This chapter looks at histories of surgery since antiquity. I examine how these histories, besides being records, are interjections into debates about the place and role of surgery. The word ‘histories’ can be misleading because until the early nineteenth century writers on surgery studied or invoked authorities as far back as Hippocrates for practical and professional reasons as well as historiographical ones. So here I discuss both self-proclaimed histories as well as the practical historical references in surgical texts because both served to situate surgeons and surgery in relationship to the past and present. This is primarily a chapter about polemical histories. I can only indicate sketchily the origins of the many learned discourses that have graced the subject since the Renaissance. I pay particular attention to the mutual constitution of the surgical idea of disease and surgery as an occupation and how contests over the boundaries of these were related to changing socio-economic conditions. I do not deal in detail with modern studies but show that many current historical questions are rooted in issues well-recognized by former surgeons. A large part of the chapter is devoted to much earlier periods since most of the themes I address originated there.
Disorders, Diseases, and Occupations in the Ancient World
In the ancient Greek medical world, a number of disorders were considered best treated manually and some practitioners’ daily work was devoted to such treatments. The Hippocratic Corpus contains texts dealing with the hands-on management of injuries and other conditions and on the requirements (personal qualities, training, skills, equipment, etc.) deemed necessary to carry out such operations. At this time the distinction between surgical and other disorders was descriptive. Surgical conditions were by definition the objects of manual work and there was no stipulation of hierarchy in the understanding of disease or the practice of healing. This perception changed markedly in the Middle Ages.
Later in Antiquity the encyclopaedic work of Celsus (c. 25 bce–c. 50 ce) contains what is described as the first history of medicine and illuminates further the ancient view of surgery. Celsus’ ‘history’ can be constructed from the prefaces (Prooemia) to the books of his main text, a massive compilation of medical observations, theories, and treatments. Celsus’ work was recovered during the Renaissance and, although little employed as a guide to surgical technique, it was recurrently cited as a historical authority and used to legitimize various views on the knowledge needed by surgeons and the place of surgery in the healing order. If Celsus had a political agenda it was signalled by his nostalgia for a Golden Age when ‘neither indolence nor luxury had vitiated’ health, for ‘it is these two which have afflicted the bodies of men, first in Greece, and later amongst us; and hence the invention of this complex Art of Medicine.’ This is why surgery alone, and even then only for injuries, was needed in the simpler Homeric age. Celsus dated surgery to ‘Podalirius and Machaon, who followed Agamemnon as leader to the Trojan War’, noting that Homer tells us that they gave no aid ‘in the various sorts of diseases, but only that they relieved wounds by the knife and by medicaments.’ He concluded: ‘Hence it appears that by them those parts only of the Art were attempted, and that they were the oldest.’ 1
Celsus recorded that Hippocrates separated medicine from philosophy and in the period immediately following, from Diocles of Carystus to Erasistratus, ‘the Art of Medicine was divided into three parts: one being that which cures through diet, another through medicaments, and the third by hand.’ 2 For convenience, I use the term the ‘Art of Medicine’ to cover all three methods of healing and I group curing through diet and drugs together as internal medicine or physic. Celsus did not explicitly value one part of the Art of Medicine over another but he accorded surgery high status by being the oldest branch of healing and gave it eminence by dint of the value Hippocrates placed on it. ‘This branch, although very ancient’, Celsus wrote, ‘was more practised by Hippocrates, the father of all medical art, than by his forerunners.’ Celsus connected surgery to a written, learned tradition. After Hippocrates, he recorded, ‘it began to have its own professors; in Egypt it grew especially by the influence of Philoxenus … Gorgias also and Sostratus and Heron and the two Apollonii and Ammonius, the Alexandrians, and many other celebrated men … In Rome also there have been professors of no mean standing, especially … Meges, the most learned of them all, as can be understood from his writings.’ Celsus’ history has a definite sense of progress; surgery in his time was better than in former ages. The authors that he mentioned, ‘have made certain changes for the better, and added considerably to this branch of learning.’ Celsus also portrayed the operator’s requirements in similar fashion to the Hippocratic Corpus. 3
The tripartite division of the Art of Medicine was the ‘central organizing device of Celsus’ entire extant work.’ 4 Celsus used this device to describe how practitioners had made distinctions between various sorts of disease (internal and external), the possible ways of learning about disease (rational and empirical), and indicated that some healers considered that there should be a hierarchy of medical occupations based on these distinctions. Roughly speaking, Celsus grouped together wounds and some external local disorders, such as abscesses, under conditions treated by surgery. Systemic disturbances such as fevers were gathered under treatment by diet and drugs. Celsus considered surgery the most straightforward of treatments. In surgery, he said, we can usually easily judge whether a treatment has worked or not. He wrote: ‘The effects of this treatment [surgery] are more obvious than any other kind; inasmuch as in [internal] diseases … it may be doubted whether recovery has been due to medicine or a sound body or good luck.’ 5
Celsus also observed that some healers considered it important to understand the hidden causes of diseases. Famous Greek authorities, he said, who ‘cured diseases by diet’, endeavoured ‘to go more deeply into things, [and] claimed for themselves also a knowledge of nature, without which it seemed that the Art of Medicine would be stunted and weak.’ Celsus was inclined to this view, the rationalist perspective, that to manage disorders required knowledge of things not presented to the senses. The opposite of this was the empiricist position. History was used by Celsus to explain and contrast the origins and state of these opinions and promote his estimation that ‘the Art of Medicine ought to be rational, but to draw instruction from evident causes.’ 6
Celsus also observed that the rationalists, by claiming that dealing with diseases required knowledge of hidden causes, introduced a qualitative element into the distinctions between practitioners. He noted, among ‘the divisions of the Art of Medicine, the one which heals [internal] diseases, as it is the most difficult, is also the most famous.’ If that is so, he asked, ‘what is the proper province of this [the surgical] part of my work[?]’ Celsus recognized that although surgeons dealt with obvious external conditions whose causes were not hidden they also encountered ‘difficult’ internal conditions which presented as surgical disorders. For instance, internal diseases might develop external ‘ulcerations’, usually the province of the surgeon. Celsus resolved this by observing, I ‘deem one and the same man’ should be able to undertake both dietetic and surgical treatment. Thus Celsus expected the surgeon to have as extensive a knowledge of hidden causes as healers by diet or drugs. Managing and understanding internal diseases might be ‘difficult’ but ‘when divisions are made [in the healing arts], I praise him who has undertaken the most [different sorts of cases].’ 7 This incipient division between internal diseases understood through the senses and reasoning and external ones known by the senses alone was later infrastructural to the organization of healing into physic and surgery.
Galen of Pergamum (c. 130 ce–c. 210 ce), probably the most influential medical author ever, presented a similar picture of surgery. For Galen, surgery was an occupational branch of the Art of Medicine, mastery of which started with knowledge of philosophy and climbed through anatomy, physiology, and pathology to clinical medicine. Galen practised surgery at Pergamum, 157–161 ce, where he treated gladiators. A great deal of surgical material is embedded in his works. As for history, however, ‘Galen displays relatively little interest in … [it] and indeed, seems to have displayed some contempt for historians.’ 8 There is no surviving history of surgery by Galen but he did meticulously record his surgical precursors. His books were a way of situating his own contributions through exegesis of the texts of his forerunners (largely amounting to attacks on everyone excepting Hippocrates). Thus subsequent practitioners learned a great deal of surgical history from him.
The historical stories of Celsus and Galen tell us about an idealized intellectual unity of medicine in a world in which there was no possibility of social union among healers. In the Roman Empire the status of individual practitioners of medicine varied enormously. Healers included slaves and h...