Trepanation and the origins of surgical practice in prehistoric times

¶ … History of Surgery had been started from the prehistoric time with its appropriate technique and tools applicable during the age. There was no sophisticated care of hygiene and anatomic knowledge in the early days; the basic research was started using trial and error on every case and it had set a very strong basic which still makes sense and counts into modern practice.

The following summary of history of surgery is compiled from various sources based on the timeline set in dr. Schell's lecture: The History of Surgery.

The Ancient Medicine (Prehistoric Time)

People had strong magic beliefs and connection to multiple gods during the prehistoric time, so that any cases of illness were also believed as the punishments from angry gods for community's or one's moral failure. Some common cases recorded were respiratory and digestive problems, infections, and gynecologic disorders. Life expectancy low, then 28-35 years was a successful range of survival. Cancer and degenerative diseases were not relevant at that time.

The early surgery practice in Europe was trepanation, drilling a hole in the head. Evidences found skulls with holes from the Neolithic European ages, about 7000 years ago. Since supernatural beliefs was very strong, the cranial drilling was also intended to get rid of evil spirits; the only possible causes for psychosis, mental illness, epilepsy and headaches or migraines.

This is how it works; a part of frontal, parietal, or occipital bones of the skull is removed, to expose the dura mater, the tough fibrous membrane forming the outer envelope of the brain. ("Trephination, An Ancient Surgery").

Still with the magical practices, they also applied other medical actions such as blood letting out of the body and finger amputations to get rid of the wicked spirits.

However, during its development, trephining was found effective during the war. Lawson (2001) discussed that Neolithic wars used a lot of blunt weapons like sling stones and clubs. Such weapons were aimed at the head, resulting severe bleeding and blood clots in the cranial arteries. Another case of cranium fractures required victims (soldiers) to have an operation.

This is how, as archaeologists said, the surgeons needed to do the trepanation "to remove splinters of skull bone," creating a way for the blood to let out and "relieve pressure from blood clots that formed when blood vessels were broken."

Neither sophisticated surgery method nor well-trained surgeons presented during the war. All the processes had to run through trial and error, since little was known about human anatomy. Lawson further explained, variety of techniques was applied. In South America, first people used obsidian, a kind of volcanic rock, which later upgraded into bronze instruments after the discovery of metal.

Charlotte Roberts of University of Durham, England, as told by Lawson explained that surgeons would scrap the skull and remove the layers of bone until breaking through to the brain; or until exposing the dura mater.

In "Trephination," it is explained; the drill to bore into the skull is hard and smooth wooden shaft, to create tidy small circular (created by drill) or rectangular (created by knife) grooves. The holes were ranging from about half an inch to 6 inches. The wound would then covered with a shell, a gourd, or piece of silver.

One that was very common was the bow drill technique. The instrument was a piece of hard but elastic stick with leather thong. Surgeons put the tip on the particular point on the head and make the hole through the bone. To perform the procedure, the operator positioned the drill tip on the head and thereby made the bore through the bone.

The skull piece must be taken very carefully to prevent fractures to avoid excessive trauma and infection during the pre-anaesthesia and pre-antisepsis era. However this practice indeed was a successful advancement of skills as it was widespread in many continents, from Europe, Peru, Bolivia, South America, and even Asia ("Trephination, An Ancient Surgery").

History of Surgery" also informs that before metal instruments were found, surgeons used "stone scalpel, wooden stick from hard material, stone knife, knives, awls, drills, scissors, saws, forceps, clamps, syringes, mirrors, needles, cast, splints, & bandages." They also developed wooden and metal limbs.

B. Mesopotamian and Babylonian Surgery

Records of Mesopotamian health and medicine services were put in historical tablets and diorite. Hammurabi (2250 BC), the renowned judge in the Mesopotamian era introduced the emergence of physician profession and also the first regulation in medical practices to the community, in the Law Code of Hammurabi. The first regulation concerning malpractice was included here.

The law clearly mentioned that physician who handled surgery case was in full responsibility of the safety of the patient. Schell further informs that when a surgeon found a failure in surgery ("opening an abscess"), which claimed a life, or "result in the loss of the eye," then he must have his hand cut off. If the patient was a slave, then the doctor must replace with a slave as well. However when operation succeeded, the patient had to pay ten shekels of silver, or two if it was a slave.

The common surgeries were the surgery of the eye, bladder, and pus drainage when infection occurred. As cited in "Medicine in Ancient Mesopotamia," explained in three historical tablets, the doctor made a cut "to drain pus from the pleura" using a knife. Sesame oil was used as anti-bacterial agent, to apply in a dressing to cover the wound. This is an early method of asepsis. In the mean time, knife was also used to scrap the skull of the patient when injuries came over the head.

C. Egyptian Surgery

Egyptians was the first advanced civilization with all organized systems and knowledge in all aspects of live. They wrote and recorded any discoveries and practices including medical skills, which enabled historians to study about it.

The Egyptians' life was a mixture of religious and intellectual customs, in which affected the development of medicine. Therefore, they also used magic spells, sometimes mixed with natural materials to cure disease.

In "The History of Medicine," Egyptians had learned about major organ functions and able to locate them. They knew life pulse come from the heart, bladder produce urine, and blood vessels were in charge of the blood circulation. They even reset broken bones, carried out eye operation and external healing of wounds from the battlefield; but all of them were less sophisticated. The knowledge was gained through the practice of embalming and mummification, but the religion still prohibited examination of the organs, especially through sections.

Papyrus (2000 B.C.) wrote about gynecologic surgery and veterinary medicine. Another expert, Edwin Smith Papyrus (1600 B.C.) described about diagnosis and examination procedures in details. According to Bune and Gregor, they used tools like knives, drills, saws, hooks, forceps and pinchers, scales, spoons, copper tools and a vase with burning incense. When they started to use metal blades, the managed to heat up the blade until it glowed red and used it to cut wound and seal up the skin, also in dental surgery to treat abscesses. No anesthetics recorded whatsoever.

Honey, grease (from vegetable or animal oil) and lint (from vegetable fiber) were used as healing application on wounds, after stitching. It was also necessary to put some meat to cover the wound, to prevent severe bleeding. Another method of using tapes to seal up wounds was also introduced, to cover up possible infection from stitches. A kind of primitive antiseptic such as willow leaves was also used.

D. Ancient Indian Medicine

Around 800 BC surgery was already known in India as Shastrakarma. Indian medicine had Shushruta. Schell archived the methods used in Indian surgery that includes incision, excision, scraping, puncturing, probing, extraction, provoking secretion, and suturing." Shusutra's book of medicine, "Shushrutasamahita," also described around 100 surgical instruments. Wine and hypnotism were used as the first anesthetics.

In "Ancient India's Contribution to Medical Science," Shushruta was a well-known surgeon in India who based his work on Hidu practice. He learned human anatomy and performed eye surgery to remove cataracts and rhinoplasty (the early generation in plastic surgery). He used a kind of lancet to extract the cataract, without any aid of anesthetics, and merely milk for comforting the eye.

At that time, cutting ear and nose was a common punishment, then he needed to perform rhinoplasty to restore it; which attract attention from people throughout the country.

Shushruta also was a pioneer in anatomy study. He was reported to use human cadaver ("required to be perfectly preserved using simple extraction from certain tree bark or grass; the dead person must not be too old and not died of disease or poison").

E. Aztec and Mexican Medicine

According to Schell, this kind of practice was well developed although it happened in 16 century. The procedure included suture and embryotomy. The society did not manage well to put everything in record, so little evidence found about medicine history. However, there were over 1200 kinds of traditional drugs recorded by Pharmacopeia.

F. Greek Medicine

Carola (1992) writes, two Greek scholars, Alcmaeon and Empedocles made their researches using human body dissection and physiology study. From this discovery, they successfully determined the function of the heart to give life to human, and transfer "pneuma" through blood vessels.

When Hippocrates (ca. 460-377 B.C) set the journey of medicine, the modern medicine had advantaged from previous study to relate diseases to more scientific manner, instead of mystical terms.

He studied about the effect of pleurisy and said that pleurisy led to empyema in 20 days and might cause death. After examination and listening to patient's succussion splash, he recommended cutting the bulge on the patient's chest and draining the pus using a tin tube (Warren, 2001).

Two other scientists, Herophilus (ca. 335-280 B.C) and Erasistratus (ca. 310-250 B.C) completed it. By performing dissection on human body Herophilus found the function of brain as the center of intelligence. He also distinguished veins and arteries, and found the nerve system. Erasistratus found that "pneuma" or air is breathed in through the lungs and transported in the arteries.

As described by "The History of Medicine," the Hippocrates principles were taught to physicians in Greece. They were well trained, handling such surgery procedures and codes of medical ethics. Along with the achievement in intellect and arts, the Greek discovered some medical instruments to perform in the theatre. Physicians worked on cataract and stone removal operations, pus drainage from infection, and sutures. Not to mention, wars and athletic contests contributed injuries, or advancement in broken bones treatment. They used the traction method to restore bones dislocations and buttress broken bones to the proper position.

Hippocrates also mentioned the use of rectal speculum (hedrodiastoleus) - now stored in the Claude Moore Health Science Library, UVA - to examine "the ulcerated parts of the bowel" (Klein, 2000).

Hooks were also very common. The blunt one was used for dissection and raising blood vessels, while the sharp one was for raising tissue during excision. This was also useful and tidy to fix and suture the edges of the wounds (Klein, 2000).

Most materials were made of bronze. There was also a kind of medicine chest, portable box substitute to doctor's bag, which was handy to carry surgical instruments like scalpel, probes, and drugs needed for in-house calls.

G. Roman Medicine

The principle of organ structures by Herophilus in Greece was revealed again by Galen (ca. AD 129-199). He was the most famous Roman physician who made a breakthrough by dissecting a monkey to find out the organ functions, considering its similarity to human's. From his experiment, Galen refined the differences of veins and arteries and other structures. He also found that blood runs through the vessel, instead of "pneuma" or air as described before. However he said that "pneuma" entered the lungs and it met the blood in the heart which gave the body the spirit to live and grow (Mayeaux).

This was a very famous era of war and violence, despite the power of the kingdom. Anyway, thanks to the wars, since they allowed surgeons to learn a lot on fixing human injuries craftsmanship. Soldiers from the wars and victims of gladiator combat were the special patients besides usual diseases to treat.

Some ancient Roman surgical instruments were excavated from the House of the Surgeon at Pompeii, now displayed at the Historical Collections and Services of the Health Sciences Library, University of Virginia.

Vaginal speculum was the one survived until the middle of 18th century and even until 20th century. This is a tool to examine the vagina during obstetrics and urinary case, with a screw to open both handles. A bronze tube might also accompany the use of the specula; this would be inserted into rectum, vagina, or nose to prevent unnecessary muscle contraction and also to help channeling the chemical treatments.

Other tool was bone lever to pick bone fractures and extract tooth, and sometimes used in serious foetal cranium injury or "depressed fracture" - to open the skull and remove the part of the bone. Bone drills and bone forceps in variety of sizes were used to make a hole in the injured bone parts and to remove particles from the healthy tissue, including metal chips from weapons. Since bloodletting still believed to be an effective cure, the bloodletting cups were also popular. There was a famous skull surgeon, Aulus Cornelius Celsus.

They still used Greek hooks, mostly in gynecologic purpose. For patients with urinary problems, surgeons might need to employ a 26 cm bronze catheter into the urinary tract. The curved catheter was designed specifically for male and the straight one was for female.

Although not using anesthetics, but Romans had found the useful use of mandragora to reduce one's consciousness. In other case, they might need to hold the patient tight during sections.

Greek and Roman physician mostly used the same kinds of instruments, which means the Roman adapted a lot of the predecessor's knowledge of medicine. The Roman contributed little innovations in surgery.

H. The Dark Ages and the Middle Ages

After the end of the Roman Empire, church became the center of the law and rules. Thus, medicine also came into the monks and clergy's hands. Mayeaux explains, little and almost nothing was improved in medical practice around 400-800 AD. The monks merely based on Galen's theory, which yet was not significantly proven. They only applied medical treatments that worked before to similar cases. Since it was also a religious matter to relate human body and God's rules, dissection of dead body was prohibited.

However, the monks made good records in archiving the medicines and herbs used widely. This encouraged the teaching of medicines too. By the end of the Dark Ages, hospitals and medical schools were established.

Furthermore Mayeaux explains, a scholar, William of Saliceto (1210-1280) had built a school of surgery and the rest was great improvement. He made some recommendations of using knife in surgery after several trials.

Surgeons also started using wine, as primitive antiseptic to clean wounds and minimal anesthetics in surgery, like opium and mandrake soaked into sponges. Thanks to Theodoric, Bishop of Cervia who first escalated the knowledge to public. He also gave friendly approach to public to accept dissection.

Therefore, dissection became popular by the 14th century, as well as traditional medicine, and the art of trepanation.

I. The Renaissance

Since professional medical practitioners were rare and expensive, people turned to barber-surgeons who gained privileges during the Dark Ages as clergy assistant. They did not get enough surgery training and gained experience through the job. However, their presence was essential since the war continued and more victims needed to be treated.

According to Mayeux, amputations even existed in this 16th century. Wounds from gunshot mostly treated using warm or boiling oil to prevent infection, but this procedure sometimes also harmed healthy tissue besides curing the wounds.

One of the barber surgeon, Ambroise Pare (1510-1590) once discovered the use of mixture of eggs, rose oil and turpentine oil to be a good ointment to heal the wounds. He accidentally ran out of hot oil during treatment of an injury, and soon replaced the oil with his own medicine and used a bandage to cover the wounds - an introduction to tourniquet, so that the patient did not suffer from bleeding. The result, it healed better.

As Holt (2001) writes, he began to announce his new assumption that ligature, tying up arteries would prevent blood loss during surgery and patients found better recovery than those of cauterization treatment. The ligature stopped the bleeding and the ointment prevented infection; those sounds like a good combination. Pare did not stop there, as he also performed hernia operation and obstetrics surgery in abnormal delivery.

It had to be a very important turning point in the medicine. In this era, while Galen's principles were still largely used, Andreas Versalius tried to make a progress and improvement. He had a more extensive research in human anatomy, and his findings were a big surprise to the preceding ideas. Two other scientists, Paracelsus and Harvey also supported his finding.

Versalius thought, Galen made several misconceptions in human anatomy since he did not perform the investigation on a human body but on a monkey.

In 1543 he published his research in the Fabricia, the first complete textbook of anatomy, which brought him the title as The Father of Anatomy. He also published "Tabulae Anatomicae" along with drawings and descriptions of human anatomy. Versalius put a fundamental why human cadaver dissection was very important to reveal how human organs really work.

For his persistence, which certainly against the large number of church committee, brought Versalius strong criticism, sabotage, and finally he was required to leave on a pilgrimage to Sinai in 1564 (Holt, 2001).

J. Pathology & Experimental Surgery (18th Century)

According to Schell, Giovanni Morgagni had his "compendium of post-mortem observations, and correlation to clinical disease."

Another famous surgeon from this era was a Scottish born surgeon, John Hunter. He was an expert who introduced the treatment of aneurysm of blood vessels. Following the principle set by Pare, he explained that ligation or tying the blood vessel would improve patient's survival during surgery. He also described inflammation as the "first principle" of surgery.

L. Modern Surgery (20th Century)

Even though medical schools had been established at this time and surgeons already learned much about human anatomy trough printed sources, surgery still faced problems of high patient's mortality rate due to infection and blood loss.

The History of Medicine writes, the blood loss problem solved when Landsteiner announced his theory about blood groupings in 1909, which allow patient to receive blood from donor of the same blood type during operation. It was also possible then to give blood type O as universal donor to the other types. He used syringes as instrument to measure the amount of transfused blood clotting and developed the anticoagulants in WWI. Since transfusion was available, many cases in the war were solved, especially after the establishment of blood bank in the 1940s.

Schell describes that Sir Alexander Fleming finally discovered the momentous knowledge to cure pleura and infection, which had been haunting human being for centuries. In 1921 he isolated lysozyme. He made a bacteria culture of staphylococcus and found a certain mold growing in his subject's media. The part surrounding the mold was clear, indicating that it produced certain agent that inhibited the bacterial growth.

He isolated this mold and invented penicillin as the first type of antibiotics to cure cases of infection and prevention against infection.

In 1920, according to Holt (2001), a gastroenterologist, Heinz Kalk designed a small telescope using 135-degree lens system to insert into patient's narrow section to examine the internal wounds or disease - then was liver and gallbladder disease. This is the first generation of laparoscopy, and named him The Father of Laparoscopy.

The pioneer of organ transplants and tissue culture was a French surgeon, Alexis Carrell. He improved the technique for sewing together blood vessels, and repairing damaged arteries, which was very valuable in World War II. For his inventory he received a Nobel.

As practitioners got aware to tissue development, in their work they learned how to remove dead tissue to allow the new, healthier one to grow covering the wounds, instead of letting the old one cover the wound in clap, like in the Civil War.

Anesthetic techniques developed in the 20th century, and people started to apply local anesthetics, especially when shape of injection needles gradually improved. The "History of Medical Discovery" also records a study of local custom anesthetic agent application on dogs in 1930, which allowed "artificially induced unconsciousness or local or general insensitivity to pain."

Antisepsis standard in the 20th century became the full standard of operation, where all tools and theatre where the surgery takes place has to be germ-free. However, physician nowadays also need to deal with new variant of infectious bacteria which also resistant from existing antibiotics.

X-ray instruments is now fully improved, including the to make accurate diagnosis about where the wounds or diseases located and how the section should be positioned.

Surgery in the 20th century" writes that there is an advanced device using high frequency waves which is very good to break kidney stones.

The same kind of waves is also employed to monitor the fetus growth in pregnancy. A pregnant woman is required to have an USG test - limited frequency since it may endanger the baby. From the test, any abnormal function on the baby will be detected earlier.

Since early 1970, laser was also used to repair wounds and make small cut in the tissue, without letting so much blood to flow. When the technique improves two decades later, it has also been a common surgical instrument to close the wound and controlled device to remove tumors, cancers, bladder stones in minor operations.

Far after Shushruta's age when he performed cataract removal using lancet, the laser beam has successfully brought a painless process to this operation. Considering that the eye contains delicate tissue, which need perfect accuracy, the technology can make very small incision, perhaps about a quarter of inch, as an opening to insert the lens implant of the same size directly on place.

Medical research developments further performs more and more research, which sometimes involves animals during the study. According to the "History of Medical Discovery," started in 1900, the injection tool - now becomes injection needle - was found after study on rabbits and dogs. This is a very important instrument that allows doctors to "feed" artificial directly into patient's vein, artery, or other narrow passages, and known as cardiology catheterization. In the first place, injection needle was merely a big needle, which needed sterilization by soaking them into antiseptics. Now it has turned to be disposable materials to prevent transmissions of contagious diseases through blood.

The development of cardiology surgery continued by the inventions of "measurement of coronary blood flow, myocardial preservation techniques, and heart bypass." Cardiology surgery made a breakthrough in 1930s, which was the first open cardiology surgery. This is a very complicated operation, even until now, but the development of applied computer system gave strong support for it.

Organ transplants continuously became a high priority. In "History of Medical Discovery," organ transplants were easier since the study towards dogs, sheep, cows, and pigs shows the possibility of using anti-rejection drugs, which enable the recipient system to receive the transplants and minimize the risk of poisoning.

Surgeons also able to carry out organ transplants; discarding the diseased organ without harming the patients, and replace it using the healthy organ from the donor. The most transplanted organ is the kidney. The first heart transplant was carried out in 1967.

However, transplanting organs is such an arduous task to accomplish. There are many obstacles such as the difficulty finding the donor while the patient is racing with time, can not wait to get the replacement. Sometimes this is also difficult when the donor is available but the organ does not meet the patient's type or exceeds the living time limit after it is taken from the donor's dead body.

The transplant surgery itself is a long and tiring process; it may take long hours, which means increase the risk of patient's survival. Even after transplants already performed, the recipient still has to wait to find out the following reaction of the body to the new organ. Many transplant cases failed from the rejection of recipient's system.

Finding the problem so hard attracts interest of biotechnologist to continue research in tissue culture and cloning. Several types on clones applied to animal tissue recently in the year of 1990 and after have given good results with the born cattle and other animals from cloning.

Experts hope after this success, they would be able to perform more clones to produce human organs. Theoretically, this should be a good alternative since all determining factors of the matched organ could be manipulated using gene isolation. Using custom combinations of genes that carry beneficial factors from the patient will raise the matching factors accuracy of the cloned organ, and hopefully will reduce the rejection.

According to the article "Surgery in the 20th Century," the manipulation on the transplant surgery may help reducing patient's shock during the section. Right now, it is possible to use the "heart-lung machine" to substitute heart function while the heart itself is undergoing a cut, bypass, or open-heart surgery.

The blood-pumping and breathing functions will be replaced for a while by the machine. In this way, the body can survive longer during hours.

There is also a technique called cold surgery or induced hypothermia. The body is cooled down to reduce the metabolism and oxygen intake, in which it performs better recovery after the operation.

Besides organ transplants, cosmetics surgery were also in high demand. It is proven that after liposuction invention in 1970s by Gerald Illouz and Pierre Fournier (Holt, 2001), the surgery became popular. Both experts practiced fat body removal technique with minimized pain and risk. Nowadays, with the help of laser technology, surgeons have been able to conduct speedy, safe, and scar-less surgery.

Cosmetics surgery also benefits from the use of laser beam. The beam produces monochromatic lights, which sometimes used to correct abnormal function of skin tissue.

After modern laparoscopic instruments discovered in 1990, the surgery process was made easier. The instrument enables the surgeons to perform minimal section - pressing down the risk of bleeding and need of blood transfusion - then insert the tiny camera into the section. The rest of the operation will be controlled from outside on a monitor screen.

It has helped gall bladder patients to return home at the same day and heal the wounds faster. It used to take a week of hospitalization and 4 to 6 weeks of recovery for such cases, while after the advancement in technology, the process only takes a day for the minor surgery and a week of recovery ("History of Medical Discovery").

With the development of digital systems, every status of the patient's organs can also be monitored during the operation, such as blood pressure, heartbeat, and sensory status. It helps a lot to cure complication and detect any slight malfunction earlier.

According to Holt, in the year of 2000 another crucial decision made a breakthrough that defeats the problem of cost and location barrier. The FDA first approved the first robot surgery device. Using this instrument, a surgeon would be able to combine the technology of laparoscopy and the ease of local area network or even the internet. The surgery tool will be operated by a robot, connected to a video imaging system, which executes the instructions of the surgeon who could happen to be anywhere outside the theatre.

Using the technology, surgeons may perform surgery from anywhere in the world, helping out patients whose location are thousand miles away, especially in rare cases where particular specialists are hard to find.

Medina (2000) explains about three advantages of using the laparoendoscopy operation. First, the narrow opening performed on the skin and internal organ reduce the trauma on the skin and muscles. That means, patient will suffer less from post-operative trauma. She made a note that patients may need only few hours to get out the bed and walked, depends on the kind of surgery it takes.

The laparoendoscopy also reduced the infection rate. Using the camera, surgeons would be able to monitor the affected organ and the surrounding tissue, without exposing the tissue to open air. Even though advanced asepsis technique is applied, tissue is a delicate material that should be kept moist, unaffected and on function to support overall metabolism system.

However since laparoendoscopy with all the relating devices are costly, not all hospitals and all surgeons are able to conduct the operation. The surgeons also need intensive training in using the equipments and handling all materials through magnified image on video screen.

It is certainly a different exposure while a surgeon has to switch operation performance which normally can be done by hand and do it indirectly through video images. It takes time to be able to perform an artwork through electronic devices. Although surgeons can master the skills through time, it is still necessary to conduct operational training intensively for a mean time.

This laparoendoscopy method may also unsuitable for patients with a series of operation record behind him or her. The body may have some tissue scar where applying electronic surgery could be dangerous. Such case must get conventional treatment.