound, followed by an incision between the fang marks with a sharp knife. Finally, if available, a concoction of ‘sarpagandra’ root was drunk. This root is from the plant now known as Rauwolfia serpentine is the source of the tranquilising drug Reserpine developed in the 1950s. In 365 BCE Alexander the Great crossed the Indus, where he unexpectedly found that many of his troops were bitten by cobras. Because the Greek physicians had no experience of this problem Alexander hired Hindu physicians to treat those who were bitten. In modern times, 2015, Nature Journal of Science records that there were 500,000 people fatally bitten by poisonous snakes. This was mainly in India, South-East Asia and Africa (2).
Reference: (1). The healing Hand by Guido Majno. Harvard University Press. 1975, paperback edition 1991. (2). Nature Journal of Science. 2017.
c. 450 BCE. India. Sushruta. Origin of plastic surgery, earlobe reconstruction.
Sushruta wrote ten pages describing earlobe piercing and its complications. The custom of enlarging an ear piercing so a heavy earring, favoured by the Brahmins of that era, could be hung from the earlobe, not infrequently resulted in sepsis and/or trauma where the earlobe was torn apart. Not being able to exhibit an earring was distressing and this complication therefore created a need for this enterprising surgeon to show off his skill. In one case Sushruta described a Brahmin whose earlobe had shrunk to a small scar. He wrote, ‘The ways to repair an injured earlobe are innumerable’, but, ‘In this case it can only be repaired by making a new earlobe out of the skin nearby.’ He then continued. ‘A surgeon well versed in the knowledge of surgery should slice a patch of living flesh from the cheek of a person devoid of earlobes in a manner so as to have one of its ends (remain) attached to its former seat (on the cheek below the earlobe). Then the part where the artificial (new) earlobe is to be (attached), should be partly scarified with a knife and the living flesh, full of blood and sliced as previously directed (the flap), should be adhesioned’ to it (1). This is a description of a pedicle flap. Thus, due to the habit of stretching their earlobes and hanging heavy earrings on them causing the complication noted above. Indian surgeons became the pioneers of plastic surgery, that remained unknown to the Europeans until well over two thousand years later, when the pedicle flap was rediscovered.
Reference: (1). The healing Hand by Guido Majno. Harvard University Press. 1975, paperback edition 1991.
c. 450 BCE. India. Sushruta. First nasal reconstruction.
In India, nasal reconstruction was uncommon and Sushruta only devotes two pages to it. The new nose was formed from a flap of skin folded down from the forehead. This work was translated into Arabic in about 800 CE by Rhazes.
Reference: A History of Surgery by Harold Ellis. Publisher Greenwich Medical Media Ltd 2001. ISBN: 1-84110-023-4.
c. 450 BCE. India. Sushruta. Couching cataracts
Sushruta devotes a chapter to this operation. The objective is to push down and out of the way a cataract of an eye. This is done with a needle or fine lancet inserted behind the iris from above and then the lens is pushed downwards, so that it is out of the line of vision (1). This is thought to be the first detailed description of couching for cataract. However, there is a claim that this operation could have occurred at a much earlier date in Mesopotamia but the interpretation of what was written is not clear (2).
References: (1). Sushruta Samhita, translated by K.L. Bhishagratna. Chowkhamba Sanskrit Series Office, Varanasi, India. Reprinted 1963. (2). Science and Secrets of Early Medicine by Jurgen Thorwold. Published by Thames & Hudson, London 1962.
c. 450 BCE. India. Sushruta. Excision of bladder stone
Hippocrates writing on Diseases, (in circa 400-350 BCE), only recommended treatment by catherization for those suffering from a bladder stone. He advised the removal of such stones be left to ‘such as are craftsmen therein’, (1). There is no record of a Greek surgeon carrying out lithotomy at that time. If we turn to the Susruta Samhita there is a gripping description of bladder stone removal by surgery as follows: ‘The surgeon was to rub the second and third finger of his left hand thoroughly with fat, and make sure his nails were clipped close. Then he introduced these fingers into the patient’s anus. He must thrust them vigorously, high enough until he could feel the stone in the bladder, for it would probably be pushed backwards and down by pressure on the abdominal wall resulting (in it being felt and fixed near the rectum), and then with the knife wielded by his right hand he cut through the perineum towards the stone. Forceps were then introduced through the incision, the stone grasped and drawn out’, (2). This operation was introduced two thousand years later to western Europe where it was used until the advent of anaesthesia when a direct abdominal approach from above was made to reach the stone. Samuel Pepys, the diarist was operated on, in London on the 26th March 1658, for a bladder stone using the method described above. These operations were done with the patient being held down there being no anaesthesia available (3).
References: (1). Cambridge Illustrated History of Medicine edited by Roy Porter. Cambridge University Press, 1996. ISBN 0 521 44211. Page 204. (2). Science and Secrets of Early Medicine by Jurgen Thorwald, Translated from the German by Richard and Clara Winston. Published by Thames and Hudson, London in 1962. Page 211. (3). Wikipedia.
c. 450 BCE. Greek. Alcmaeon of Croton. Conception of the brain as the seat of consciousness
Alcmaeon (a Greek born c. 520 BCE) was possibly a pupil of Pythagoras of Samos (c. 570-c.490) and made two fundamental contributions to medical thinking. He was the first to develop the concept of the brain as the seat of consciousness, separating sense perception from intelligence. His second concept was that disease was the ‘unbalance’ of opposite qualities, or the difference between wellness and illness, which were thought to constitutes the beginning of a rational explanation of disease (rather than being the will of a god or gods) which has come down to us from antiquity (1).
Reference: (1) C.R.S. Harris. The heart and vascular system in ancient Greek medicine. Oxford University Press 1973.
c. 425 BCE. Greek. Hippocrates of Cos. First to record the pattern and outcome of diseases.
Hippocrates (460 – 370 BCE), famous for his medical oath, kept meticulous records of his patients. This enabled him after treating and recording the pattern of diseases in many patients, to be able to recognise the disease that a new patient was suffering from. Hippocrates then could impress the patient by relating precisely what his or her symptoms had been from the onset of disease to when he was first consulted by them and give a prognosis (1). If his prognosis was that the disease or wound was terminal he would not treat the patient, but probably called a priest.
Reference: (1). Hippocratic writings edited by Sir Geoffrey Lloyd, translated by J. Chadwick and W.N. Mann. Penguin Classics 1950, reprinted 1983.
c. 260 BCE. Greek. Erasistratus of Ceos. The heart recognised as a one-way pump
Erasistratus (c. 304 – c. 250 BCE), a Greek physician in Egypt, who studied at the Museum in Alexandria during the reigns of the of the early members of the Ptolemaic dynasty (305 BCE – 30 BCE), advanced anatomy through human dissections and first understood the heart as a one-way pump. He recognised that the cardiac valves would only permit flow in one direction. However, the role of the lungs, heart and arteries was not then understood. From the time of Aristotle, (384-322 BCE), it was believed that the heart was the seat of intelligence, it was Erasistratus who was the first to believe that it was the brain (1). Erasistratus was a contemporary of Herophilus (see next entry). Note. The circulation of the blood was unknown until 1628 when Dr William Harvey (1578 – 1657) published his description of the circulation based on his observations, nearly one thousand-nine-hundred years later. (See the Medieval Surgery Time-line for a detailed account of Harvey’s discovery.
References: (1). Greek science after Aristotle by G.E.R. Lloyd. Published by W.W. Norton & Company in 1973. (2). De Motu Cordis. 1628 by Dr William Harvey.
c. 260 BCE. Greek. Herophilus of Chalcedon. Anatomy, first human dissections
Herophilus (335-280 BCE) practiced human dissections, often publicly at the medical school in Alexandria in Egypt, as they were permitted during the reigns of the early Ptolemies such as Ptolemy II Philadelphus who reigned from 285-246 BCE. Herophilus considered it essential to found knowledge on an empirical base and proposed that the brain rather than the heart was the seat of the intellect, he also began to name parts of the body with specific names e.g. duodenum. His works were lost but he is quoted by Galen of Pergamon, (129-199 CE), who was also an anatomist but did not dissect the human body. Dissection to gain knowledge about human anatomy was rekindled in the early modern times by Vesalius (1514-1564) about 1700 years later. Herophilus was a contemporary of Erasistratus.
c. 250 BCE. Greek. Ctesbius of Alexandria. The invention of the syringe and pump
The concept of a piston and cylinder forming a syringe, was developed in Alexandria in Egypt by Ctesbius, (c. 285-222 BCE). It was used for injecting liquids and sucking out pus from wounds and abscesses. Further, he invented the valve and because of this the pump. He was one of the greatest engineers of antiquity. His work was reported by the Roman architect, Vitruvius 250 years later.
c. 40 CE. Rome. Aulus Cornelius Celsus. Ligation of blood vessels.
Celsus (c.25 BCE – c. 50 CE) produced an encyclopaedia, ‘De Medicina’, which was used as a primary source of medicine and surgery from the Roman era to the 16th century. Celsus wrote that; ‘when a man has been wounded who can be saved…… he should not die from haemorrhage or inflammation (sepsis)’ (1). He then described simple methods of treatment, such as pressure on the wound and applying vinegar, but proceeded to say; ‘the blood vessels which are pouring out blood are to be seized’ and a double ligature applied above the bleeding point. The discovery and application of ligation to stop or prevent bleeding remains a fundamental technique of modern surgery.
Reference: (1). Celsus on Medicine, Volume II Book V, translated by W.G. Spencer. Loeb Classical Library, Harvard University Press. ISBN 978-0-674-99335-8.
c. 40 CE. Rome. Aulus Cornelius Celsus. Amputation of limbs.
Celsus (c. 25 BCE – c. 50 CE) advised the amputation of gangrenous limbs. He recognised that this was not a ‘safe’ option but is the only one in the circumstances. He wrote, ‘Between the sound and the diseased part, the flesh is to be cut through with a scalpel to the bone (1)’. He then directs that the joints should be avoided and that ‘sound flesh’ should be cut away (if necessary) to ensure that all diseased tissue is excised. The bone is then bared well above the level of the skin incision before cutting through it with a saw, the rough parts of the bone are smoothed and the skin is drawn over it. He must have ligated the blood vessels although they are not mentioned (2). Celsus’s operation was used during the war of 1914-1918 when bone stumps that were beginning to protrude through the skin following previous emergency amputation and were cut back to a higher level.
References: (1). Celsus on Medicine, Volume III Book VII, translated by W.G. Spencer. Loeb Classical Library, Harvard University Press. ISBN 978-0-674-99370-9. (2). The Healing Hand. Guido Majno. Harvard University Press 1975. ISBN 0-674-38331 1.
c. 40 CE. Rome. Aulus Cornelius Celsus. Surgery for fistulae including anal fistula.
Celsus (c. 25 BCE – c. 50 CE), describes fistulae of the chest wall, abdomen and anus. All were generally secondary to internal infections that developed into abscesses that then discharged through a spontaneous rupture in the skin to cause a fistulous tract. His description follows. ‘Initially the external tract is laid open and the probe, (that has been passed down the fistula, from the external through to the internal opening) is to be drawn back, followed by a linen thread (passed through an eye) made for that purpose at the other end of the probe. Then the two ends of the linen thread are taken and knotted so as to grip loosely the skin overlying the fistula (1).’ This linen thread, (seton), is therefore tied around the anal sphincter muscle whose integrity must be preserved to avoid incontinence. The seton needs changing regularly as it becomes loose. The muscle of the anal sphincter heals behind the seton as it slowly cuts through it. It is remarkable that this operation was again noted in the eleventh-century in Arab Spain (2) and is still practiced in the twenty-first century.
References:(1) & (3). Celsus on Medicine. Book 7. Translated by W.G. Spencer. First published 1938 by Loeb Classical Library. ISBN 978-0-674-99370-9. (2). Medieval Islamic Medicine. Peter E. Porman & Emily Savage Smith. Edinburgh University Press. 2010. ISBN 978 0 7486 2066 1.
c. 40 CE. Rome. Celsus. Excision of tonsils.
Tonsillectomy as described by Celsus (c. 25 BCE – c. 50 CE), was limited to those that have a thin ‘tunic’ round them following (chronic) inflammation and were (large enough to be) mobilised with a finger, then transfixed by a hook and excised with a scalpel (1). It seems to modern ears that tonsils excised at that time were probably necrotic, otherwise torrential bleeding could occur that would be difficult to stop owing to difficult access to a bleeding point.
Reference: Celsus on Medicine. Vol III Book V11. Translated by W.G. Spencer. First published 1938 by Loeb Classical Library, Harvard University press. ISBN 978-0-674-99370-9.
c. 40 CE. Rome. Celsus. Description of the four cardinal signs of inflammation.
The signs of inflammation were first described by Celsus (c. 25 BCE – c. 50 CE), and are, ‘redness, swelling, heat and pain (1). (Rubor, Tumor, Calor, Dolor). This is still being taught in Medical Schools.
Reference: (1). The Legacy of Rome edited by Cyril Bailey. Oxford University Press. 1923, reprinted 1940.
c. 30 CE. Rome. Celsus. Operations for inguinal hernia, hydrocele and varicocele.
The description of these operations by Celsus (c. 25 BCE – c. 50 CE) are difficult to follow from an anatomical point of view. However, the operations were carefully carried out and in all of them he ligated bleeding vessels as necessary (1). He also replaced bowel and omentum into the abdomen if they had prolapsed into the hernial sac.
Reference: (1) Celsus on Medicine Book VII translated by W.G. Spencer. Loeb Classical Library, Harvard University Press 1935. ISBN 978-0-674-99322-8.
c. 40 CE. Rome. Celsus. Varicose vein surgery
Celsus (c. 25BCE – c. 50 CE) wrote; ‘Any vein that is troublesome may be shrivelled by cauterising or cut by surgery’. For cautery, on moderate sized veins, an incision was made over the vein and then cauterised with a fine, blunt hot cautery iron, this was repeated throughout the length of the vein. In large twisted veins, he preferred surgery. This was carried out through incisions four fingers apart down the leg, the vein being retracted with a hook through each incision and cut away (1). He would have carried out ligations of bleeding veins as necessary.
Reference: (1). Celsus on Medicine. Book 7. Translated by W.G. Spencer. First published 1938 by Loeb Classical Library. ISBN 978-0-674-99370-9.
c. 40 CE. Rome. Celsus. Excision of impacted urethral stone.
Celsus (c. 25BCE – c. 50 CE), describes how an impacted urethral stone should be extracted by passing an ear-scoop into the urethra and pulling it out. If that fails then the surgeon pulls the prepuce over the glans and ties it in place. Then makes an incision over the stone into the urethra and extracts it directly. Then the tie round the prepuce is released ‘so as intact portion of skin covers the incision into the penis and urine flows out naturally’ (1).
Reference: (1). Celsus on Medicine, Volume II Book VII. Translated by W.G. Spencer. First published 1938 by Loeb Classical Library. ISBN 978-0-674-99370-9.
c. 79 CE. Rome. The first hospitals.
In the 1st Century CE, as the Roman Empire expanded and as the distance to its frontiers lengthened the military commanders found it necessary to provide special quarters for the sick and wounded. These ‘valetudinaria’, of which at least 25 have been excavated, were strung along the frontiers of the Roman Empire, from Scotland to Palestine, and were built to a standard plan. The hospital was constructed in a quadrangle with a corridor and leading off this were small rooms. In an archaeological excavation of the ancient Roman military camp in Inchtuthil in central Scotland, it was discovered that the valetudinarian had sixty-four rooms or wards off the corridor and each could accommodate four to five men. The maximum capacity was for 220 wounded or sick soldiers. There is strong evidence for the existence of a medical corps (1), the personnel and doctors were mainly Greek. These doctors would have used instruments similar to those discovered during excavations of Pompeii, which was destroyed in the volcanic eruption of Vesuvius in 79 CE. They included scalpels, forceps, tissue hooks, male catheters made of bronze, saws and specula with a screw ratchet, such as are used in modern gynaecological examination and other more delicate probes (2).
Reference: (1). The Healing Hand. Guido Majno. Harvard University Press 1975. (2). Wikipedia.
c. 180 CE. Rome. Claudius GALEN of Pergamon, Advances in anatomy
Galen (129 or 130 – c. 200 CE) was a Roman of Greek origin from the Roman Province of Asia Minor. While his medicine was essentially Hippocratic (c.460-c. 377 BCE), his learning reached at least one order of magnitude beyond that of Hippocrates. Galen had been to the Alexandrian school in Egypt from 152 CE for five years and there expanded the knowledge of anatomy and also carried out physiological experiments (1). Galen spoke Greek throughout his life, but was born in the golden age of the Roman Empire. ‘The Empire was bilingual; Greek was the language of science and philosophy, Latin that of administration, commerce and the military.’ (2). Galen dissected many species of animals, the most frequently dissected were apes because of their similarity to man (3). He also dissected domestic animals and locally found wild animals, including lions, bears and several elephants. He would have known that Aristotle 384-322 BCE (3), in whose footsteps he followed also dissected over one hundred species of animals and wrote his ‘Historia Animalium’ (4). Galen’s dissections were very detailed (4) and the knowledge so acquired enabled him to accurately perform physiological experiments as described in the next entry.
Reference: (1). The Healing Hand by Guido Majno. Harvard University Press, 1975. (2). Galen of Pergamon by George Sarton. University of Kansas Press 1954. Library of Congress number: 54-8112. (3). Galen on Anatomical Procedures. Translation of the Surviving Books by Charles Singer. Oxford University Press 1956. ISBN: 0-19-924016-7. (4). The Works of Aristotle Translated into English. Historia Animalia by D’Arcy Wentworth Thompson. Oxford at the Clarendon Press 1910.
c. 180 CE. Rome. GALEN of Pergamon. First physiological experiments
Galen (129 or 130 – c. 200 CE) performed carefully planned physiological experiments. These included opening arteries in live animals, so proving that the arteries contained only blood and not air as was previously thought. (Galen did not understand the function of the heart or know about the circulation of the blood), he believed that blood was formed in the liver and was mainly found in the veins. The arteries had a separate function. In another experiment on a live animal, he tied the ureters to demonstrate their filling with urine, proving that urine came from the kidneys, a fact previously disputed (1). In another separate experiment he tied an animal’s urethra, to demonstrate that when the bladder was full the ureters did not distend due to backflow. He thereby showed that there was a non-return valve where the ureter traversed the bladder wall now understood as an example of a ‘flutter valve’. Then in another entirely novel series of experiments, he made the correct deduction that the brain controls all the motions of the muscles by means of the cranial and peripheral nervous systems. To demonstrate this, Galen severed in sequence different nerves and also portions of the spinal cord at different levels of an animal. He observed and described the exact extent and distribution of the paralysis that was caused by each division (2). In one such experiment he severed the recurrent laryngeal nerves noting: ‘With the nerves damaged, the animal becomes dumb’ (3). His experiments significantly advanced the knowledge of anatomy and physiology, structure and function. The means to this knowledge would now be considered unacceptably cruel. In mitigation, surgeons before the discovery of anaesthesia one-thousand six-hundred years later, had to be composed and unruffled while they operated on patients, who were suffering agonising pain throughout the operation. Galen had also been physician and surgeon to the gladiators in Pergamum for several years and must have been hardened to the cruelty of man. It is reputed that his skill as their surgeon reduced the mortality among the gladiators significantly. After his lengthy training, experimentation and extensive travel Galen settled in Rome where he became physician to the Roman Emperor Marcus Aurelius (b.121-180 CE).
References: (1). The Healing Hand by Guido Majno. Harvard University Press, 1975. (2). Galen on the ‘Usefulness of Parts of the Body’. Translated by M.T. May, Cornell University press 1968. 2 vols. (3). Galen on Anatomical Procedures. Translation of the Surviving Books by Charles Singer. Oxford University Press 1956. ISBN: 0-19-924016-7.
c. 180 CE. Rome. GALEN of Pergamon. Suture of tendons and muscles
Galen (129 or 130 – c. 200 CE) returned to Pergamon in 157 CE and stayed for four years during which time he was physician to the gladiators even though he was only 29 years old (1). He recorded his observations of the trauma inflicted on the gladiators from 158 to 162 CE and also of the treatment he carried out on the wounded. Celsus (c. 25BCE – c. 50 CE), had observed that severed or disrupted tendons were common in the arena. It was Galen who was the first to have sutured the divided tendons together and he also sutured muscles. (The belief at that time was that the tendons did the contracting and were confused with nerves, while the action of muscles was unknown). Following Celsus’s ligation of bleeding arteries Galen did the same to the bleeding arteries of wounded gladiators. Thus, he reduced their mortality during his time in Pergamum. It is interesting that he did not use a tourniquet. However, haemorrhagic shock was not understood or even recognised at that time. Galen gradually changed his thinking from observation and experimentation to philosophy and religion (2). He possibly wrote thirty books, of which twenty-two still exist, amounting to two-and-a-half-million words written in Greek. His works were translated into Arabic and Latin and dominated medicine in the Arabic world and then Western Europe. He had made great advances and was the most famous physician of his time. From the point of view of innovation and discovery in surgery a dark age had then descended and lasted for thirteen centuries. During this time dissection was forbidden as was experimentation, so Galen’s writings came to be accepted as the final word in medicine and surgery until early modern times. The dominance of Galen’s writing was such that whenever a question of anatomy or medicine was asked during those centuries, the answer was sought by reference to his works. The lack of curiosity shown or permitted during those centuries stopped the development of medicine and surgery. Unfortunately, Galen’s treatments rested on the damaging Hippocratic triad of: starving, purging and bleeding patients that was continued as a mainstay of medical practise (3). The rationale for the malign theory of bleeding or venesection of an ill patient is worth exploring., Now known to be useless as a treatment it had its origins in Ancient Egypt and lasted into the twentieth century. It was rationalised in antiquity as follows. The ancients believed that ‘Blood ebbed and flowed in the veins’. (The circulation of the blood was unknown until William Harvey proved it in 1628). So, when an injury occurs, ‘blood is attracted to it’. This was considered self-evident, so the theory then supposed, that blood stagnated around the injury and caused decay (suppuration). It was also considered self-evident that decay would occur if nothing was done. So, by following this theory it was necessary for the doctor to try to prevent this by draining away the blood, where possible, by opening the vein nearest to the site of injury. This should prevent or reduce suppuration and decay from occurring. The resulting venesections were often repeated in ill and debilitated patients and must have exsanguinated many of them. An innumerable number of patients must have been sent to an early grave on account of repeated blood-letting. The practise of venesection continued to the beginning of the twentieth century but by then the blood-letting was done by leaches. The damage done was expressed forcefully by Dr Majno who wrote; ‘Europe sank into the Dark Ages…. only the number of wounds did not decline, as I fear it will always -be a basic means of human communication’ (4).
References: (1). Galen of Pergamon by George Sarton. University of Kansas Press 1954. Library of Congress Catalogue Card Number 54-8112. (2) Galen on the ‘Usefulness of Parts of the Body’. Translated by M.T. May, Cornell University press 1968. 2 vols. (3). Galen on the Natural Faculties by Arthur John Brock 2016. Erik Publications. (4) The Healing Hand by Guido Majno. Harvard University Press, 1975.
c. 158-161 CE. Rome. GALEN of Pergamon. Wounds can heal without sepsis
Galen (129 or 130 – c. 200 CE) was the greatest surgeon of his age. When a young man he served as physician to the gladiators in Pergamon, which was possibly the second most important city in the Roman Empire. It was here that he reduced the mortality of wounded gladiators by his suturing severed tendons and muscles and following Celsus (c. 25 BCE – c. 50 CE) in ligating bleeding blood vessels. He also noted and recorded that wounds could heal by ‘first intention’, (without sepsis) (1). Until the discovery of the role of bacteria in causing sepsis, followed by the development of the anti-septic surgical technique by Lord Lister (1827-1912 CE) in the nineteenth century, Galen’s observation of healing without sepsis was lost to posterity. The problem goes back to the ancient Greek language where the same word means both wound and ulcer (i.e. septic wound) (2). Not surprising, nearly all wounds until Lister’s time became septic and this was accepted as the norm. Even in the nineteenth century physicians were talking of laudable pus.
References: (1). Galen of Pergamon by George Sarton. University of Kansas Press 1954. Library of Congress Catalogue Card Number 54-8112. (2). The Healing Hand by Guido Majno. Harvard University Press, 1975.
c. 431 CE. Byzantium. The spread of Greek medicine to the East.
Byzantium was the Eastern Roman Empire (330 – 1453 CE) so the link is direct to the Roman Empire before the fall of Rome in 476 CE to a Germanic prince. Byzantium was a Christian theocracy and there was little in the way of advance in surgery after the fall of Rome. The preservation of written knowledge from the age of Antiquity was transferred to the Islamic civilisation by translation of the mainly Greek texts. One such example is described below. In 431 CE, Nestorius, the Patriarch of Constantinople in the Byzantine Empire, was excommunicated by the Christian Council at Ephesus for heresy. Nestorius was exiled and probably died in Egypt in 451. His followers were persecuted and fled to Egypt and Edessa in upper Mesopotamia. The Byzantine authorities reached Edessa to persecute the ‘Nestorians’, as they were now called, who fled to India, China and Persia. Many settled in Jundi-Shapur, an ancient and beautiful Persian city with a university and hospital that also functioned as a medical school. Their scholars began translating the ancient Greek medical and other texts into Syriac. In 636 CE Jundi-Shapur was conquered by the Arabs. The university was not disturbed, possibly because the Arab commanders were aware that two of the Prophet’s physicians were graduates of the medical school. Then in the 8th Century as Baghdad became the Capital of the Caliphate some Nestorians migrated there. Their work continued, now translating the old Greek documents from Syriac into Arabic. Eventually some of these documents found their way across the Caliphate to Spain in the west where they were eventually translated into Latin in the middle-ages. The claim of Jundi-Shapur as one of the conduits for transmission of knowledge to the Islamic Califate is challenged, as there is no evidence that there was either a hospital or medical school there (1). This conundrum can perhaps be explained as between the 8th and 11th centuries it appears that twelve members (generations) of the Bukhtishu family of Nestorian Christians served the caliphs of Baghdad as physicians and advisors and rose to great prominence following the migration from Jundi-Shapur. Some claim that they forged a mythical past to give themselves more leverage at court. This is apparently based on an account of a thirteenth century medical historian (2). There is no doubt that many scholars were welcome in Baghdad at the height of the Califate. Egypt was also conquered by the Arabs in 639, and there is no doubt that Alexandria remained a place of learning where the translation of documents into Arabic continued over a long period of time.
References: (1) Medieval Islamic Medicine by P.E. Porman & E. Savage-Smith p.20-21. Edinburgh University Press 2010. (2) Ibid.