“The patient who has been fed, does not faint, and he who is rendered intoxicated, does not feel the pain of the operation”

Suśruta (c.600 BC)

Ayurvedic medicine was established hundreds of years later, not long after the birth of Christ. The first and most defining texts of Ayurvedic medicine are the Caraka Samhita and the Suśrutasaִmhitā. The latter is attributed to Suśruta, a physician who taught surgery and advocated the use of dead animals and vegetables for practising various procedures. In reality, the text has been revised many times, and is unlikely to be written by Suśruta’s own hand but is thought to be based on his oral teaching (Fig. 1.2). Surgical procedures discussed in his text include cataract couching and forehead rhinoplasty, whereby he remodels the nose of a patient using skin from their forehead. Over one hundred surgical instruments are described in the Suśruta, including details about their manufacture, but unfortunately none of these ancient instruments have survived. One theory is that surgery was given up by caste Brahmins and delegated to other artisan surgeons who continued to practise well into the mid-twentieth century [8].

“He who wishes to be a surgeon should go to war”

Hippocrates (460–371 BC)

Legend has it that Hippocrates (460–371 BC) was born on the island of Cos and was a true descendent of Asclepius, the Greek God of Medicine. As well as being revered as the ‘father of modern medicine’, Hippocrates’ name is also attributed to the Hippocratic Corpus; a body of around sixty medical manuscripts that were actually drawn together around 250 BC, long after Hippocrates’ death. How much of the Corpus was actually written by Hippocrates himself is a subject for debate, but nevertheless it formed the foundations of medical knowledge for the next thousand or so years. The Corpus contains some advice on the management of surgical conditions, in particular head injuries, wounds, fractures, bladder stones and gangrenous limbs. However, it mostly advocated conservative medical treatment over ‘dangerous’ surgical intervention. For example, catheterisation was opted for over lithotomy for bladder stones, and amputation was only performed as a last resort. In fact, the Hippocratic Oath itself seems to forbid the practice of cutting by physicians: “I will not cut, and certainly not those suffering from stone, but I will cede this to men who are practitioners of this activity”. However, there has been much discussion about whether this denotes surgery as a whole, or is an early concept of surgical specialism [4].

Hippocratic medical theory was based on vis medicatrix naturae (“the healing power of nature”) and the balance of the four ‘humours’, namely phlegm, blood, bile and black bile. The equal distribution of these bodily fluids in the human microcosm was deemed essential for health. Illness struck when there was an imbalance, therefore treatment was focused on maintaining an equilibrium [1].

A few hundred years later in Ancient Rome, Celsus (25 BC–AD 50) wrote Artes, essentially an encyclopaedia of medical and surgical theories. His work is divided into eight books, the last two of which discuss surgical conditions and their treatment. Celsus is the author of the terms calor, dolor, rubor and tumor, which every doctor is familiar with today as the cardinal signs of inflammation.

Perhaps the most famous physician of the Roman period was Galen (AD 129–c. 216). Born in Pergammon, Galen (Fig. 1.3) conducted his medical studies in Alexandria, before returning to his home city, where he became an expert in trauma surgery by working as a surgeon to the gladiators. He arrived in Rome in AD 162 where he truly made his name. Galen was an avid dissector, and his works formed the basis of anatomical knowledge until the Renaissance period. He wrote almost 350 separate works, all of which were based on Hippocratic medicine and Humoral theory. Surgical reflections are spread throughout some of these, including a description of the removal of nasal polyps [3].

“It is impossible to be a good surgeon if one is not familiar with the foundations and general rules of medicine [and] it is impossible for anyone to be a good physician who is absolutely ignorant of the art of surgery”

Henri de Mondeville (1260–1320)

It would be wrong to discuss medicine in the medieval period without mentioning the developments in medicine and surgery that were taking place in the Middle East. At the time, the Arab World had found itself under a variety of ethnic influences, especially from the Byzantine Empire and the persecuted Syriac-speaking Christians. These groups passed on the principles of medical knowledge, which had mostly been acquired from the teachings of Greek medicine in Alexandria. In the ninth century the Greco-Arabic translation movement got underway, and the majority of Greek medical texts were translated into Arabic; forming the foundations of the development of Islamic medicine. Key figures in this development include the famous Avicenna (d. 1037) (Fig. 1.4), whose Canon of medicine (a medical encyclopaedia divided into five books) was hugely successful, and was still used as a textbook in European universities up until the eighteenth century; Ibn al-Nafīs (d. 1288), an Arabic philosopher and physician who discovered the pulmonary transit centuries before Realdo Colombo (1516–1559) and William Harvey (1578–1657); and Al-Rāzī (c. 865–925), a physician who lived and worked in Baghdad and wrote a multitude of treaties on medicine and philosophy [7]. Lists of surgical instruments and operations performed can be found in some surviving Byzantine manuscripts, and al-Rāzī discusses surgical procedures in many of his works. However, there is no evidence that the surgery discussed was actually ever carried out [10].

Albucasis (c. 936–1013) was a Muslim physician who practised in Cordoba, and is recognised for his contribution to surgery, in particular his illustrations of surgical instruments used at the time. He specialised in cautery, ‘incisions and perforations’, and bone-setting [6].

In Northern Europe in particular, there remained a wide gulf between surgeons and physicians, and the teaching of surgery was mainly organised on a guild basis. In Paris, a surgeons’ organisation was established at the College of St Cosme (1210), with practical training and the opportunity to gain a degree and licence to practise. The Fellowship of Surgeons was founded in London in 1368, and a Company of Barbers in 1376. It wasn’t until 1540 that this Company joined with the Guild of Surgeons, forming the Barber-Surgeons Company, which was chartered by Henry VIII (Fig. 1.5).

“A chirurgien should have three diverse properties in his person… that is to say, a heart as the heart of a lion, his eye like the eyes of a hawk, and his hands as the hands of a woman”

John Halle (1529–1568)

The Renaissance period involved the cultural rebirth of classical ideas and theories, across all academic fields. It was the age of philosophical revival and the celebration of classical works. This resulted in the mass re-translation of original Greek and Latin texts, aided by the recent invention of the printing press (1450) and spurred by the fear that several medical mistranslations had occurred throughout the ages. The resurgence of the classics also spread to the world of art, which celebrated the form of the human body, and sparked interest in anatomy. Galen’s de anatomicus administrandis (“On the handling of anatomical matter”) was discovered anew in 1531, and contained a step-by-step guide on how to carry out a dissection. The true father of anatomy in the renaissance however, was Vesalius (1514–1564) (Fig. 1.6). Vesalius was an avid dissector, and believed that true anatomy could only be learnt from cadavers. Although he was a supporter of Galen, he soon discovered through his dissections that there was some discrepancy between the anatomy before him on the table, and that described by Galen. It came to light that Galen had actually carried out all of his dissection on animals, and therefore physicians and surgeons had been learning erroneous anatomy for centuries. This was a momentous event in the history of anatomy and led to the creation of Vesalius’ masterpiece De humani corporis fabrica. The development of anatomy was essential for the progression of surgery as a specialty, as although it was taught by physicians, the dissection itself was often carried out by surgeons. It was also essential for the understanding of physiology, and led in turn to the most recognised discovery of the pulmonary transit by Colombo (excluding of course Ibn al-Nafīs’ discovery in the thirteenth century) and to the discovery of circulation by Harvey.