From Trepanation to Cosmetics: Mindboggling Ancient Surgeries

Humanity’s progress in the fields of medicine and medical surgery has been particularly astounding. In the course of the last two hundred years, humans have learned how to perform incredibly sophisticated operations and have even managed to eradicate an entire disease — smallpox. Even though medicine in the past was not as advanced, ancient surgeries were not barbarous pokes and prods at one’s body. The ancient world had a system of understanding and its own medical knowledge, though not in line with the scientific method.

The Four Humors Theory, first espoused by Hippocrates, claimed that the human body consisted of four humors: blood, yellow bile, phlegm, and black bile. The various diseases were believed to be created by an imbalance of these four humors. This is why there was such a heavy focus on bloodletting throughout Antiquity and up through the Middle Ages. Still, some of the practical operations of the Roman medicus were successful in their aims with the patient living after the ordeal.

Nobody likes feeling unattractive. Despite the fact that all human beings are beautiful, people often undergo sophisticated operations to “fix” a part of their body with which they aren’t comfortable. Antiquity was not different. To differentiate slaves from free members of society, the Romans sometimes branded or tattooed their slaves. Therefore, after their manumission, some Roman slaves sought to undo or cover up these reminders. These were rarely sophisticated operations compared to the surgical knowledge of other parts of the world.

However, Graeco-Roman surgical knowledge paled in comparison to that of Ancient India. Cosmetic surgery was one of the tricks of the trade of Sushruta, whose collected works are called the Sushruta Samhita. One of the many operations he describes is a forehead flap rhinoplasty, also referred to as Paramedian Forehead Flaps, the name under which it is performed to this day. This was intended to fix any cosmetic damage to or even replace the nose.

Basically, a piece of skin is cut from another part of the body, usually the forehead, and artificial nostrils are shaped around the vacant cavity. After a little while, the new and old skin begin to grow together, after which they can be separated. Obviously, this would have left quite a substantial scar on the forehead of the patient, but in time the scar would heal, and they would be left with a new body part — the nose — that would be otherwise forever gone.

Trepanation: The Ancient Surgery That Lasted up to the Modern Day

Trepanation is a surgical procedure in which a hole is made through the cranium to expose the dura matter of the brain with the intent of alleviating pain within the head. It is an incredibly old form of surgery, potentially going back to the 8th Millennium BCE.

What is remarkable about trepanation is its seemingly independent development among many different societies. Not only have there been trepanned skulls found in Europe and Africa, but also in modern-day Peru dating from the Precolumbian period. Interestingly, it was practiced up until relatively recently, with subjects who continued to live up until the 20th Century in some parts of the world.

Trepanation is described by both Hippocrates and Galen of Pergamum, the most significant ancient authors on the topic of medicine. For his research, Galen typically dissected animals, as dissecting corpses was particularly taboo in Antiquity. Trepanning for him had two uses; one was pedagogical and the other medical.

Galen’s pedagogical method of dissecting animals, sometimes while still alive, sought to understand the uses and functions of various sides of the brain. These experiments would require one to push down on certain parts of the brain and note the animal’s physiological response. However, trepanation was a widespread method of relieving cranial pain, typically as a result of a fracture or breakage often caused in battle.

For Galen, this surgery aimed to remove the tension (τόνοϛ) on the pneuma — the Ancient Greek concept of the soul or spirit — which he believed to be centered on the brain. This may not have been the only impetus for seeking trepanation. Indeed, there were some practical concerns, such as the removal of dead or damaged bone from the cranium. Also, as suggested by Charles D. Gross in Trepanation (2003), the procedure would ensure the removal of bad or stagnant blood which was believed to be harmful according to the Hippocratic understanding of the Four Humors.

But of course, while Greek writers initially described trepanation, it is one of the ancient surgeries that continues to the present day. Nowadays, the surgery is referred to as a craniotomy, although it is merely a more precise and scientifically informed trepanation. Also, due to the invention of antisepsis and modern prophylaxis, it comes with much less risk. Up until relatively recently — that is, the 19th century — trepanation was a commonly practiced surgery around the world, used to treat depressed fractures and penetrating head wounds. However, it became increasingly unpopular due to the high mortality rate. Some people even joked that a prerequisite for seeking trepanation was a physician who themselves had been trepanned.

Our eyes are of fundamental importance to our daily operations. In the ancient world, as it would be today, losing ability in one’s eyes was incredibly debilitating. While nowadays we have eyeglasses as an easy solution to both short and long-sightedness, those living in Antiquity were not as lucky.

A common issue for people living in ancient times was Trichiasis. A stage in the disease known as Trachoma, it is an irritation of the eyes that may cause damage to the cornea or even threaten one’s eyesight. It is caused by the misdirection of the eyelashes towards the eye itself and still affects many people today. Indeed it is considered a public health problem in 44 countries, according to the WHO.

In antiquity, various medical experts offered treatments for Trichiasis. However, the most interesting was that of Dioscorides, a Greek herbalist who claimed to have been a physician with the Roman military during the time of Nero. Dioscorides’ work focused on the various medical applications of plants. It must be noted that his writings were never lost as they were consistently used throughout the Middle Ages and later periods. His solution to the issues caused by Trichiasis was to bind abnormally growing lashes to each other, as well as to normally growing ones, using mastic gum (which is extracted from the trunk of the mastic tree), and lithokolla, a similar glue formed from bull’s hide and marble.

Eye Surgery II: Cataracts

Cataracts — another common issue of the eyes — are when the lens develops cloudy patches, which, in time, begin to make the vision in the affected eye steadily impossible. Cataracts typically form as a course of aging, but they can also develop due to an injury to the eye. Aulus Cornelius Celsus described ancient surgeries which treated cataracts in his work De Medicina. In Book VII, he details a variety of different surgical techniques, one of which is known today as ‘Cataract Couching’ whereby the affected lens is pushed within the interior of the eye, thereby moving it out of the way and, through its absence, improving vision.

Celsus begins with an emphasis on the patient’s preparation. He considers both old age and childhood unsuitable times for this particular surgery. The “intermediate ages” are ideal for him also because the cataract itself must appear “to have coalesced to some sort of hardness” rather than being fluid. Evidentially this was a procedure of which he had a great understanding. Furthermore, the patient was also to abstain from all food and drink the day before the surgery. On the day of the surgery, the patient was to be seated facing the light, with the surgeon above them and their assistant holding the patient’s head. The operation, done with a needle, was to be quick and deliberate. Celsus provides specific detail on the necessary motions. However, for the sake of a squeamish reader, it will not be detailed here.

Ultimately the surgeon would know that they succeeded if the cataract stuck at the back of the eye and did not come back up. Celsus states that the lens should be separated into several pieces and couched within the eye if it did. After the surgery was finished, the eye would be covered in white wool soaked in the white of an egg and bandaged. The patient should refrain from eating anything solid for the subsequent days to avoid using their jaws. Usefully Celsus does not state a period for recovery, merely stating that the inflammation will end.

In contrast to the modern-day, doctors were not held in particularly high regard in Ancient Rome. Considering the means by which medical knowledge could be gained at the time, it is understood why doctors were deemed suspicious. In a letter of Cato’s, quoted by Pliny the Elder, there is clear disdain for doctors or medici. Cato — known for despising all things Greek — believes doctors to be part of an organized conspiracy of the Greeks against all other people. He writes:

“[The Greeks] are a most iniquitous and intractable race, and you may take my word as the word of a prophet, when I tell you, that whenever that nation shall bestow its literature upon Rome it will mar everything; and that all the sooner if it sends its physicians among us. They have conspired among themselves to murder all barbarians with their medicine; a profession which they exercise for lucre, in order that they may win our confidence, and dispatch us all the more easily.”

Note that in the above quotation, the translation of “medicos” is ‘physicians’ rather than doctors, but it means both in translation. For Romans, medical ailments were typically treated by the Paterfamilias, both solely and primarily. This is seen in Cato the Elder’s De Agri Cultura, which provides recipes for a variety of goods with medical uses, such as wine for stimulating the bowels “ut alvum bonam faciat” and heavily encourages the consumption of cabbage. In fact, the entirety of two sections is devoted to Cato’s praise of cabbage and its medical uses. It opens “Brassica est quae omnibus holeribus antistat.”, translated as “The cabbage is superior to all other vegetables,” and goes on to list some of its uses in many beneficial uses for the body.  

Marcus Valerius Martialis, writing roughly three centuries later, echoed these sentiments. While Cato was writing at a time before Greek influence had become widespread in Ancient Roman society, Martial was a member of a society that was very much Greco-Roman. Doctors had become household staff members for many of the elite and were also attached to some legions by Augustus. However, doctors tended to be self-trained or gained most of their knowledge either through observation or trial and error. One of Martials’ epigrams, translated in Jo-Ann Shelton As the Romans Did relates an incident involving a Dr. Symmachus and the students shadowing him:

“I felt a little ill and called Dr. Symmachus. Well you came, Symmachus, but you brought 100 medical students with you. One hundred ice-cold hands poked and jabbed me. I didn’t have a fever, Symmachus, when I called you- now I do.”
(Martial, Epigrams, 5.9, p. 91)

Pliny the Elder, too, expressed significant distrust of doctors, attested in his Natural History. What is interesting about Pliny’s polemic is that he immediately associates doctors with the Greeks. He writes, “Very few of our citizens are attracted [to medicine] even by its considerable monetary rewards, and those who are immediately begin to act like Greeks.” It is interesting to note that medicine, then as now, was a lucrative profession in the ancient world. No doubt, this led to many people posing as doctors without much training or knowledge of the subject. Indeed, Pliny builds on this idea stating:

“Medicine is the only profession, by Jove, where any man off the street gains our immediate trust if he professes to be a doctor, and surely no lie would be more dangerous.”

Evidentially, medical knowledge has progressed significantly in the last few centuries, and the practices of the ancient world are today the domains of quacks rather than of trained professionals. Ancient surgeries, while successful, occurred without any anesthetic, antiseptic or antibiotic, all of which can easily prevent discomfort or death. While our ancestors managed to get by, and some were able to accrue impressive amounts of knowledge, without a scientific understanding of the body, they were working with an inaccurate foundation from which any further information was fundamentally flawed. Still, their attempts at understanding the human body form an important and valuable legacy.