From bone setting in ancient Egypt to organ transplants: a brief history of surgery

Emily Briffett: What has the word surgeon meant historically, and how has the role changed?

Paul Craddock: A surgeon is someone who cures bodily diseases using their hands; the word literally means “hand working”. While surgeons still cure their patients manually, what it means to treat someone by hand has changed enormously due to technological advances. For the patient, it's obviously much less risky to undergo most kinds of surgery – and it's quite another thing now that we have anaesthesia.

Historians tend to cite a surgeon in the 18th century called John Hunter when they talk about surgery turning from a craft into a science. In 1776, the philosopher David Hume found a lump in his abdomen and consulted the best physicians that money could buy. They did what doctors generally did: take a history, ask questions and consult the stars, before they worked out a treatment plan based on what they’d learned at medical school. None of these doctors actually touched Hume. Doctoring back then involved book learning and following the authority of ancient Greek predecessors. But when Hume consulted Hunter – who was becoming a famous surgeon and anatomist – he did something different: he put his hand on Hume's abdomen and felt a tumour. Hunter didn't need ancient texts to tell him what it was.

EB: Why have surgeons been seen as separate from doctors? Where did this stem from?

PC: From the Middle Ages, medical practitioners have organised themselves in a kind of a pyramid. There were physicians at the top, who took the highest degrees. They knew the medical texts and the medical system as it had been set out by the ancients, particularly Galen, Hippocrates and Aristotle. Traditional systems were a mishmash of various ancient writings, which had been translated from Greek into Arabic and then Latin. Using this confusing and sometimes contradictory system of knowledge, a physician could help a patient with their lifestyle, diet and exercise, and recommend courses of treatment to be administered by people lower in the hierarchy.

Below physicians were the surgeons, those who healed with their hands. From about the 16th century, they coalesced into their own company of barber-surgeons, and performed or prescribed all kinds of hands-on treatments. A common one for most ailments was bleeding. Under the concept of the four humours – where the human body is made up of black bile, yellow bile, phlegm and blood – doctors thought that if a person was in a state of health, the humours were balanced. If in a state of disease, they would be imbalanced. Bleeding is one of the ways to balance the humours.

While much of a surgeon's time would be taken up with bleeding, they did other things like pull teeth, give enemas, apply ointments, drain soles, remove tumours, and perform amputations. And since they were barbers, they could also cut a person’s hair! In 1745, surgeons fought to be split from barbers, with an act of parliament separating the professions.

On a similar level to surgeons in the hierarchy were the apothecaries, and below them were other kinds of healers and quacks.

EB: What is the earliest recorded surgical procedure?

PC: Dated around 1550 BC, the Ebers Papyrus (so named as it was bought in the 19th century by a German Egyptologist called George Ebers) contains the earliest written descriptions of procedures. These include bone setting and the treatment of abscesses. It also has a remedy for baldness – which, if you’re curious, involved smearing the head with fat from a hippopotamus, crocodile, tomcat, snake and ibex.

Another early document would be the ancient Sanskrit text, Sushruta Samhita, written between 200 and 600BC. It’s worth mentioning as it contains quite complex surgical procedures, like caesarean sections and transplants. But no look at the history of surgery would be complete without exploring ancient Mesopotamia. While doctoring and surgery has for most of history been separated, Mesopotamian surgery was not separated clearly from medicine or healing, or even spiritual and magic powers. If their holistic treatments could be deemed to be surgery, it could be argued that Mesopotamian texts are the oldest surgical texts, since they came from a good 600 years or so earlier than the Ebers Papyrus.

A similar point could be made about bones dug up by archaeologists. If they count as recorded history then surgery can be dated back to around 6500 BC, which is the age of skulls found in France with holes drilled into the bone.

EB: What are some of the most influential scientific discoveries that have affected surgical practice?

PC: The work of John Hunter has already been mentioned: his greatest contribution was to give scientific credibility to surgery, which led to a big shift of surgery being informed by science and experience. But I also want to nominate dentistry. We tend to think that dentistry has been around forever, but it hasn't. Dental care was traditionally limited to pulling teeth, but in the 18th century it became more desirable to look after your teeth and to achieve a good smile.

• Read more | The origins of dentistry

EB: When did surgeons first start performing more intricate surgery?

PC: This follows on nicely from the last question because if I was to choose a second influential scientific discovery, it would be vascular anastomosis. It sounds complex, but it basically means sewing together blood vessels. Without this, effective trauma surgery can’t really be performed – if a person was stabbed, surgeons couldn't effectively treat them.

My research suggests the technique comes, at least partly, from French embroidery in the 19th century. To this day, medical students are taught that a French surgeon named Alexis Carrel perfected a technique in 1901, for which he won a Nobel Prize (although there is some question about whether he should have been the sole recipient or not). His biographers don't tell you how he managed to come up with his particular technique, but there are clues. Carrel didn't use typical surgical needles and instead used a special lace-making needle; rather than the catgut that other surgeons used, he chose fine linen or cotton thread bought from a local haberdashery; and he had lessons from the famous embroiderer, Marie Anne Leroudier, who – amongst other high-profile works – embroidered the gold thread on the Paris Opera House curtains. Carrel’s biographers usually mention that he learnt to sew from a seamstress.

The history of surgery is full of self-styled great men. Anastomosis shows how something that could be considered masculine evolved from French embroidery, and so at the heart of some of today's most important, intricate and vital surgeries are skills developed by generations of women craftspeople.

EB: What has the historical role of women been with surgical practise?

PC: For much of the history – in surgery and medicine in general – women had key roles to play outside of the narrative. In a lot of cases, there were women who had no real recourse to legitimate university education, but were skilled at caring for others. My favourite story of a woman surgeon is that of Dr James Barry. I don't know what Barry's pronouns are, so I'll just go with ‘they’ for the purposes of answering this question. Although Barry lived their life mostly presenting as a man, they were named Margaret at birth. Barry became a military surgeon and was known particularly for improving conditions for soldiers. It was because of their external appearance as a man that they were allowed to go to university and pursue a career as a surgeon in the first place. People didn't know Barry was born a woman, until their biological sex was revealed in a post-mortem in 1859.

Another notable figure is Elizabeth Blackwell, the first woman to graduate as a doctor in the United States. Believing that nature made women better healers than men, she was accepted to Geneva Medical School, New York, where she graduated in 1849 at the top of her class. In Britain, Elizabeth Garrett had to exploit loopholes to get her diploma from the Society of Apothecaries in 1865.

Until 1970, women made up no more than six per cent of any medical school class in the US and Canada. By 2001, that number was 24 per cent. Currently, it's about equal.

EB: Which surgical procedure do you think was the most advanced for the time it was pioneered?

PC: About 500 years ago, it was an age of scientific exploration and discovery, when fragments of the New World started to make their way to European shores. Andreas Vesalius, a famous anatomist, published his great work De humani corporis fabrica libri septem. It sounds like a minor thing today, but it recorded what he saw when dissecting bodies. This was published the same year that Copernicus placed the sun at the centre of the solar system.

But one of my favourite characters in the history of surgery is a 16th-century empiric called Leonardo Fioravanti. He travelled all over Italy looking for cures and observing surgeries. There's a story that he performed surgery on a patient's spleen and requested his assistants and spectators to unbutton their trousers and relieve themselves into the open abdomen. I think he must have picked up somewhere that urine had cleansing properties.

Skin grafting was another type of operation that Fioravanti observed. He noticed that it was more or less the same procedure farmers performed on plants. In fact, it was so close of a procedure that he called transplant surgery the “agriculture of the body” in one of his books. In another, he called it the “farming of men”. This was advanced surgery for the time, but it had nothing to do with what we might call modern science. It was a traditional approach.

EB: How different is transplant surgery today from its earlier roots?

PC: It could hardly be more different. The Sanskrit text Sushruta Samhita includes information about a transplant that involved moving skin from the forehead to the nose of the same body. It was possible to lose a nose in many ways back then, whether it be a sabre wound or as a punishment. In Egypt, an entire town was inhabited with people with no noses! A surgeon basically had to shape the skin into a nose; it’s an early example of plastic surgery. It seems to have been quite a successful operation because, of course, a person’s body was not going to reject its own skin.

Alexis Carrel and his vascular surgery have to be mentioned again, since an organ cannot be transplanted with being sewn in. He attempted some of the earliest organ transplants as well, but every one of them failed due to some unknown biological force that caused the organ to be rejected.

In 1946, Russian scientist Vladimir Petrovich Demikhov performed the first heart transplant in dogs, followed by the first lung transplant a year later and a liver transplant the year after that. In the 1950s, he created 24 two-headed dogs by transplanting the front portion of a puppy onto another dog. All of these poor animals died.

The first successful human-to-human transplant was for two American twins in 1954. When he was 22, Richard Herrick came down with kidney disease and ended up in hospital, first in Chicago before being sent to Boston. There, a surgeon called Joseph Murray had the idea that Richard’s twin might be a good organ donor, having recently discovered that grafts between identical twins weren't rejected. The medical team approached the brother, Ronald, and he decided to donate his kidney.

This was quite a gesture on Ronald’s part because it wasn’t clear what the repercussions were of living with one kidney. But his brother would have died otherwise and, as it turned out, the operation was a complete success. Richard ended up marrying one of his nurses and having children. Unfortunately, he died within eight years when his kidney disease returned. Ronald went on to live until he was 79.

Transplants only really became routinely successful since the introduction of effective immunosuppression, or using drugs to suppress the immune system. This is important because it shows how integrated surgery has become with other professions.

EB: In the past, what were the greatest dangers with surgical procedures?

PC: It was extremely dangerous and risky. The main risk was of bacterial infections and sepsis. As recently as the early 19th-century, a patient would be lying on a wooden table, with sawdust underneath to soak up the blood. The surgeon wore a gown caked in various stains – blood and pus – from other patients, and while they might wash their hands they'd wait until after the operation. Washing hands was not deemed necessary before an operation. As a consequence, sepsis and gangrene were rife.

This came into focus in Vienna in the 1840s on two maternity wards. One ward had a mortality rate of 29 per cent; the other three per cent. The difference was that the births in the first were being handled by medical students, and midwifery students in the second. As an experiment, the two groups changed places, and the deaths followed the medical students.

What were these students doing that the midwives were not? Coming straight from autopsies and bringing their instruments with them – and not necessarily washing their hands – they were being exposed to all kinds of bacteria. An assistant physician named Ignaz Semmelweis ordered that hands be washed in chlorinated water before any deliveries were attempted, and this solved the problem. The problem was that his colleagues didn't believe him. I understand that towards the end of his life, Semmelweis walked around the city and approached pregnant women to warn them to make sure that the person delivering their baby washed their hands. He was admitted to a Viennese mental hospital, where – in a cruel twist – he died of the same infections that he had identified.

In 1865, British surgeon Joseph Lister concluded that bacteria could be combated with carbolic acid as it had antiseptic properties. He suggested it be used to clean wounds and keep out infection. I've got to give a shout out to Lindsay Fitzharris here, who has written an extraordinary book on Lister called The Butchering Art (Penguin, 2018).

There's one story about a boy called James, who had been run over by a cart. Lister used lint soaked in carbolic acid and linseed oil to dress the wound, and it stayed infection free. A few months later, he applied the same treatment and, again, the wounds healed without infection. He henceforth developed a kind of ritual for antisepsis. When Lister wrote about his experiences tackling sepsis for The Lancet in 1867, he was able to report that none of the patients he worked on had died.

Semmelweis and Lister were two important names in how surgeons really became convinced that washing hands was a good idea.

EB: When did anaesthetics come about?

PC: The first effective anaesthetic was ether, first used in 1842 by a surgeon called Crawford Williamson Long. He removed a tumour from the neck of a patient using ether to knock them out. But he wasn't good at publishing his results, so he's not always credited. Most people cite the first official use of ether as being in 1846 by a dentist in Boston.

Chloroform was also used around that time, with the first recorded use being in 1847. But if a surgeon administered this incorrectly, it could cause all kinds of problems – even death.

Dr Paul Craddock is a cultural historian, Honorary Senior Research Associate at UCL’s Division of Surgery and the author of Spare Parts: An Unexpected History of Transplants (Penguin, 2022)