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History of Medicine
www.onk.ns.ac.rs/Archive Vol 20, No. 1–2, July 2012
Arch Oncol 2012;20(1-2):28-35.
UDC: 616-089.8: 93/94: “-“
DOI: 10.2298/AOO1202028D
1Pediatric Surgery Clinic Institute for
Children and Youth Health Care
of Vojvodina, Novi Sad, Serbia,
2Clinical Center of Vojvodina Novi Sad,
Serbia,
3Clinic for Pediatric Surgery and
Orthopedic Clinical Center Niš, Serbia,
4Oncology Institute of Vojvodina,
Sremska Kamenica, Serbia
Correspondence to:
Dušanka Dobanovački, MD PhD,
Pediatric Surgery Clinic Institute for
Children and Youth Health Care of
Vojvodina, Hajduk Veljkova 10,
21000 Novi Sad, Serbia
dudob@yahoo.com
Received: 20.03.2012
Provisionally accepted: 26.03.2012
Accepted: 29.03.2012
© 2012, Oncology Institute
of Vojvodina, Sremska Kamenica
Glossary
* B.C.E. (Before the Common Era)
is used instead of B.C. (Before Christ);
C.E. (Common Era) is used instead of
A.D. (Anno Domini)
** Surgery (cheirourgike in Greek)
(chirurgiae in Latin) – meaning “hand
work”
*** Small possession of tools, or
instruments
****Ayus – duration of life, long life
(Sanskrit); Vedas – science of life,
knowledge (the most sacred books of
ancient Indian civilization); Ayurveda –
knowledge of life is called “medicine of
the God” for its divine origin
SURGERY B.C.E.*
Surgery** is a medical specialty that uses manual and instrumental
techniques on a patient to investigate or treat a pathological condition
such as disease or injury, to improve body function or appearance as a
consequence of diseases and congenital anomalies.
This short overview of the development of surgery points out the major
milestones in the several millennia long history of medicine and surgery
before the common era presenting as author’s critical compilation from
the sources listed in references: “It is our duty and hard task to preserve
the heritage of medicine and keep, for the next generation, this treasure
from the past” (1).
At the very beginning of prehistoric medicine, treatments of the sick or
injured were very simple, and reflected in essence the relationship of
prehistoric people to nature. They were hunters and lived in small tribes,
constantly on a move in search for better life conditions and food. The
prehistoric period ended with the development of literate societies, which,
in different parts of the world, happened in different times (2).
The study of prehistoric medicine is mainly dependent on sources such
as skeletons, artifacts, and cave paintings or inscriptions. Also, the
studies of people who at present live in tribal societies, like East African
tribes, Aborigines in Australia, or native Americans can help understand
the idea and practice of prehistoric medicine (burning of parts of a body
to remove, tying of blood vessels with tendon and closing of wounds
with acacia thorns). Prehistoric people used medicinal herbs and animal
fat for healing wounds, and animal skin for dressing and bandaging the
wounds. Setting broken limbs was also practiced in primitive medicine.
The injured area with fractured bones was covered using river mud or clay
materials, which then set hard so that the bone could heal properly (2, 3).
Trephination was practiced in every part of the world where prehistoric
people lived and is believed to be the oldest known surgery, since the
earliest evidenced were from the Stone Age. Trepanned human skull
fossils of all ages date as far back as 10,000 years, the Neolithic era in
Europe, Russia, the Canary Islands, North Africa, Peru and Bolivia. The
reasons for trepanning are not known, but it might have been performed
as a procedure for releasing evil spirit in people who suffered epilepsy, ter-
rible headaches, or mental diseases. It was practiced by a special group
of priests or “medicine man”, more or less experienced, using primitive
instruments like knives of stone, obsidian, bronze, or bone (4).
This procedure involves cutting or drilling an opening in the skull and clos-
ing up the wound. In some skulls there is no sign of healing, indicating
Surgery Before Common Era (B.C.E.*)
Dušanka Dobanovački1, Ljiljana Milovanović2, Anđelka Slavković 3, Milanka Tatić1, Sanja Skeledžija Mišković1,
Svetlana Škorić-Jokić4, Marija Pećanac1
SUMMARY
Based on skeleton examination, cave-paintings and mummies the study of prehistoric medicine tells that the surgical
experience dated with skull trepanning, male circumcision and warfare wound healing. In prehistoric tribes, medicine
was a mixture of magic, herbal remedy, and superstitious beliefs practiced by witch doctors. The practice of surgery
was first recorded in clay tablets discovered in ancient rests of Mesopotamia, translation of which has nowadays been
published in Diagnoses in Assyrian and Babylonian Medicine. Some simple surgical procedures were performed like
puncture and drainage, scraping and wound treatment. The liability of physicians who performed surgery was noted in
a collection of legal decisions made by Hammurabi about the principles of relationship between doctors and patients.
Other ancient cultures had also had surgical knowledge including India, China and countries in the Middle East. The
part of ancient Indian ayurvedic system of medicine devoted to surgery Sushruta Samhita is a systematized experi-
ence of ancient surgical practice, recorded by Sushruta in 500 B.C.E. Ancient Indian surgeons were highly skilled and
familiar with a lot of surgical procedures and had pioneered plastic surgery. In the ancient Egyptian Empire medicine
and surgery developed mostly in temples: priests were also doctors or surgeons, well specialized and educated. The
Edwin Smith Papyrus, the world’s oldest surviving surgical text, was written in the 17th century B.C.E., probably based
on material from a thousand years earlier. This papyrus is actually a textbook on trauma surgery, and describes ana-
tomical observation and examination, diagnosis, treatment, and prognosis of numerous injuries in detail. Excavated
mummies reveal some of the surgical procedures performed in the ancient Egypt: excision of the tumors, puncture
and drainage pus abscesses, dentistry, amputation and even skull trepanation, always followed by magic and spiritual
procedures. Various types of instruments were innovated, in the beginning made of stone and bronze, later of iron.
Under the Egyptian influence, surgery was developed in ancient Greece and in Roman Empire. Prosperity of surgery
was mostly due to practice in treating numerous battlefield injuries. Records from the pre-Hippocrates period are poor,
but after him, according to many writings, medicine and surgery became a science, medical schools were formed all
over the Mediterranean, and surgeons were well-trained professionals. Ancient surgery closed a chapter when Roman
Empire declined, standing-by up to the 18th century when restoration of the whole medicine began.
Key words: General Surgery; History of Medicine; History, Ancient
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that the death of the patients occurred during or shortly after the opera-
tion; however, many show extensive healing of the bone edges, indicating
the patients’ survival (5). Some of the trepanned skulls might be battle
resulted casualties. There is no evidence of using any kind of anesthesia
during these surgical procedures, not even among Central American tribes
who did know the effects of coca leaves (6, 7).
Circumcision was also practiced in the prehistoric days – some believe as
early as in 4000 B.C.E. This was confirmed on exhumed bodies from pre-
historic graves (8). It is still questionable whether circumcision procedure
originated from Egypt some 15,000 years ago and was spread throughout
the world in prehistoric migrations, or developed independently in different
cultures. When Columbus arrived to the New World, he found that many
of the natives were already circumcised (9).
The primitive closing up of wounds by using some insects in America
and Africa is a well-known practice. It was also practiced in ancient tribal
medicine: the pincers of certain ant species were used, the ant being held
above the wound until it bit, then its head was removed allowing the pin-
cers to hold close the wound (“ant suture”) (10). Ancient Indian surgeons
also used ants to close intestinal wounds.
Medical knowledge, as it was so, increased gradually into oral databases
that were transferred through hundreds of generations until literacy.
THE DOWN OF CIVILIZATION
began with Sumerians in Mesopotamia c.3500 B.C.E., when the system
of writing developed and society was no longer prehistoric. A lot of infor-
mation about life and science are available from cuneiform clay tablets
that have survived from the library of king Asshurbanipal (the originals are
in the British Museum, London). Some of them are about medical issues
(the first translation by R. C. Thompson was published in 1923) (11).
The newest translation was published by Scurlock JA, an assyriologist
and cuneiformist, and Anderson BR, a physician and medical historian, in
2005 offering advances in interpretation of the text (12).
All the records were organized in separate subsections about disorders,
surgery, gynecology and pediatrics. There were two types of professional
practitioners in ancient Mesopotamia. The first type was “ashipu” who
made a diagnosis of the disease. Type “asu” was a healer, a specialist
in herbal remedies that treated wounds in three fundamental techniques:
washing, bandaging and making plasters (13).
Four surviving clay tablets describe specific surgical procedures like: a
procedure in which the doctor cuts into the chest of the patient in order to
drain pus from the pleura, the next mentions the knife scraping the skull
of the patients, or the use of some plants to stop the bleeding. The final
surgical tablet mentions the instruction for a surgical wound care. This
tablet recommends the application of a dressing consisting mainly of the
sesame oil, which acted as an anti-bacterial agent (11, 14).
Medicine in Mesopotamia was a well-recognized profession and a lot of
information about Mesopotamian physicians is written on a large block
of polished diorite known as a Law Code of Hammurabi, dated c. 2000
to 1700 B.C.E. (preserved in Code of Hammurabi stele in Louvre, Paris).
Eleven paragraphs, among 282, refer to the practices of physicians.
Basically, it is a collection of legal decisions that pertained to liability of
physicians who performed surgery or “use a knife”. These laws state that
the doctor was responsible for surgical errors and failures depending on the
status of his patient: if a surgeon operated and saved the life of a person of
high status, the doctor was well paid in silver. If the surgeon operated and
saved the life of a slave, he received a small compensation for his service.
However, if a person of high status died as a result of surgery, the surgeon
risked having his hand cut off. While if a slave died from receiving surgical
treatment, the surgeon only had to pay to replace the slave (according to
Charles Edwards, London, paragraphs 215-224) (13, 15).
The primary center of health was the home, and the majority of health
care was provided at the patient’s own house with the family acting as
care givers. Other important sites for religious healing were nearby rivers
for Mesopotamians believed that the rivers had the power to carry away
evil substances and force the healing.
Temples belonging to gods and goddesses of healing were places used
for health care practicing: petition, therapy and thanksgiving. The Temple
Gula, dedicated to the significant goddess of healing and her sacred dog,
was a center where information and paraphernalia *** were stored and
distributed to the health consultants. The excavations of such temples
show signs that patients were housed at the temple while they were
treated. The temples contained libraries and held many useful medical
texts as a source for education and transmission of surgical knowledge
and skill (16).
INDIAN MEDICINE AND SURGERY
The heritage of Mesopotamian civilization was evident in ancient India,
where the Vedic**** system of medicine promoted health as harmony
among body, mind and spirit. The period of Vedic medicine lasted from
approximately 3000 B.C.E. until about 800 B.C.E. Ayurvedic medicine has
eight branches, surgery being one of them.
The earliest recorded knowledge about Ayurvedic medicine is from the
2nd millennium B.C.E. A great reservoir of information was written in
a surgical text by Sushruta, a Hindu surgeon and founder of plastic
surgery, in Sushruta-Samhita (The Collection of Sushruta) in 500 B.C.E.
Descriptions and instructions were given of how to perform a tonsil-
lectomy, caesarean section, amputation, rhinoplasty, otoplasty and repair
of anal fistulae. Reconstruction of the nose was common because the
punishment for adults was often a nose cut off. There is a description of
14 types of immobilization, many types of anesthesia (“wine should be
used before the operation to produce insensibility to the pain of the opera-
tion”, or the patient inhaled the fumes of burning Indian hemp – cannabis
as an anesthetic), and simple surgery like incision, puncture, drainage,
wound suturing. In general surgery, some very difficult operations were
performed like opening of the intestine and removal of any blockage
(ileus), rinsed with milk, lubricated with butter and finally closed by the
ant head method – and some operations were successful.
Ancient Indian surgeons were very skilled because their training for inci-
sion was important and they used melons, gourds, and animal bladder
to practice. Instruments were described in detail in Sushruta surgical text.
They used triangular, round-bodied, curved, or straight needles, and sutures
made of hemp, hair, flax, bark fiber. Bengal ants were used because their
stiff jaws held together the wound edges. Bowstrings, presumable made of
sheep gut, possibly, were the first absorbable suture threads.
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Ancient surgeons practicing Ayurvedic medicine also had an extensive
knowledge of poisons, internal diseases and vegetable drugs and were
specialists in treating snakebites. Ancient Indian medicine played a great
role in Asia and Buddhist monks spread Ayurvedic teaching to Indo-China,
Indonesia, Tibet, Central Asia, and as far as Japan (17-19).
Almost at the same time, a great civilization developed on the banks of
river Nile.
ANCIENT EGYPTIAN SURGERY
More than twenty-five centuries B.C.E., ancient Egypt was a highly orga-
nized society in which medical practice was developed and recorded.
Early Egyptian medicine was a mixture of religious (magic) and medical
(scientific) procedures. The duties of Egyptian physicians included creat-
ing medications, providing magic spells and prayers to provide healing,
mending broken bones, dentistry, embalming, surgery, especially on their
wounded, and autopsy (20).
According to the wall inscription from the Old Kingdom (2635-2155
B.C.E.) anatomy was very well understood and dissection of human body
was a common procedure. The amputation or deep surgery were avoided
for the rules that the body must not be disintegrated, for the whole body
is necessary for the afterlife. Circumcision was an exception to this rule,
the Egyptians, like other ancient peoples recognized the importance
of circumcision. The world’s first known picture of a surgical opera-
tion, carved on the wall of a tomb of Ankh-Mahor at Saqquara around
2250 B.C.E. shows doctors performing a circumcision (Figure1)(21).
According to Herodotus, Egyptians were the first to circumcise children
and it was practiced for reasons of hygiene (22). The ancient Jews may
have learned the surgical technique of circumcision from Egyptian civili-
zation; and circumcision is the only surgical procedure mentioned in the
Old Testament (23).
Figure 1. Adolescents in ritual circumcision, Tomb of Ankhamor, Saqquara – Egypt
Ancient Egyptian medicine refers to the practices of healing commoners,
this medicine was highly advanced for the time, and included simple sur-
gery, settings of bones and an extensive set of pharmacopoeia (24). They
usually performed surgical procedures such as lancing boils, drained
abscesses, and stitching up battle wounds.
Trepanation was practiced occasionally using a mallet and chisel. Limb
amputations and some kind of prosthetics were also performed as
observed in the mummies (25). At any rate, people at least occasionally
survived surgery. Bodies of amputees from as the Old and the Middle
Kingdoms have been found which display signs of healing. Prostheses,
which show signs of wear have also been discovered.
Egyptian surgeons were excellent in management of injuries. Trauma was
present in many forms: warfare, bites of dangerous animals, accidents
in mining, quarrying and erection of large buildings. A wall painting in the
tomb of Ipwy at Deir el-Medina (Tomb 217 20th Dynasty) displays a variety
of occupational injuries and their treatment – dropped mallet on the foot,
removing foreign body from the eye, reducing a dislocated shoulder (26).
There are many medical papyri providing detailed descriptions of surgical
procedures and other topics related to medicine. Many papyrus scrolls
have been lost by the ravages of time, and disastrous fires in the library of
Alexandria in 47 B.C.E. and 389 A.D. and only a small fraction of medical
papyri is available.
The Edwin Smith (ES) Papyrus is the world’s oldest surviving surgical
treatise that was written in Egyptian hieratic script around the 17th century
B.C.E., probably based on material from a thousand years earlier (27,
28). The papyrus is an ancient textbook on trauma surgery, a document
arranged in 22 pages and 48 examined cases of trauma (Figure 2). The
papyrus opens with eight paragraphs concerning head wounds, followed
by nineteen paragraphs on treatment of wounds of the face.
Figure 2. Ancient medical instruments in inscription on the Temple of Kom Ombo,
Egypt, Ptolemaic period
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This treatise contained description of anatomy, the examination,
diagnosis, treatment, and prognosis (i.e. a protocol of management).
Numerous injuries were presented in detail beginning from head, face,
jaw and neck, arms and torso, spine, after which it cuts off stopping
before consideration of the lower part of the body (29). Each of 48
cases is presented in four clearly differentiated parts: the title of each
case details the nature of trauma. The examination starts with “If you
examine a man having…” followed by objective examination process.
The diagnosis and prognosis contented three viewpoints: I can treat this
condition, I can contend with this condition, and I can do nothing for
this condition (27, 29).
Scrolls include a vast experience in fractures that can be acquired at a site
where accidents were numerous, as during the building of the pyramids:
how to set a fracture, reduction of a dislocation, and simply bandag-
ing by splints and casts (27). For “puss-filled tumors” (abscesses), it
recommends cauterization, in which very hot copper instruments were
to be used, not only to cut away the damaged tissue but also to seal
all blood vessels. Removal of the spears and arrows were sometimes
accomplished with great skill. It is believed that this trauma textbook was
the result of military battles (29).
In the Edwin Smith Papyrus an inguinal hernia is well described. The
mummy of Meren-Ptah (19th Dynasty) shows a sign of an open wound
resulting from surgical interference (30).
Reading the ES Papyrus records we have to conclude that Egyptian
medicine was rational, used scientific practice constructed through
observation and examination despite everyday use of magic and prayers
(31, 32). ES Papyrus today is the property of the Academy of Medicine
in New York and displayed at Rare Book Room. The entire translation of
scrolls is available online (33).
The medical papyrus purchased by Georg Ebers, well known as Ebers
Papyrus, today is a property of University Library of Leipzig. The con-
tents are arranged in seven parts, the last one being about the surgical
disease (34, 35).
In this treatise, an inguinal hernia was described as a tumor above the
genitalia, which appears on coughing, and could be restored by heat
application (one of the methods to reduce a strangulated hernia). The
Papyrus Ebers informs us of practices relating to the removal cysts and
tumors and offers a variety of methods to achieve this. It also mentions
treatment of volvulus: ”if he does not evacuate for a twist in the bowel and
it phlegm does not find a way out, it shall rot in the belly”.
They used direct pressure on cuts to stop bleeding, also used tourniquet,
cautery and styptic plant substances. Egyptians used antiseptics to aid
the healing process (willow leaves and bark which are known to decrease
the likelihood of infection) (29).
In the Ebers papyrus there is a recipe for treatment of bleeding resulting
from circumcision (36). In these documents, the anesthetic action of car-
bon dioxide resulting from the acetic effect of vinegar was used to relieve
the pain in children during the circumcision procedure.
Ancient Egyptian surgeons often cleaned and treated open wound with
honey. Freshly peeled garlic wrapped in muslin was hopped to protect
against infectious disease. Tannic acid derived from acacia nuts com-
monly helped heal burns.
Here is an example of one injury (translated version from ES Papyrus):
“Treat wound with mixture of grease (snake or other kind) and honey
(prevents bacteria from growing in an open wound and thus decreases
the risk of an infection), and lint (cover up the wound) every day until it
recovers”. The meat was used as a clotting agent in the bleeding wound
and fresh meet was used in some wound treatments.
There are the instructions to close wounds using tapes and adhesives.
Sometimes they recommend suturing the wound with acacia thorns used
as needles, primitive needles or needles with eye made of sharp bone,
piece of pointy cane or metal and pieces of flex as suturing material like
plants, fibres, hair, tendon and wood threads. Use of silver wire for wound
clamping was practiced much later; it describes also the after manage-
ments of sutured wounds: “hast it stitched, you should lay fresh meat
upon his wound the first day. You should not bind it. You should treat it
afterward with grease, honey and lint everyday, until he recovers” (31).
They routinely used suturing in the preparation of mummies for burial (the
oldest suture of the world was found on a mummy’s abdomen applied in
1100 B.C.E. practiced always on the left side) and it was also used in
medical practice of the time on living patients (27, 37).
Though the Egyptians were effective healers they did not have knowledge
of cellular biology and germ theory but used some natural antiseptic and
antibiotics like honey, mouldy bread or willow bark to dress wounds to
prevent the infection (38,39). Bacterial infection was regarded as a nor-
mal consequence of the open wound and the classic signs of superficial
infection are described in ES Papyrus: pain, swelling, redness and heat. If
those signs appeared around of the stitches, as foreign objects within the
skin, they had to be removed.
Surgical supply was very useful and practical. A famous relief on the wall
of the temple at Kom Ombo Temple shows about 40 different medical
instruments (Figure 3). These include speculums to open the vagina and
rectum for internal examinations, containers for holding solid and liquid
medicines, forceps, dental tools, suction cups, hooks for special spread-
ing open incisions and wounds, and curettes for scraping away infected
tissue. Surgical tool also included knives, drills, saws, hooks, scalpels,
retractors forceps and pinchers, scales, spoons and a vase with burning
incense (25, 27, 40, 41).
Figure 3. Edwin Smith’s Papyrus: Plates VI and VII (displayed at the Rare Book
Room in New York Academy of Medicine)
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The knives used had stone blades. Flint or obsidian has edges sharper
than modern surgical steel. When metal instruments were used, the act
of cauterizing accompanied it. In some procedures, the blade was heated
until it glowed red, and then used to make incisions. It cut well as it sealed
up the blood vessels limiting the bleeding.
Copper had been used for making instruments until 700 B.C.E. when the
iron period started. Copper needles were used for clothing and for sutur-
ing the abdomen in mummification process (1, 42).
Ancient Egyptians were allowed to use opium and poppy, cannabis and
mandrake known from the New Kingdom. Poppy seeds were used to
relieve insomnia, headaches, and as an anesthetic. Opium was used for
diminishing pain and hyoscyamus as a sedative drugs. Stone of Memphis
mixed with water resulted in formation of carbon dioxide and it might have
resulted in analgesia over the skin. They also used wine in embalming,
as disinfectant and preservative. The fire drill was employed in surgery
for cauterization (1).
The most famous physician is Imhotep, a powerful figure in ancient
Egypt, who lived around 2725 B.C.E. in Egypt and is credited with being
the founder of medicine (31, 43). Some archaeologists speculate him of
being the author of medical treatise, the so-called Edwin Smith papyrus
(44). Two thousand years after his death, his status was raised to that of
a deity and he became the god of medicine and healing (45).
The earliest known physician was Hesy-Ra in 27th century B.C.E. (stone
inscriptions indicate that Hesy Ra performed an early form of oral sur-
gery). The earliest women physicians were Peseshet (2613-2494 B.C.E.
stela in the tomb of Akhethotep) and Merit Ptah (2700 B.C.E. picture on
the tomb in the necropolis near the step pyramid of Saqquara), they had
graduated as midwives in the medical school in Sais (46).
Women in ancient Egypt were able to study and practice medicine and
were much respected. They particularly studied obstetrics, and were
known to have been instructors at Egyptian medical training schools.
Doctors-surgeons were literate and often scribes and the priests at the
same time. They acted as physicians for different parts of the body (like
specialization) as they believed that different gods governed different sec-
tors of the human body. According to Herodotus, there was a high degree
of specialization among physicians (22).
Doctors in ancient Egypt usually went through years of training at temple
schools.
Sometimes the sons following the profession of their fathers, they were
instructed from childhood by their fathers or relatives. Medical Schools
“Houses of Life” were institutions settled in Sais, Bubastis Abydos,
Edfu, Tell El-Amarna as centers for teaching medicine, Some centers
with special interest in medicine (1) were established by the 1st Dynasty.
By the time of the 19th Dynasty, their employees enjoyed such benefits
as medical insurance, pension, sick leave and worked eight hours per
day. In 332 B.C.E., Alexander the Great established a medical school in
Alexandria and it had a profound influence on Egyptian medicine during
the Ptolemaic, Roman and Coptic periods (22, 27). At Deir El-Medina
there was a system of free medical aid (1).
Egyptian physicians had an excellent reputation and sovereigns from
foreign lands frequently appealed to pharaohs to send them their doctors.
It was common that scholars from ancient Greece and other parts of
Mediterranean studied medicine in Ancient Egypt, the most notable of
these traveling scholars were Herodotus, Hermes and Pliny whose medi-
cal records contributed from ancient to modern medicine.
ANCIENT GREEK SURGERY
In terms of political governance, ancient Greece was not a single country
but consisted of numerous independent city-states like Athens, Sparta
Thebes, etc. that shared a similar culture and religious beliefs. Medical
practice was mostly influenced by Egyptian medicine and also reflected
the society’s relationship to nature and religious beliefs.
The earliest description of ancient Greek medical practice derives from the
two epic poems attributed to Homer (47), the Iliad and the Odyssey, dated
around the 8th century B.C.E., presenting last parts of Aegean war against
Troy. Surprisingly enough, among the poem lines there are descriptions
of nearly 150 different battle wounds: injuries made by arrows and spears
are with excellent anatomic description (Iliad XIII. 640-653) (48), 31 lethal
head injuries (48,49, 50, 51). The procedures of healing and care giving
are also recorded. Medical care among Greek warriors was organized by
professionals. One of the art healing masters was Machaon, the son of
the legendary Asclepius. He was very skilled in taking up the arrows and
healing the wounds (48). The solders were educated to help themselves
and also to help each other (Figure 4). They cleaned the wounds with wine
(Iliad XI. 638) (48), and bandaged them with certain herbs. In military
surgery, many scientific rules were applied and it comprised systematic
observation. Surgical procedures were always accompanied by prayers
and magic (52).
Figure 4. A cup by Sosias: Achilles bandaging the injured arm of Patroclus (vase
displayed in Antikenmuseum, Staathliche Museen Preußisher Kulturbesitz, Berlin
Ancient Greeks used scientific observation and logic to conclude what
caused diseases and what they could do. In the Hellenistic period (300’s
B.C.E. and afterward), Greek doctors worked out a logical system for
understanding disease. Their writings on this subject have been collected
in the Hippocrates Writings (written by him or his followers), named after
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the first and most famous of these doctors, Hippocrates. His idea that a
doctor can learn to understand and treat diseases by using careful obser-
vation and logical thinking is very important to modern medicine and is
present in recent methodology (53, 54).
Much later published as “De Medico” are Hippocrates’ records on military
wounds, diagnostics and therapy. They contain descriptions of fractures,
joints luxation and reposition. There are also very clear descriptions of
organization of operation theatres, instruments, assistance, and many
operations like trepanation, hernia, hemorrhoids, empyema of the pleura,
amputation of the extremities etc. Ancient Greek surgeons applied cautery
in hemostasis, bending and casting (52). Suturing was applied only on
superficial flesh wounds. The common suture materials were: fibers
made from various, particularly strong animal tendon, fascia trips and
gold wire for bone sutures.
According to Christopher Freville the first documented chest surgeries were
conducted by Hippocrates and his findings are still relevant today (55).
The surgeon Antillus (3rd century B.C.E.) performed a bone and joint
resection, tracheotomies and the first operation on traumatic aneurysms,
using chordae material (an animal gut string) (37). The first record of
tracheostomy being carried out by a physician is given by Galen, who
credits Asclepiades of Bythinia (124 B.C.E.) with the operation (56, 57).
For medical practice, no professional qualifications were required, and
doctor’s reputation was essential property for his success: a doctor had
to have in mind interests of patients and his own reputation, and was
expected to inspire confidence and trust. The so-called Hippocratic Oath
(attributed to Hippocrates but may have been written after his death)
represents the guiding ethical concept of ancient Greek medical profes-
sion (58, 59).
Due to conquering of Egypt by Alexander the Great close relations between
Greece and Egypt in medicine and surgery maintained during the rules of
Ptolemy dynasties in Alexandria, a great city founded by Alexander the
Great. There the most important medical center of that era was organized
serving as a center for Greek medical education (60). Many of the doctors
educated there continued to disseminate their knowledge elsewhere in
the Mediterranean. Pliny the Elder recounts that in 219 B.C.E. the Spartan
doctor Archagathos was working as a surgeon in Rome (61).
In ancient Greece, temples dedicated to healer god Asclepios, and
his daughters Panacea and Hygeia were called asclepeias, and they
functioned as centers for medical advice, healing and prognosis (62).
According to records from the Aesclepieon of Epidaurus, 350 B.C.E.
soporific substances, such as opium, were used in some surgical pro-
cedures as opening the abdominal abscess, or the removal of traumatic
foreign materials to diminish the pain (63).
After the Roman invasion in 48 B.C.E. Alexandria gradually declined. Its
famous Royal Library of Alexandria (founded in the 3rd century B.C.E.)
had housed all the learning of the ancient world, around 700,000 vol-
umes from Assyria, Greece, Persia, Egypt, India, etc. but was destroyed
in a great fire during the Roman rule over Egypt. Medicine and surgery
were practiced by Greeks and other scholars but in a Roman cultural
environment (2). Soon, Greek medicine and surgery were assimilated by
the Romans. Its influence on present-day medicine is evidenced by the
predominance of Greek terminology.
SURGERY IN ANCIENT ROME
There was an obvious close proximity of Greece and Rome. The Romans
came into contact with the Greeks in about 500 B.C.E. By 146 B.C.E.,
some parts of Greece had become a province of the Roman Empire and by
27 B.C.E. the Romans were in control of the land around Mediterranean.
Much of Roman medicine was Greek medicine and Roman doctors
accepted a lot of Greek medicine. In fact, most of the doctors who were
practicing in the Roman Empire were Greek. Works of Hippocrates served
as the basis for training of numerous Roman doctors. Doctors in the
ancient Rome would have received formal training, and would often serve
as surgeons in the Roman Empire’s army (64). There were no licensing
boards and no formal requirements for entrance to the profession. Anyone
could call himself a doctor. Medical training consisted of apprentice work.
Men had been trained as doctors by another doctor. Roman doctors did
not fare so well and their social standing was quite low.
Deriving knowledge from the medical treatises and methods of the
Greeks, the Etruscans, the Egyptians, the Persians and other conquered
peoples, the Romans came up with one of the best and most sophisti-
cated medical and surgical systems of the ancient world. Ancient Roman
surgery was a combination of physical techniques using various tools
and holistic medicine using rituals and religious belief system. Magical
treatment was commonly applied. Healing was sought after from religious
temples.
In ancient Rome, all surgeons knew how to use tourniquets or clamps to
stop blood flow. They practiced amputation to prevent deadly gangrene or
as a consequence of war.
All surgical tasks were performed by appropriate specialists. An Ancient
Roman doctor’s tool kit included forceps, scalpels, catheters, and even
arrow-extractors. Ancient Roman surgeons had a wide range of painkill-
ers and sedatives to help in surgery, including extracts of opium poppies
(morphine) and of henbane seeds (scopolamine).
The Romans did not understand the infection process but they did use
many of the techniques that diminished or kill germ cells, like boiling
their tools before use and would not reuse the same tool on a patient
before reboiling it. Wounds were washed with acetum, which is a very
good antiseptic.
The Romans were unaware of bacteria but placed an emphasis on public
health, personal hygiene being considered the imperative of public health.
Roman war doctors learned how to prevent many battlefield epidemics
and organize surgery rooms. They invented permanent hospitals with
specialized rooms for different tasks.
Many implements were used in ancient Roman surgery – some dating to
460 B.C., the period when Hippocrates wrote The Oath.
Aulus Cornelius Celsus (25 B.C.E. to 50 C.E.) (37) was one of the main
medical writers of the Roman era. He was the first to produce a detailed
description of ligatures used for hemostasis. He knew both continuous
and simple sutures.
The needle and a fitting needle holder were part of the surgeon’s standard
equipment. Material used for adapting the wound edges were linen and
wool threads, silk and human hair and metal clips.
The ancient Romans operated on people’s eye. They also pioneered
cataract surgery.
34
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www.onk.ns.ac.rs/Archive Vol 20, No. 1–2, July 2012
Ancient surgical practice and science in Europe declined with the fall of
the Roman Empire. Temples in Egypt were abandoned and covered with
sand and the ideas about anatomy and technique of surgery were kept
alive only by the Arab doctors for centuries (65) but almost disappeared
in the Middle ages with the destruction of Arabian culture in Spain. Dark
ages for surgery in Europe lasted until the 18th century when restoration
in the whole medicine began.
Conflict of interest
We declare no conflicts of interest.
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