The History of Surgery

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Are you interested in becoming a surgeon? Do you like the idea of using your hands, lifting a scalpel, and curing ailments with immediacy? Surgery is romanticized and idealized for good reason. This is the history of surgery.

Over the last century, the human lifespan has been extended by almost 30 years. Given that humans have been walking the planet for 200,000 years, this is the product of something recent and immensely profound. During the Renaissance, a collective scientific conscience was born that bred revolutions in math, physics, chemistry, biology, anatomy, human physiology, philosophy, and religion. We started to understand the way the world works at an unprecedented pace, and with a framework in place for understanding nature, we rebuilt the discipline focused on the inner composition of the human body – anatomy – the basis of medicine. Soon after, surgery was reborn and equipped to do so much more than the bloodletting and trephination procedures, in which holes would be drilled in skulls to “free illness, spirits, and demons” during the Ancient Times.

Before this period, one couldn’t even dream of antiseptics and anesthesia. We didn’t understand that microorganisms could invade the body and cause illness and infection, and as a result, doctors would wear black, unwashed overcoats layered with blood, pus, and other bodily matter. The same set of instruments would be used on different patients and wiped down by the same unwashed cloth before each operation. Patients would be strapped down to the table as it was believed they should remain alert and awake to increase the odds they come out of the procedure alive. With the horrific nature of this work preceding anesthesia, surgeons were praised for operating quickly to minimize suffering. Of course, this came at the cost of accuracy and precision, leading to an additional layer of issues.

The timeline of surgical history is dated all the way back to 6500 BC. However, we’re going to highlight the past two thousand years, focusing on events prior to the Renaissance, during the Renaissance, and during the modern times when this field took shape into what we recognize surgery to be.

 

Ancient Times & Galen

You can’t delve into the history of surgery without discussing Galen [129-210 AD], a surgeon of the Roman Empire and a pioneer anatomist whose ideas – many of which were massive misinterpretations – influenced (and misled) western medicine for 1,300 years.

Having studied in Alexandria, the grandest medical center of the ancient world, Galen’s contributions to medicine rank him second only to Hippocrates.

A cut-throat gunner, Galen regularly tested his medical contemporaries with his intellect and daring attitude. On one occasion, Galen disemboweled a live ape and challenged his dumbfounded medical rivals to fix the wound, none of whom could. He then beamed in, secured the intestines, repaired the wound in a glamorous surgery, and won himself the opportunity to serve as the chief physician to a reputed troop of Gladiators.

Today, when an NFL player takes a hard hit, the NFL team physicians kick into action to treat injury and restore functionality. Galen’s role wasn’t so simple. Throughout the Roman Empire, gladiators would entertain audiences through violent, bloody combat with other gladiators, wild animals, and condemned criminals.

At his core, Galen was focused on understanding man’s anatomy, but human dissections had been strictly forbidden. Given this constraint, Galen needed to be resourceful: when he treated dying gladiators, he would carefully peer into fatal wounds, trying to understand what the human body looked like from the inside. He made many original observations about wound healing and wound management, some of which were glaringly wrong. He thought, for example, that bone was composed of sperm.

Galen resorted to performing experiments and dissections on living and dead monkeys, pigs, sheep, goats, and other animals. He felt that the anatomical structures of these animals mirrored those of humans, and used their composition to make inferences about the human body. Though he ultimately contributed greatly to the understanding of many different organ systems, Galen was also responsible for many misconceptions. The problem was that he was incredibly prolific – having published over 2,000,000 words in his lifetime – and his ideas, though not corroborated, were taken as dogma, dominating medical science for over a thousand years.

Somehow the fact that Galen’s work was centered around animal dissections and not humans was lost in translation. For 1,300 years, Galenic physiology misguided the scientific world, and it’s an interesting exercise to imagine what medicine would be like today if those 1,300 years of science had been used more productively.

 

Early Renaissance

During the early renaissance, physicians who had been trained in universities considered surgery beneath them. Again, these physicians were primarily learning from Galen’s animal research, unaware that the knowledge they were taking in did not apply to the patients they’d be responsible for treating.

These physicians diminished the field of surgery, which consisted mainly of amputations and bloodletting. Bloodletting was rooted in the Ancient Times when Hippocrates [460-370 BC], The Father of Medicine, said that existence was represented by four elements – earth, air, fire, and water – which were related to humans through four basic humors, or fluids: blood, phlegm, black bile, and yellow bile. This was the basis of the famous humoral theory: each humor was related to a particular personality type, and illness was seen as an imbalance of the four humors. When Galen declared blood as the most dominant humor, propagating his ideas through the power of his pen, bloodletting – the process by which blood was drained to relieve illness – became accepted as the standard treatment for many conditions. Over time, the practice was subject to increasing controversy and Renaissance physicians started relegating this procedure to Renaissance surgeons.

However, the surgeons of the early Renaissance were not even physicians – they were barbers. Yes, the same barbers that hook you up with crisp fades and beard lineups were wielding the scalpel as well. Though they didn’t have a medical education, these barber-surgeons were apprenticeship-trained to cut hair, conduct amputations, drain blood, and complete small surgical procedures.

You could theoretically have a clean shave and an amputation in one sitting by the same practitioner. Just as blacksmiths would become masters of their craft, barbers would also become excellent at performing tooth extractions and treating war wounds.

The red-and-white-striped barber poles at your local barbershop actually represent the blood and bandages of barber-surgeons. Because these individuals were not doctors, they were also addressed as Mister instead of Doctor. Today, some British surgeons continue to address themselves as Mister for historical significance.

During the 16th century, surgeons would use red-hot pokers and boiling oil to seal off the raw, bleeding flesh of amputation wounds. And just as agonizing as this treatment was, it was just as ineffective at stopping blood loss or preventing infection.

Then one day, a barber-surgeon named Ambroise Paré found himself short of hot oil. In what happened to be a sweeping turn for medical history, he decided to use threads from his coattail to tie off the ends of bleeding vessels before dressing a wound with gauze.

To great surprise, prompt healing ensued, and Paré established himself as the father of modern surgery, catalyzing a series of surgical breakthroughs that soldiers on the battlefield have been forever thankful for.

 

Renaissance

Since 210 AD, Galen’s ideas prevailed and massive misconceptions had been forged in the minds of generations of scientists and physicians.

Finally, during the Renaissance, Andreas Vesalius forced the world to rethink it all.

For centuries, the medical establishment had been teaching students in a two step process: first, professors would read anatomical text, most of which was built off of Galen’s inaccurate ideas; then a surgeon (or his servant) would perform a dissection for students to observe. The medical students of the time rarely had opportunities to engage with cadavers themselves, they didn’t have textbooks to take home, and they definitely didn’t have Anki or Memm flashcards to shuffle through from the comfort of their couch. Their learning opportunities were limited, and a true familiarity of the human body could only be acquired after a long surgical career.

The irony lies in the fact that Galen’s greatest virtue – his emphasis on observing for oneself – was lost over time. However, Andreas Vesalius broke with this tradition and began openly doing dissections himself because for the first time since the Ancient times, human dissections had been permitted. He started relearning human anatomy from cadavers and scrutinizing ancient text, which helped him ultimately recognize that most of Galen’s research was founded on animal vivisections.

Vesalius began to rewrite anatomical text from his own research, pointing out Galen’s errors and facing resentment from the scholars of the time. Then, in 1543, he published De Humani Corporis Fabrica – which means On the Fabric of the Human Body – a landmark, revolutionary textbook. Besides the fact that this was the first resource accurately compiling information on the anatomy of the human body for medical students, it was also one of the first publications where illustrations – the earliest anatomical models – had been incorporated alongside ancient text.

Now this might seem small, but I assure you that it is not.

The incorporation of anatomical illustrations catalyzed a paradigm shift in medical education, science, and surgery because it provided students with a much-improved method to study human anatomy. Up until this time, students had been learning primarily by watching operations and hearing professors read out anatomic text. If a cadaver was available by mere chance for medical students to use, they were expected to work quickly, dissecting and studying each organ system as efficiently as they could. However, they were entirely reliant on their memory and retention of this newly acquired knowledge since graphic visuals of the human body were absent from their coursework.

These illustrations – intricately shaded with fine, visceral detail – served as 2D models to truly gather a deep understanding of the human body, liberating students from their learning constraints, and more importantly, it forced interdisciplinary collaborations to take place between anatomists, like Vesalius, and artists, like Leonardo da Vinci.

This collaboration evolved as artists and sculptors started producing three-dimensional wax anatomical models by the 17th and 18th centuries, many of which are still available today in cities like Florence. These wax models captured an unprecedented volume of information and allowed students to understand the human anatomy from a three-dimensional, spatial orientation that increased the rate at which surgeons in training and medical students could understand the inner layout of the human body. These models were eerily accurate – capturing the intricacies of death and decay, blood vessels, the brain, and even facial expressions – and are truly significant to the advancement of medical education. Wax anatomical modeling during the Renaissance was all the rage.

For the first time in the course of human history, medical students were fed a deep understanding of the human body as they could sit with surprisingly accurate three-dimensional wax anatomical models and fully take in the composition of the human body.

 

Early Modern Times

These didactic tools allowed scientists and physicians to understand anatomy and physiology to a greater degree than ever before, but there was still much to learn. In the 1700s, body snatchers would flock to cemeteries, stealing cadavers for dissection.

In the 1800s, ether and chloroform started to become popular as anesthetics, and for the first time, patients didn’t have to face an excruciating amount of pain in their surgical procedures. With the newfound capacity to sedate patients, we could spend much more time studying the human body and making sense of disease, advancing the rate at which we acquired medical knowledge.

One of my personal favorites from this era is Dr. William Halsted, a cocaine-addicted, incredibly badass surgeon whose influence is difficult to overstate. Spending his early life as a jock with subpar grades, he eventually found an interest in medicine and emerged at the top of his class at the Columbia University College of Physicians and Surgeons. After studying under the tutelage of many prominent surgeons and scientists in New York and Europe, he started to teach surgery, creating a hands-on experience for his students. Known for being a charismatic, inspiring teacher and a bold surgeon, he also performed one of the first gallbladder operations in the US on his own mother at 2 AM – with no experience, he meticulously removed seven gallstones, and his mother made a full recovery.

In 1884, Halsted started self-experimenting with cocaine for its anesthetic power. In an effort to understand whether it could be used on his patients, he would inject it in himself, ultimately enslaving himself to the drug. After years of recovery, his friend, William Welch, invited him to serve as one of four founding Professors of the Johns Hopkins School of Medicine.

At Johns Hopkins, he pioneered medical education by establishing the first formal surgical residency training program in the United States. He designed this system off of ideas that he had come across in Europe and laid the foundation for how residency training programs across the country would be organized: they’d start with an internship, followed by six years as an assistant resident and two years as a house surgeon. This structure created role models and teachers that future generations of surgeons could look up to, and under this system, Halsted trained Harvey Williams Cushing and Walter Dandy, the founders of neurosurgery.

In an era where surgeons were praised for operating with speed, Halsted became increasingly slow and meticulous. He believed that cancers spread through the bloodstream and led the first radical mastectomy for breast cancer in New York in 1882. He even pioneered many aspects of modern surgery, having introduced rubber gloves into the operating room in 1889, the use of local anesthetics, and aseptic techniques. He also revived Ambroise Paré’s ancient saying: ‘God cured him; I assisted,’ and if you’ve ever had surgery, you can thank him for it not being a barbaric mess.

Towards the end of the 19th century, with the advent of germ theory, surgeons began sterilizing surgical instruments, clothes, and hands. By the 1940s, blood transfusions, antibiotics, and penicillin made surgery safe, and the surgical field started taking leaps and bounds, with physicians donning white coats for the first time in human history.

Today, in the 21st century, surgeons are performing full face transplants and using minimally invasive laser surgery to treat brain cancer. The field is moving at the speed of light and is already at a point our ancestors couldn’t have even dreamed of.

We might laugh at the bloodletting procedures and failures of our predecessors, but what will physicians think of our current medical practice in 100 years? Will they laugh at our overuse of antibiotics, our tendency to prescribe a multitude of drugs over simple lifestyle interventions, or the use of radiation and chemotherapy? We can expect that with advances in scientific knowledge, our diagnoses will become more accurate and our treatments less invasive and more effective. Hopefully our medical research will be left alone by commercial and political pressures, allowing us to move closer to the goal of the purest scientific truth.

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