Surgery, or manual intervention, mediate and immediate, in all lesions or malformations of the human body, was already an art when medicine proper was but a phase of superstition. The earliest notices of it occur among the Egyptians, who, as we find represented on obelisk and in temple, practised incisions, scarifications, probably even amputation, long before the date of the Ebers papyrus (3500 B.C.). Castration (to supply eunuchs for the royal harem) was also a frequent operation. Preserved in museums may be seen surgical instruments contemporary with votive offerings of the remotest Egyptian epoch—lancets, tweezers, catheters, uterine specula, iron rods for the actual cauterity, &c. Among other indications of early proficiency in ophthalmic surgery, couching cataract must have been known to them.
Jewish surgery, like Jewish medicine, was an importation from the Egyptians. The sexual regulations characteristic of the Jews affected their surgery, from simple circumcision up to the Cæsarean section, which very early in their history was practised on pregnant women in death as in life.
Without entering into the controversy as to the Greek origin of the Indian healing art, we find surgery enjoying high esteem among the Indians in very remote times. 'A physician who is no surgeon,' so ran their proverb, 'is like a bird with but one wing.' Surgical instruments skilfully made of steel, to the number of 127, still attest their proficiency in cutting and cauterising—the latter performed in observance of an aphorism quite Hippocratic in its ring—'What drugs and knives cannot cure may be cured with fire.' Their surgeons were trained to operate by practising not on animals or on the dead human subject, but on wax-covered boards, on beasts' skins, or on succulent plants and fruits. Haemorrhage they checked by cold, by compression, and by styptics. The ligature they seem not to have known. Amputation was confined to the hand in cases of intractable haemorrhage. Lips or surfaces of wounds they smeared with an arsenical salve. For intus-suscep- tion, volvulus, and such abdominal lesions they practised laparotomy, while fistula in ano (diagnosed by the speculum) they treated with the knife and corrosives. Lithotomy, in no case performed without the sanction of the rajah, they practised on the method (sectio lateralis) described by Celsus. The claim asserted for them of having independently of the Greeks devised the operation of rhinoplasty (constructing a nose from the neighbouring tissue—in this case from the cheek), and also that for cataract, has still to be made good.
As to the surgery of the other orientals we possess but obscure notices. Among the Persians we find Greeks in general practice under King Cambyses. The Chinese six centuries B.C. performed surgical operations (castration, for example) in the rudest fashion, and placed much reliance on acupuncture and the moxa. Japanese surgery betrays similar features.
In Greece surgery had attained high development before Hippocrates put medicine on a rational basis, and in the Hippocratic books we find a rich collection of surgical doctrine and practice drawn from centuries of experience. The treatise called Iatreion contains a description of the practitioner's room, its lighting, the instruments and appliances necessary, the duties of assistants, the accommodation of the patients, the position of the operator, the use of the hands, of water, of bandages, of sounds manufactured from tin or lead, &c. A full account of wounds and their treatment is given, hæmorrhage being arrested by cold, by compression, and styptics, the wounds themselves healed by primary union or through suppuration. Cataplasms cold and warm and plasters are also described in this connection. Lesion of the joints and its manifold consequences, and injuries to the medulla spinalis (paraplegia, &c.) are also dealt with. Dislocations and fractures have special treatises devoted to them. On the battlefield, on shipboard, in building operations, gymnastic and athletic contests the Greek surgeon lost no opportunity of perfecting the knowledge to which the latter-day world has surprisingly little to add. Medical scholarship has proved that many of the rarest forms of dislocation had not escaped Hippocrates. Even modern appliances were in great part anticipated by him—splints, for example, and bandages of various kinds. The gem of the Hippocratic surgery (according to Häser) is the treatise on injuries of the cranium—fractures, fissures, and contusions with or without depression. For such cases trepanning is the sovereign operation, to be performed as early as possible, less to get rid of effused blood, pus, &c. than, by removal of the injured osseous structure, to prevent inflammation of the scalp. This bold and circumspect practice creates surprise that the greater operations (extirpation of tumours, aneurysms, amputations, &c.) were ignored, till we remember that in their meagre knowledge of anatomy Hippocrates and his school were slow to risk section of the more important vessels and nerves. The removal of extremities which had become gangrenous shows again the Hippocratic surgery in a wonderfully favourable light. Hernias, hæmorrhoids, fistula are also described and treated with a judgment and skill remarkable for the time.
The post-Hippocratic school (its greatest surgeon being Praxagoras of Cos, noted for his cure of volvulus) has little to detain us; but the Alexandrians left a distinct mark on every branch of the healing art—surgery included. Our best knowledge of them comes from Celsus, who names as the most celebrated surgeon of Alexandria Philoxenus, a voluminous writer on the subject. Ammonius, the lithotomist, is another light of the school, lithotripsy being his special contribution to practice.
Roman surgery can hardly claim M. Porcius Cato (234–149 B.C.) as more than a shrewd amateur who left some handy rules for the treatment of fractures, ulcers, nasal polypi, fistulæ, strangury, &c., having doubtless drawn on his experience as a slave-owning patrician. Archagathus (218 B.C.) was a regular practitioner, known, for his skilful handling of dislocations, fractures, and particularly wounds, as the 'Vulnerarius.' The senate confirmed the popular appreciation by providing him with a 'taberna' in a much frequented thoroughfare. But when from such practice he proceeded to operate with the knife his popularity fled, he was nicknamed the 'Carnifex,' and had to leave the city. Celsus, the patrician dilettante in medicine, is really the highest name in Roman surgery, though it is doubtful whether he ever operated. Of the eight books of his admirably written work the last two treat of surgery, including plastic replacement of defects in the outer ear, the nose, and the lips; lithotomy as practised on boys (a celebrated chapter); amputation, previously described by no other author; diseases of the bones, with the operation of trepanning, fractures simple and compound, and dislocations.
Galen, though a master of surgery and, before his settling in Rome under M. Aurelius, a practitioner of it, seems to have contributed nothing of his own to its doctrine or practice. As he found it (with some notable additions) it remained to the close of the Byzantine period. An intimate knowledge of its modus operandi during these centuries may be inferred from the collection of surgical instruments dug up at Pompeii and now on view at Naples. These are about 300 in number, consisting of some sixty different kinds: needles, hollow probes (straight, curved, and toothed), catheters, specula vaginæ, pincers, cauteries, bistouries, lancets, scissors, &c., mostly of bronze, many of the cutting ones of iron. To sum up: blood-letting was practised in antiquity by venesection, arteriotomy, cupping, and (later) by leeches. Hæmorrhage was checked by cold water, styptics, cauterising, ligature, and torsion—the two latter not mentioned by Hippocrates, the ligature being a device of the Alexandrians, as torsion was of the empire, after which time it fell into desuetude. The treatment of fractures and dislocations was practically the same from Hippocrates to Paulus Ægineta (650 A.D.). Trepanning received several modifications in practice up to Galen's time, while tracheotomy (introduced by Asclepiades, 1st century) was by Paulus restricted to cases of choking, when the deeper air-passages were free. The evacuation of pus in empyema, frequently mentioned by Hippocrates, was seldom performed in later times—Paulus recommending, instead of the knife, the application of the actual cautery to the wall of the thorax. The operation for hernia, perfunctorily dealt with by Hippocrates, had by the epoch of Celsus assumed the practical development in which it is found during the later empire, Heliodorus, under Trajan, being noted for his radical cure of the scrotal form. Lithotomy, in the Hippocratic period confined to specialists, was by the Alexandrian school raised to full surgical honours, to be supplemented under the Byzantine empire again by lithotripsy. In Paulus we find a well-nigh exhaustive list of operations for disease or malformation of the genitals, even including syphilis (Häser), while rectal and anal affections (hæmorrhoids, fistula, &c.) were skilfully treated by Leonides (200 A.D.), who seems to have used the écraseur as well as the knife and the cautery. Large tumours in the neighbourhood of great vessels were untouched by Hippocrates or Celsus, though the latter makes mention of the surgical cure of goitre. On the other hand, Leonides extirpated the cervical glands;
Antyllus (300 A.D.) tied their vessels above and below the point of section; and Paulus removed them by constricting them at their base by a ligature. Cancerous tumours after Celsus' time came within the category of Noli me tangere. Aneurysms find no place in Hippocrates, and Celsus refers only to the extirpation of varices. Antyllus seems first to have classified and dealt with the former—in true aneurysm isolating the artery with a ligature above and below the sac, which he then opened and emptied. Amputation after Celsus is described by Archigenes, haemorrhage being obviated by ligature of the great vessels or constriction of the limb. Flap-amputations were performed by Heliodorus and Leonides. Resection of the humerus, the femur, and the lower jaw proves (according to Häser) the high development to which surgery under the empire had attained, as also do the plastic operations which Antyllus describes with a fullness and freedom unknown to Celsus. A word may be added here for the medico-military service of that time, afloat and ashore, apparently quite as well organised as the combatant arm. Under the Byzantine emperor Maurice (582-602) the cavalry had an ambulance-company whose business it was to bring the severely wounded out of action, and who were provided with water-flasks and cordials to relieve the fainting.
The Arabs borrowed their surgery from the Greeks, chiefly from Paulus Ægineta, even more slavishly than their medicine. Their neglect of anatomy and their oriental repugnance to operations involving the effusion of blood serve to explain the fact that except Abulcasim (died 1122) they contribute no memorable name to this branch of the healing art.
Salerno did incomparably less for surgery than for medicine, partly because its representatives being mostly ecclesiastics held aloof from manual intervention, partly because its copyist monks reproduced from the classic authorities only the medical writings, leaving out those which had little or no interest for men of the cloister—gynaecology, surgery, paediatry, &c. Still there is evidence that from the 10th to the first half of the 13th century they did take cognisance—theoretical at least—of wounds, burns, abscesses, fractures, dislocations, cancer, urinary calculi, and external applications.
Surgery continued to be looked down upon by physicians, all the more that the recently founded universities gave the latter the prestige of a culture denied to the adventurers who healed wounds, reduced dislocations, and set fractured limbs. Throughout the middle ages surgical literature seems to have shared the fortunes of medical literature—first the Greeks were in the ascendant, then their servile imitators the Arabs. The earliest mediæval writers in surgery were Italians, superseded in the 14th century by the French, while the same period witnessed the first English, Dutch, and German books on the subject. Guy de Chauliac, the highest name in that century, laboured to bridge the chasm between surgery and other branches of medicine. For all that, the mediæval surgeon in eastern Europe remained far behind his predecessors of the Roman and Byzantine empires. Traumatic haemorrhage was arrested by the cautery and styptics, though the ligature had not quite fallen into oblivion. Operations for hernia and vesical calculus ranked highest in importance. Plastic surgery was a 15th-century revival of the ancient procedure, carried to rare perfection a century later by Tagliacozzi, again to sink into disuse. Similar fate befell the narcotic drinks (see ANÆSTHESIA), resuscitated in the same century, to dull the pain of surgical operations. The active principle of these had been inhaled even in the 13th century, and Guy de Chauliac also used opium internally for the same end.
With the 16th century we find surgery sharing the advance communicated to every art by the Renaissance, while its practitioners improved their social standing. In this the way had been led by Paris with her College of Surgeons (Collège de St Côme, 1279), which in the teeth of the university 'faculty' conquered the right to create licentiates in surgery. Other qualifying corporations (in London, for example, and Edinburgh) arose gradually on similar lines. But what crowned the recognition of surgery as a liberal profession was its steady progress as a beneficent public agent in peace as in war. Skill in treating gunshot wounds, in substituting the ligature for the cautery in amputations, and in dealing with the cutaneous affections due to pestilences like that of syphilis reinforced the claims to respect already established by fuller anatomical, chemical, and botanical knowledge. The powerful if eccentric genius of Paracelsus was signally instrumental in this direction; still more so the sound sagacity and nobly philanthropic inspiration of Ambrose Paré (1517-90). Galileo, Bacon, and Descartes revolutionised scientific method, among the fruits of which was Harvey's discovery of the circulation of the blood. With the diffusion of juster and more comprehensive notions of structure and function surgery took bolder and more effective flights, reaching her highest point in the 17th century under Richard Wiseman, 'the father of English surgery,' from whose Seven Chirurgical Treatises may be gathered the great accessions he made to sound practice, particularly in tumours, wounds, fractures, and dislocations. The lines of scientific surgery were now laid, and her advance became at once safer and swifter. In the 18th century Paris improved upon her Collège de St Côme by her Académie de Chirurgie, long the headquarters of the highest professional and literary culture. England contributed Cheselden and Pott, Scotland James Douglas, the three Monros, Benjamin Bell, and above all John Hunter to the promotion of a more enlightened practice, based on anatomical and physiological research. London, Edinburgh, and Dublin became centres of surgical education, which, by the admission of Häser, no continental school, not even Paris, could equal in the sovereign qualities of sagacity in diagnosis and assured boldness in operation. Prussia came far behind with her Collegium Medico-Chirurgicum in Berlin, and Austria only in 1780 and 1785 obtained the means of training surgeons of the higher grade, civil and military; while America by her school, under Dr Shippen in Philadelphia, laid the foundations of her subsequent and nobly sustained proficiency.
To the distinguished anatomists Mascagni and Scarpa in Italy, Breschet and Geoffroy St Hilaire in France, the brothers John and Charles Bell in Great Britain, the Meckels, Berres, Tiedemann, C. M. Langenbeck in Germany, seconded by physiologists like the Italian Panizzo, the Scottish Charles Bell, the English Marshall Hall, the French Magendie, Flourens, Duchenne, and Bernard, the German Prochaska, Purkinje, the brothers Weber, and Joannes Müller, surgery owes the mighty advance she made in the first decades of the 19th century. Of these pioneers some were themselves surgeons of the first rank, such as Scarpa and the brothers Bell; while among those who were equally great as teachers or writers and operators must be noticed Desault, Dupuytren, Roux, Delpech, and Lallemand in France; Lizars, Allan Burns, Liston, and Syme in Scotland; Abernethy, Astley Cooper, Brodie, and Lawrence in England; Warren, Mott, and Gross in America; Wattman, Siebold,
Walther, Chelius, Langenbeck (already mentioned), Stromeyer, Graefe, and Dieffenbach in Germany; Kern, Pitha, and Linhart in Austria; Pirogoff and Szymanovsky in Russia. Anatomico-pathological museums and clinical instruction, displaying a wealth in object-lessons impossible before, are among the chief causes of the perfection to which the surgical profession is rapidly attaining. Add to these the introduction of anæsthetics, of the antiseptic ligature and dressing, of the galvano-cautery, of the transfusion of blood, and of the engrafting on patients of tissue taken from the healthy subject, and we can realise the revolution that has so altered the surgeon's art as to make its present position one of the greatest triumphs of human intellect, energy, and resource.
Häser's and Puschmann's works (the latter translated into English by Hare, Lond. 1892) give the fullest and most trustworthy account of the healing art, surgical as well as medical. Monographs like Wise's History of Medicine among the Asiatics, Young's Annals of the Barber-Surgeons of London, Struthers' Historical Sketch of the Edinburgh Anatomical School, and Cameron's History of the Royal College of Surgeons in Ireland may also be consulted. Special operations in surgery (Lithotomy, Ovariotomy, &c.) are dealt with under their respective heads, or in connection with the articles on such subjects as AMPUTATION, DISLOCATION, EYE, FRACTURE, HIP-JOINT, SHOULDER, &c. There are articles on CATHETER, OPHTHALMOSCOPE, STETHOSCOPE, TOURNIQUET, &c. See also Ashhurst's International Encyclopædia of Surgery (6 vols. 1882-86); A System of Surgery, by various authors, edited by Treves (1895 et seq.); the articles in this work on the great surgeons; and for a record of contemporary surgery the annual summaries in the concluding numbers of the Lancet and British Medical Journal.