Surgery in History: It’s Complicated

From Conan calling for a “chirugen” in 1936, one who never lost a patient to shock or infection and whose dying patients always had for last words, to Mercedes Lackey’s Oathbound series in 1998 where
anesthesia or at least magic sleep was enough to move a primitive surgeon to modern levels; getting surgery wrong can pull your readers out of your story. One the other hand surgeons and surgery well done, as in Charles Saunders’s “IMARO” or “The Vapors of Crocodile Fen” in Sword and Sorceress XXIV, can make great plot devices and characters.

If you get the level of surgery right.

How can a writer determine what level of surgery a historical or fantasy culture had? Some things go in nice straight lines of gradually increasing technology or interconnected webs of trade. We can figure out that a medieval level culture is not going to have a pool table because the technology to make very flat slabs of stone hadn’t been invented yet and there was no way to transport large fragile goods. But could that society have the ability for your warrior to survive a stab wound? That’s more complicated.

If you want to find out what level of general medicine a culture had it’s easier. The history of general medicine is in a hundred books. And I would recommend reading several. The first of them was written
during the Roman Empire by Celsus (De Medicina). But the history of surgery is written in bones. And bones must be found. This means that what we know can change fast and I may already be out of date.

One thing we know is that some procedures are more easily mastered than others, whether by an individual surgeon or by a culture. We can think  of a three-dimensional spiral going outward from the heart to the extremities. Techniques are mastered, with the exception of abortion, from the outer parts of the body inward. The surgery that seems to be the first to be mastered is brain surgery. This may seem surprising but the brain has no pain nerves and the urgency of a blow to the head has led people through the ages to heroic measures.

We can say that human skulls have been found with trepanations (holes cut into the skull) from the Late Stone Age on every continent (skullduggery). But we can't say why. Some archeologists give mystical explanations or say that there was little reason for drilling the skull. How well the patient survived is clear by looking at the growth of bone in the space left from the surgery. In South America the survival rate for this operation (trepanation) was sometimes higher than 80%. We can also say that the majority of people that had trepanation done had some traumatic injury to their skulls, and that surgeons used different techniques based on how much time they had.

However, there was a skull from South America that had six holes in it and none of them showed signs of traumatic injury. We'll never know why the holes were there; but we do know that the patient survived every surgery for at least a year.

The next surgery to be mastered by a person or culture is amputation. It requires less surgical skill and talent to remove a leg than to properly set a compound fracture. Again surgery begins at fingers and
moves inward. There is some evidence that Neanderthal skeletons had fingers surgically amputated. (Smithsonian) Amputation of limbs was also mastered in Europe in the Late Stone Age. (Telegraph)

Speed was vital in early surgery. Pain was the biggest killer. (Pain can cause the body to go into shock. Shock reduces blood pressure, reducing oxygen flow to cells. Combine that with an injury and surgery and you have a very serious situation.) That is one of the reasons that the world record for amputation of a leg (Guinness Book of World Records: less than two minutes) was set during the Napoleonic Wars and no one has tried breaking it. Ligation (tying off) of veins rather than cauterization was the main reason for surgeons to slow down and that required sutures that would dissolve instead of having to be pulled out later. Some early surgeons using ligation left sutures long so they could be later removed through the skin, thus leaving a route for infection. Others figured that the sutures could be pulled out through the pus.

The speed at which a Civil War surgeon could amputate a limb cannot now be equaled. Modern surgeons take three times longer, if they’re in a rush. (Emergency Treatment and Management) Tools  (the catlin) were made specifically to make the first lightening fast cut to the bone starting in the 1500's in Europe; these tools are no longer made.

The next surgical technique generally mastered by a surgeon (or culture) is abortion. Chemical methods, drugs that induce abortion, are some of the earliest prescriptions in ancient Egypt. (Kahun Papyrus) Surgical abortions, with reasonable survival rates, are recorded by Tertullian, although he disapproved of it. (Quintus Septimius Florens Tertullianus, c. 160 – c. 225 AD, a Christian author from Carthage.) The reason these operations were mastered so early is simple, remember, pain was the number one killer of patients before anesthesia and the uterus has very few nerve endings.

After abortion, the next surgeries to be mastered are bladder and breast surgery. The bladder is a very tough organ and not prone to infection. Also the agony of  bladder stones are a  strong motivator. There are two major forms of bladder stone surgery. The first is oneis dilation of the urethra and breaking the stone into pieces. The second is cutting the bladder itself, the "cutting for the stone" that
Pepys records in his journal. Cutting is surprisingly the less painful but more dangerous of the two. (Samuel Pepys was an English naval administrator and Member of Parliament who is now most famous for the diary he kept for a decade while still a relatively young man. Born: February 23, 1633, London. Died: May 26, 1703, Clapham.)

The breast tissue is surrounded by fat, which retards infection. Unfortunately for ancient surgeons, by the time most breast cancers were large enough for them to detect, they had often spread.

The next level of surgery involves plastic surgery of the skin and head. These procedures are only done when patients and surgeons believe that the possibility of death from surgery is low enough to be risked for minor reasons. Records from around 600 B.C. in India indicate to surgeons when it was safe to perform elective surgery. (Sushruta) Their considerations included astrological reasons, and weather conditions. Elective surgeries were only done during the dry season, in the day and in a tent. This sort of surgery includes fixing harelips, removing moles and lumps and trying to replace cut-off noses.

Then cataract surgery comes in. This may seem odd for an extremely delicate surgery, but blindness is the number one complication of cataract surgery and if the patient is already blind it may seem to be
an almost risk-free surgery. The first cataract surgery involved pushing the clouded lens aside, (acouchment) and only years or decades later actually removing the clouded lens. (Sasuruta) Chest and
abdominal surgery can only be done successfully when the surgeon has both anesthesia and sterile techniques. That means only in the late 1800’s in Europe and America. Or so we are told.

The hardest thing to remember about the history of surgery is that it isn't a straight line. A soldier wounded in battle had a better chance of getting a competent surgeon during the Roman Empire than during the American Revolution. There also is no one culture that always had good or bad surgery.

During the Mongol empire, China had excellent surgeons, but in the 1900's European missionary surgeons were shocked to discover that the Chinese refused to ever cut patients open. The change occurred during the Ching Dynasty, beginning in the 1500's when strict Buddhism became the state religion and all things foreign were denigrated.

India in 1100's through the 1500's was the height of surgical skill. Indian surgeons of the time were able to repair harelips, cleft palates, and do cosmetic repairs on ears and noses.  Some could remove
cataracts. Surgeons were expected to prove their proficiency at more than ten different stitching techniques before they could be licensed. (Susruta) Doctors were expected to practice stitching on rabbit skins, practice probing on wood and bandaging on watermelons. The 'watermelon test' determined if they could keep the juice in.

But when British surgeons came to India in the 1800's, they were shocked to discover that Hindu surgeons were more likely to send their patients to shrines than to use the ancient books the shrines
preserved. (Dr. Ida) During the Muslim invasions and early European wars, in the 1500's and 1600's, medical schools were destroyed and only the lowest level of medical practitioners survived, many of them illiterate.

The archeological history of surgery depends on chance. There are hundreds, perhaps thousands, of Roman medical books surviving, but none of them cover surgery. Roman surgeons weren't
considered doctors but craftsmen. Many of them were illiterate. They were often soldiers who were apprenticed to an experienced surgeon. Archeologists couldn't even look at the bones of survivors of Roman surgery because the Romans cremated the dead.

Until recently, it was assumed that Roman surgery was primitive. Then the skeletons of Herculaneum were found. (Nat Geo) They included the body of a soldier who had been wounded in the leg. A piece of the iron blade of the sword that he was stabbed with is still in his thighbone. With that evidence,
archeologists could say that the surgeon had stopped the bleeding, cut off the sword blade, and prevented bone infection.

Then another discovery added more to our understanding of Roman surgery. About one century after Christ, a Roman barracks was built too close to a swamp and sunk. It was abandoned hurriedly and one
surgeon left his medical kit behind. (British Museum) When the barracks was excavated in the 1990's, archaeologists discovered that Roman surgeons used pre-scored metal surgical staples instead of
infection prone silk or sinew sutures. 

By the way, surgical staples were next used in the 1960's.

Among the barrow-graves of the Russian and Chinese steppe nomadic peoples, a few frozen or dried bodies show signs of remarkable medical knowledge. The bodies' abdominal organs were removed, to retard decay, through a tiny slit in the stomach. This slit was then sewed up through all the layers of the abdominal wall, stitching each layer separately. (Mummies of Urmchi) Such steps are unnecessary on a corpse. Was this practice for similar stitching on a live person following abdominal surgery? That would seem to be the logical conclusion.

Hundreds of surgeries leave no mark on human bones and these are to hardest to track in history. When was the vasectomy first done? We have no idea because it was probably done by illiterate midwives. By thinking of that spiral, it should have been an early one. Certainly it is less invasive and less painful than many forms of genital alterations that are still performed today without anesthesia.

There were often two tiers of medicine: the physicians and the surgeons. The two sides often maligned each other and the physicians kept the records. Writers should be careful of texts by doctors
criticizing non-doctors, such as midwives and barber-surgeons.

Legal reasons are another reason that there are no records on some surgeries. Not just abortion but any surgery for contraception was illegal as recently as the 1920’s in the USA, due to the Comstock Laws.

Surgical skill could vary widely in one time period because it was learned by apprenticeship. As late as the 1700's a person could find in one town, (London, England) a fairly decent bone surgeon, Sally
Map (not a doctor but a "bonesetter") (Time of Agony). One might also find physicians who believed that pus was good and if there wasn't enough in a wound were known to add some from another
patient. There were some physicians who believed in the law of similarities and tried to cauterize a wound by a applying a hot iron to the blade that had made the wound. Sally Map was famous for being
able to reset a dislocated hip unaided. If true, quite a feat of strength. She could also set broken bones that doctors said should be amputated.

One of the major lessons of an archeological survey of surgery is that Europe only became a recognized surgical leader in the later 1800's when anesthesia was rediscovered.

As the university trained doctors increased in power they set out to get rid of their competition. In the 1300's, monks and nuns were not only the physicians but also the surgeons. They performed amputations, trepanations, and abortions. (It wasn't until Pope Pius in 1869 that the Catholic Church forbid abortion at all stages of pregnancy, though a full discussion of the Church's position would fill several pages.)  

Anesthesia has also appeared and disappeared in the history of surgery. There are references to Roman surgeons (Celsus) giving their patients a sleeping drug but no specifics are given. Hashish and opium were often given in China and India. There are references to European surgeon-monks of the 1200's having some kind of paralytic or sleeping drug. The most common anesthesia, nitrous oxide, was discovered in the 1400's by an alchemist but he used it as a recreational drug. (Magic in a Bottle)

The answer to my first question is simple; if you can make your readers believe it, you got it right. Your imaginary world could contain almost-modern societies with very primitive medicine and “simple” nomadic societies with highly complex medicine, and both would accurately reflect our own history here on Earth.

Sources Cited

  • 2010 Skullduggery catalog,
  • Smithsonian Institute Shanidar Cave exhibit “Emergency Treatment And Management”; Flint, Thomas and Cain, Harvey; 1970; W.B.Saunders Co.; ISBN 0-7216-3727-2
  • “Call The Doctor”; Turner, E.S.; 1959; St. Martins Press,
  • “The Age of Agony”; Williams, Guy; 1986; Academy Chicago publishers; ISBN 0-89733-202-4
  • “Magic in a Bottle”; Silverman, Milton; 1953; The MacMillillan Co.
  • “Dr. Ida”; Wilson, Dorothy Clark; 1959; McGraw-Hill
  • “Trepanation”; Robert, Arnott; Finger, Stanley; Smith, Chris; Taylor & Francis e-Library; 2005
  • “The Mummies of Urumchi”; Barber, Elizabeth Wayland; 1999; W.W. Norton&Co.; ISBN-393-04521-8
  • “Illustrated Susruta Samhita”; Murthy, K.R. Srikantha (Trans.) 3Vols., 2010 Vedic Books
  • “On Idolatry”; Tertullian; Thelwall, Rev. S.; 1869; Christian Classics Electronic Library
  • “Greek and Roman surgical instruments in the British Museum” catalog; Jackson, Ralph; (ed) 2007 Un. Pub.
  • “The Dead Do Tell Tales at Vesuvius”; National Geographic Magazine; 1984; May; Gore, Richard; 556-613
  •; 1 May 2010
  • Kahun Medical Papyrus; Quirke, Stephen (Trans); Petrie Museum of Egyptian Archaeology
  • Guinness book of World Records; 1973; Guinness publishing, UK; McWhirter, Norris; (Ed)