history of surgery history of surgery surgery is the branch of medicine that deals with the physical manipulation of a bodily structure to diagnose, prevent, or cure an ailment. ambroise paré, a 16th-century french surgeon, stated that to perform surgery is, "to eliminate that which is superfluous, restore that which has been dislocated, separate that which has been united, join that which has been divided and repair the defects of nature." the extraction of the stone of madness (the cure of folly) by hieronymous bosch since humans first learned how to make and handle tools, they have employed their talents to develop surgical techniques, each time more sophisticated than the last; however, until the industrial revolution, surgeons were incapable of overcoming the three principal obstacles which had plagued the medical profession from its infancy — bleeding, pain and infection. advances in these fields have transformed surgery from a risky "art" into a scientific discipline capable of treating many diseases and conditions. origins the first surgical techniques were developed to treat injuries and traumas. a combination of archaeological and anthropological studies offer insight into much earlier techniques for suturing lacerations, amputating unsalvageable limbs, and draining and cauterizing open wounds. many examples exist: some asian tribes used a mix of saltpeter and sulfur that was placed onto wounds and lit on fire to cauterize wounds; the dakota people used the quill of a feather attached to an animal bladder to suck out purulent material; the discovery of needles from the stone age seems to suggest they were used in the suturing of cuts (the maasai used needles of acacia for the same purpose); and tribes in india and south america developed an ingenious method of sealing minor injuries by applying termites or scarabs who bit the edges of the wound and then twisted the insects' neck, leaving their heads rigidly attached like staples. trepanation the oldest operation for which evidence exists is trepanation (also known as trepanning, trephination, trephining or burr hole from greek τρύπανον and τρυπανισμός), in which a hole is drilled or scraped into the skull for exposing the dura mater to treat health problems related to intracranial pressure and other diseases. in the case of head wounds, surgical intervention was implemented for investigating and diagnosing the nature of the wound and the extent of the impact while bone splinters were removed preferably by scraping followed by post operation procedures and treatments for avoiding infection and aiding in the healing process. evidence has been found in prehistoric human remains from proto-neolithic and neolithic times, in cave paintings, and the procedure continued in use well into recorded history (being described by ancient greek writers such as hippocrates). out of 120 prehistoric skulls found at one burial site in france dated to 6500 bce, 40 had trepanation holes. folke henschen, a swedish doctor and historian, asserts that soviet excavations of the banks of the dnieper river in the 1970s show the existence of trepanation in mesolithic times dated to approximately 12000 bce. the remains suggest a belief that trepanning could cure epileptic seizures, migraines, and certain mental disorders. there is significant evidence of healing of the bones of the skull in prehistoric skeletons, suggesting that many of those that proceeded with the surgery survived their operation. in some studies, the rate of survival surpassed 50%. amputation the oldest known surgical amputation was carried out in borneo about 31,000 years ago. the operation involved the removal of parts of the lower leg and foot close to the ankle and heel. the child survived the operation and lived for another 6 to 9 years after this life altering surgery. this surgery was carried out without any anesthetics due to lack of technology. this is the only known surgical amputation carried out before the neolithic farming transition. the next oldest known amputation was carried out about 7000 years ago on a farmer in france whose left forearm had been surgically removed due to an infection that was eating away and rotting his flesh. setting bones examples of healed fractures in prehistoric human bones, suggesting setting and splinting have been found in the archeological record. among some treatments used by the aztecs, according to spanish texts during the conquest of mexico, was the reduction of fractured bones: "...the broken bone had to be splinted, extended and adjusted, and if this was not sufficient an incision was made at the end of the bone, and a branch of fir was inserted into the cavity of the medulla..." modern medicine developed a technique similar to this in the 20th century known as medullary fixation. anesthesia bloodletting hirudo medicinalis. leeches for bloodletting bloodletting is one of the oldest medical practices, having been practiced among diverse ancient peoples, including the mesopotamians, the egyptians, the greeks, the mayans, and the aztecs. in greece, bloodletting was in use around the time of hippocrates, who mentions bloodletting but in general relied on dietary techniques. erasistratus, however, theorized that many diseases were caused by plethoras, or overabundances, in the blood, and advised that these plethoras be treated, initially, by exercise, sweating, reduced food intake, and vomiting. herophilus advocated bloodletting. archagathus, one of the first greek physicians to practice in rome, practiced bloodletting extensively. the art of bloodletting became very popular in the west, and during the renaissance one could find bloodletting calendars that recommended appropriate times to bloodlet during the year and books that claimed bloodletting would cure inflammation, infections, strokes, manic psychosis and more. antiquity mesopotamia the sumerians saw sickness as a divine punishment imposed by different demons when an individual broke a rule. for this reason, to be a physician, one had to learn to identify approximately 6,000 possible demons that might cause health problems. to do this, the sumerians employed divining techniques based on the flight of birds, position of the stars and the livers of certain animals. in this way, medicine was intimately linked to priests, relegating surgery to a second-class medical specialty. nevertheless, the sumerians developed several important medical techniques: in ninevah archaeologists have discovered bronze instruments with sharpened obsidian resembling modern day scalpels, knives, trephines, etc. the code of hammurabi, one of the earliest babylonian code of laws, itself contains specific legislation regulating surgeons and medical compensation as well as malpractice and victim's compensation: 215. if a physician make a large incision with an operating knife and cure it, or if he open a tumor (over the eye) with an operating knife, and saves the eye, he shall receive ten shekels in money. 217. if he be the slave of some one, his owner shall give the physician two shekels. 218. if a physician make a large incision with the operating knife, and kill him, or open a tumor with the operating knife, and cut out the eye, his hands shall be cut off. 220. if he had opened a tumor with the operating knife, and put out his eye, he shall pay half his value. egypt pictures of surgery tools at kom ombo, egypt around 3100 bce egyptian civilization began to flourish when narmer, the first pharaoh of egypt, established the capital of memphis. just as cuneiform tablets preserved the knowledge of the ancient sumerians, hieroglyphics preserved the egyptians'. in the first monarchic age (2700 bce) the first treatise on surgery was written by imhotep, the vizier of pharaoh djoser, priest, astronomer, physician and first notable architect. so much was he famed for his medical skill that he became the egyptian god of medicine. other famous physicians from the ancient empire (from 2500 to 2100 bce) were sachmet, the physician of pharaoh sahure and nesmenau, whose office resembled that of a medical director. on one of the doorjambs of the entrance to the temple of memphis there is the oldest recorded engraving of a medical procedure: circumcision and engravings in kom ombo, egypt depict surgical tools. still of all the discoveries made in ancient egypt, the most important discovery relating to ancient egyptian knowledge of medicine is the ebers papyrus, named after its discoverer georg ebers. the ebers papyrus, conserved at the university of leipzig, is considered one of the oldest treaties on medicine and the most important medical papyri. the text is dated to about 1550 bce and measures 20 meters in length. the text includes recipes, a pharmacopoeia and descriptions of numerous diseases as well as cosmetic treatments. it mentions how to surgically treat crocodile bites and serious burns, recommending the drainage of pus-filled inflammation but warns against certain diseased skin. edwin smith papyrus plates vi and vii of the edwin smith papyrus (around the 17th century bc), among the earliest medical texts the edwin smith papyrus is a lesser known papyrus dating from the 1600 bce and only 5 meters in length. it is a manual for performing traumatic surgery and gives 48 case histories. the smith papyrus describes a treatment for repairing a broken nose, and the use of sutures to close wounds. infections were treated with honey. for example, it gives instructions for dealing with a dislocated vertebra:thou shouldst bind it with fresh meat the first day. thou shouldst loose his bandages and apply grease to his head as far as his neck, (and) thou shouldst bind it with ymrw. thou shouldst treat it afterwards with honey every day, (and) his relief is sitting until he recovers. india a statue of sushruta (800 bce), author of sushruta samhita and the founding father of surgery, at royal australasian college of surgeons in melbourne, australia. mehrgarh teeth discovered from a neolithic graveyard in mehrgarh had shown signs of drilling. analysis of the teeth shows prehistoric people might have attempted curing toothache with drills made from flintheads. ayurveda sushruta (c. 600 bce) is considered as the "founding father of surgery". his period is usually placed between the period of 1200 bc - 600 bc. one of the earliest known mention of the name is from the bower manuscript where sushruta is listed as one of the ten sages residing in the himalayas. texts also suggest that he learned surgery at kasi from lord dhanvantari, the god of medicine in hindu mythology. he was an early innovator of plastic surgery who taught and practiced surgery on the banks of the ganges in the area that corresponds to the present day city of varanasi in northern india. much of what is known about sushruta is in sanskrit contained in a series of volumes he authored, which are collectively known as the sushruta samhita. it is one of the oldest known surgical texts and it describes in detail the examination, diagnosis, treatment, and prognosis of numerous ailments, as well as procedures on performing various forms of cosmetic surgery, plastic surgery and rhinoplasty. greece and the hellenized world