World J Surg (2008) 32:21142121
DOI 10.1007/s00268-008-9662-1
From Hippocrates to Tissue Engineering: Surgical Strategies
in Wound Treatment
Nicolo` Nicoli Aldini Milena Fini Roberto Giardino
Published online: 26 June 2008

Societe Internationale de Chirurgie 2008
Abstract The history of wound treatment has been vir-
tually the history of surgery for many centuries and also is
a history of alliance and conflicts between the physician
and nature. The Hippocratic statement about natura med-
icatrix has been well known since antiquity, but often was
neglected. Suppuration was considered a necessary event in
the healing process and was elicited by the surgeons with
traumatic and painful procedures. The concept of sim-
plicity in treating the wounds was suggested by Teodorico
Borgognone and Henry de Mondeville in 13th century and
was confirmed only three centuries later by the works of
Ambroise Pare and Cesare Magati. The history of wound
management has been characterized by empiricism since
the 18th century, but it took a physiopathological direction
during the 19th century when Virchow investigated tissue
reaction to injuries, and Lister introduced antiseptic pro-
cedures in surgery. By establishing the basis for a
biological method to treat wounds, the seeds were sown to
enhance the pathways involved in tissue repair, also with
the support of new strategies and technology.
N. Nicoli Aldini (&)
M. Fini
R. Giardino
Department of Experimental Surgery, Research Institute
Codivilla-Putti Rizzoli Orthopaedic Institute, Via di Barbiano,
1/10, 40136 Bologna, Italy
e-mail: nicolo.nicolialdini@ior.it
M. Fini
e-mail: milena.fini@ior.itroberto.giardino@ior.it
R. Giardino
Chair of Surgical Pathophysiology, Faculty of Medicine,
University of Bologna, Bologna, Italy
e-mail: roberto.giardino@ior.it
123
Introduction
The management of wounds was written in the history of
humanities before appearing in the history of medicine.
The wound is an event that is directly exposed to obser-
vation; it is ubiquitous and usually unpredictable, and
occurs without preference with respect to age, sex, race, or
other human and environmental variables. These factors
influence the course and prognosis of the lesion.
However, the wound also is a medical act used by the
surgeon to treat the patient. To heal the patient, the surgeon
also must heal the wound that he made to treat the disease.
The surgeon wounds to heal, but without an appropriate
technique, the consequences of that wound may be worse
than those of the disease to be treated. This conflict has
permeated the history of surgery, at least until recently.
The history of wound management shows that the human
body may recover despite some inappropriate procedures
performed by physicians; furthermore, we can appreciate
that beneficial measures might be proposed despite the lack
of knowledge, sometimes being only mere intuitions gen-
erated from day-to-day experience. The purpose of this
survey was to highlight some meaningful landmarks that
became actual guidelines during the times, until the under-
standing of the biological pathways of tissue repair laid the
bases for the modern approach and strategies.
The ancient background: natura medicatrix and their
supports
In classical poetry, in which epic events and military feats
took place, the care of the wounded was not only the
physicians task, but was frequently left up to the com-
panions of those who were wounded in battle.
World J Surg (2008) 32:21142121
According to Homer, in the Greek poem Iliad [1], when
King Menelaus was injured during the siege of Troy, he
was assisted by the son of Asclepius, divine healer
Macaon but when Macaon himself was wounded, the Greek
hero Patroclus was compelled to treat the wound of his
companion, Euripilus. He operated skillfully, by extracting
the arrow, cleaning the wound, and stopping the bleeding as
Homer related: He laid him down, extracted the sharp
arrow, then with warm water cleaned the dark blood and
wiped a sour root that relieved the pain, and the pain dis-
appeared. And the blood stopped, and the wound dried.
The Homeric poem describes more than 140 cases of
wounds and relevant treatments. The mortality rate can be
assessed as [70 percent [2]. In these ancient descriptions,
the fundamentals about the treatment of wounds were
already outlinedhemostasis, cleaning, and dressingto
address three major problems: the mechanical disruption of
tissues, bleeding, and infection [3]. It is interesting that
much of our knowledge about wounds and wound man-
agement comes from the experienced military surgeons of
all times [4, 5].
Undoubtedly, despite primitive and rudimentary tools
and procedures, the wounds could heal. It is likely that
since the early times of mankinds history, the idea that
nature was the true artificer of the healing process was
established in the human mind, but only after Hippocrates
(VIV century B.C.) was this concept positively stated. As
Temkin stated: Nature alone could (and can) mend a
broken bone, and the doctor could (and can) help it by
setting the fractured bone, by splints and bandages [6].
The idea of the physician as a coworker of nature was
clear, but the pathway to be pursued in the art of healing
often remained obscure.
Hippocrates opened his treatise, On Wounds, by sug-
gesting that wound suppuration was effective to avoid the
involvement of surrounding parts (to avoid inflammation
around recent wounds promote their suppuration and hin-
der the staying of matter), and reaffirmed this precept in
the book, On Head Wounds [7]. The concept known as pus
bonum et laudabile with its misinterpretations influenced
the work of surgeons until the 19th century, and this is a
demonstration that also the thorough observation, without
adequate interpretation of facts, can lead to wrong theories.
Majno observed that now we can find several reasons to
justify this attitude of Greek physicians, e.g., the natural
cleaning and debridement of wound produced by pus dis-
charge and also the fact that a complete absence of
suppuration may be considered a sign of failure of the
organisms defences, and so can be correlated with a bad
prognosis [2].
In the Hippocratic book on Fractures, the occurrence of
sores as a complication of too tight a bandage is consid-
ered: Ulceration is recognized by pain and throbbing,
2115
swelling on the extremity which gets harder, and erythema
which resolves under pressure by the finger tip but returns
rapidly. Therefore, when suspecting a sore, you should
undo the dressing [8]. Pain, swelling, and erythema are
classic signs of inflammation; they will be systematized by
Celsus (I century A.D.) approximately five centuries later
as dolor, tumor, rubor, with the addition of the temperature
increase, calor [9].
The Hippocratic works, as well as many ancient medical
writings, list a wide variety of animal or vegetable products
regarded as effective for wound treatment. The practice of
ancient surgeons was mostly empirical, but often supported
by a thorough practice, and many of these topical agents
are now recognized as endowed of some curative action.
In the Odyssey, Homer wrote that the physicians of
ancient Egypt were more experienced than anyone else in
medicine [10] and Herodotus emphasized the skill of the
Egyptian practitioners [11]. In the Edwin Smith papyrus, a
surgical document that dates back to the XVII century
B.C., much information is contained about wound man-
agement [12]. The standard treatment included the use of
grease, lint, and honey [13]. Now we know that lint, by
packing and filling the wound space, determine an oxygen-
poor environment, which could stimulate angiogenesis.
Grease decreases the sticking of bandages to the wound
and honey has an effective antibacterial effect. This prop-
erty of honey is due to its high osmolarity and to its
glucose-oxidase content. The enzymatic action of glucose-
oxidase on glucose and molecular oxygen leads to the
production of hydrogen peroxide and gluconolacton, which
have an antibacterial effect [14].
Wine and vinegar also were widely used. Hippocrates
wrote [On Wounds] that Every kind of wound will benefit
by washing in wine. The antibacterial properties of wine
are not only related to its alcohol content, but also to the
presence of malvosides or oenosidespolyphenolic com-
poundswhich are more effective than phenol in their
antibacterial effect [2].
The equipment of ancient surgeons also included a
selection of plants, some of them with recognized medical
properties, i.e., Pistacia terebinthus (turpentine, antiseptic),
Alchemilla vulgaris (tannin, astringent), Symphytum offi-
cinale (allantoin, antibacterical, promote granulation) [15,
16].
The most extensive ancient collection of medical
knowledge after Hippocrates is contained in the books De
re Medica by the Latin encyclopedist Aulus Cornelius
Celsus during the first century A.D. [9]. In the fifth book of
this treatise, considering wound treatment, Celsus points
out the importance of a careful control of bleeding, and
foretells the primary closure of the wound with suture or by
fibulas and threads, advising the correct application of the
bandage.
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Galen of Pergamum (129212 A.D) shares with Hip-
pocrates the role of leading physician of the antiquity. He
started his medical career as a surgeon of the gladiators
performing, as he himself wrote, a successful practice in
treating wounds. Galen emphasizes that every surgeons
act has reference to two fundamental maneuvers: separa-
tion and approximation. The approximation of tissues is the
task of the surgeon treating a wound. He must put together
the separated parts, keeping them in place with the aid of
bandages, metal pins (fibulae), and sutures. The penetration
of foreign bodies between the edges must be avoided; the
use of proper potions is recommended to preserve the
healthy of the matter of the part. The control of bleeding
was obviously one of the foremost concerns for the sur-
geon; the ways considered by Galen were: to exert a gentle
pressure with fingers, to prickle and twist the vessel with a
hook, to grab with forceps and then tie it, and the topic use
of styptics (astringent) preparations [2].
The thoughts of Galen became unchallengeable and
were the guidelines for practitioners until the Renaissance
and beyond. After the invention of printing in 15th century,
Galens treatises had widespread diffusion with renowned
editions (Fig. 1) that maintained their primacy in medical
Fig. 1 Frontispiece of Galens surgical treatises in an elegant 16th
century edition (Venice, Iuntas, 1556). Iuntas [Giunti] was a
renowned printing firm working in the XVXVII centuries (private
collection of one of the authors)
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World J Surg (2008) 32:21142121
education. Consequently, little advancement can be rec-
ognized in wound treatment between the 5th and 16th
centuries [17].
From the Middle Ages to the 18th century:
aggressiveness or simplicity?
The Italic School of Salerno (XIXIII century) emphasized
the theory that wound suppuration was necessary to obtain
good healing, thus perpetuating the doctrines spread by
Galen [18]. During the medieval period, there was conse-
quently the custom to mistreat, rather than to treat these
lesions, with recurrent and inappropriate medications that
impaired the healing processes.
Repeated dressings were performed and a wide variety
of topical drugs were used to promote cleaning, sealing,
and cicatrization of the tissues, but their effectiveness often
was unsupported, and the mistreated wounds were fre-
quently destined to become sores [2].
The Frenchman Henri de Mondeville (12601320),
chairman in Montpellier and Paris [19] was one of the most
distinguished surgeons of the Middle Ages. In his Chir-
urgia, he dwells on the debate about the management of
wounds. Mondeville emphasizes that three main trends in
wound treatment were proposed at the time. The first trend,
aggressive suggested by Ruggero Frugardo (12th cen-
tury) and Rolando da Parma (13th century) referred to the
doctrines of the School of Salerno (strict diet and probing
the wound to promote suppuration); the second trend was
followed by Guglielmo da Saliceto (12101277) and
Lanfranco da Milano (13th century): they applied mild diet
and less traumatic packing and dressing. A third and
innovative procedure was suggested by Ugo de Borgog-
noni (11601256) and his son Teodorico (12051298). In
opposition to the doctrines of Salerno, Teodorico said that
it is not necessary, as Roger and Roland have written, and
as many of their disciples teach and profess, that the pus
should be generated in wounds. Such a practice is indeed to
hinder nature, to prolong the disease and to prevent con-
glutination-consolidation of the wound [18]. On the
contrary, Teodoricos method was based on a gentle
cleaning with tepid wine, on the suture of the damaged
tissues and on a protective bandage. Henry de Mondeville
agreed with the latter way and criticized the pus laudabile
theory [19]. The repair per prima intentione [primary
union] was thereby proposed and opposed to the secunda
intentione [delayed union] that is the necessary conse-
quence of wound suppuration.
Cyrurgia Magna written in 1363 by Guy de Chauliac
(1290?1368) was one of the most popular textbooks of
surgery during the Middle Ages. Chauliac was still under
the influence of Galen, but some of his thoughts on wound
World J Surg (2008) 32:21142121
treatment are worthy of interest, such as The common
purpose in every solution of continuity is union. This
general primary intention is accomplished in two ways; by
nature as the principal operator, which works with its own
powers, and with suitable nourishment; and by the physi-
cian as a working servant.
According to Chauliac five steps or intentiones are
involved in wound care: the first requires the removal of
foreign bodiesthe second to reapproximate the separated
partsthe third to maintain the reapposed parts in their
proper form, and to unite them together as one. The fourth
is to conserve and preserve the substance of the member.
The fifth teaches the correction of complications [20].
Advice to conserve the substance of the member is note-
worthy, because it demonstrates an early attempt to apply
the principles of reconstructive surgery.
The primary union of wounds was a laudable objective,
but unfortunately not always feasible [21]. This way was
ignored by the majority of surgeons during the middle ages
and was seriously reconsidered only three centuries later.
Between 16th and 17th centuries, the onset of experi-
mental investigations and the decline of Galenism led to a
more critical approach to the medical knowledge.
The Frenchman Ambroise Pare (15101590) is one of
the most representative figures of Renaissance surgery
(Fig. 2). Pare started his career as a military surgeon.
During a campaign in Italy in 1536, he was compelled to
replace the boiling oil, with a mixture of egg yolk, rose oil,
Fig. 2 Portrait of Ambroise Pare` from his Opera Omnia printed in
1585 (courtesy of the Clendening History of Medicine Library,
University of Kansas Medical Center)
2117
and turpentine, which was used, according to the leading
surgeon, Giovanni da Vigo (14601525), to cauterize
wounds. This cruel procedure was supported by the idea
that gunshot injuries were poisoned by gunpowder con-
tamination. The results were unexpectedly favorable and
Pare decided never to burn wounds again [22]. The episode
is significant, because a new way of treatment was found,
which was more respectful and less traumatic for damaged
tissues (the cauterized wound also became a burn!) and less
painful for the patient.
A few years later, the Italian surgeon, Cesare Magati
(15771647) (Fig. 3), in his masterpiece De rara medi-
catione vulnerum (Fig. 4), proposed a way of dressing
based on the opinion that the healing of a wound is better
and faster if the lesion is at absolute rest [23].
The history of the clinical case that led to a new
approach is described by Magati himself. He dressed a sore
in the leg of a girl one or two times daily without any
improvement of the lesion. Thus, tired of the long treat-
ment I began to dress it only every other day; later
medicating the ulcer every three days, in a short time it
healed. I used the same method in other patients, with
positive results. Magati states that the task of the physi-
cian is first of all to protect the work of nature. Maintaining
the wound covered and at rest, he says the secretion is
Fig. 3 Sculpture of Cesare Magati. In 1630, he entered into the
religious order of Capuchin Friars with the name of Fra` Liberato da
Scandiano, while continuing surgical practice (courtesy of the
Archive of Capuchin Friars, Bologna)
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The elaborate variety of medication aids that are

described in surgical treatises does not diverge much from
the medieval equipment. References to Hippocrates, Galen,
and Celsus are still commonly included in the texts.
The introduction of the tourniquet proposed by Etienne
Morel (16481710), later improved and popularized by Jean
Louis Petit (16741750), allowed a better and safe control of
bleeding and can be considered the sole widely accepted
innovation of this period in surgical instruments [25].
However, the literature also shows a critical reappraisal
of some concepts and procedures, not only due to casual
observations, but also a systematic attitude based on the
collection of a large number of cases. The debate between
the promoters of conservative methods and those who
pursued aggressive treatments went beyond the XVIII
century.
John Hunter (17281793) (Fig. 5), an outstanding
Scottish anatomist, surgeon, and teacher [26] collected
significant observations when participating as military
surgeon during the Seven Years War. During an expedition
to Belle Isle (1761), he was impressed by the favorable
outcome of some gunshot-wounded French and British
soldiers, who received only minimal care, in contrast
with the usually aggressive surgical procedures. Hunters
preference for a more conservative treatment was popu-
larized in his Treatise on Blood, Inflammation and Gunshot
Fig. 4 Frontispiece of Magatis De rara medicatione vulnerum in
the edition of 1616 (Venice, Ambrosium and Bartolomeum Dei
Wounds, which was posthumously published in 1794 [27,
printmakers) (from the Putti Collection, courtesy of the Rizzoli 28]. Similar conclusions were obtained, in the same epoch,
Orthopaedic Institute Library, Bologna) by the Swiss surgeon, Johann Ulrich Bilguer (17201796),
who regarded amputation as an improper procedure, and
smallest, the danger of bleeding is removed, and there is no
pain. The method was therefore favorable for both the
patient and the surgeon, and less expensive.
Two centuries before the onset of bacteriology, Magati
raised the problem of the influence of air contamination on
the wounds (What therefore happens to a wound exposed
to polluted, contaminated or poisonous air? Copious
putrefaction and decaying often occurs), and he protected
the injured parts from the environment with a careful
dressing (The elegant physician will easily prepare a
dressing with small clothes folded in two, three, four or
moreto widely cover also the surrounding healthy tis-
sues). It is interesting to observe that the occlusive
concept of Listers medication, which developed more than
two centuries later, was anticipated by Magati, despite the
absence of any knowledge of the biological processes of
infection and inflammation [24].
We are hence near a turning point. Pare and Magati with
their observations and suggestions recommended a new
approach in wound treatment after the Dark Ages and
before the XIX century. The two following centuries can be
Fig. 5 Engraving of the Scottish surgeon, John Hunter (courtesy of
considered as a transitional period, in which classical tra- the Clendening History of Medicine Library, University of Kansas
dition and innovative thoughts blend, match, and oppose. Medical Center)

123
World J Surg (2008) 32:21142121
supported his observations by an outcome survey on
thousands of wounded soldiers [29]. However, in major
limb trauma, amputation remained the widely adopted and
unavoidable treatment even though the consequent deaths
recorded in several case studies exceeded 70% [21].
Since the 19th century: toward a modern approach in
wound management
During the 19th century, pathological investigations moved
from the macroscopic observation toward the microscopic
dimension. The technical improvement of the microscope,
with the construction of achromatic lenses, which increased
the resolving power and magnification, as well as the
procedures of tissue preparation, allowed the recognition of
tissues and the cells as the seat of diseases, and of the
bacteria as morbid agents.
During the first half of the century, the destiny of
wounded or surgically treated patients was still quite
uncertain. The conditions of wards were discouraging, and
the rate of infections and mortality after trauma or major
surgery was high.
The British surgeon Frederick Treves (18531913), in
his memoirs [30], describes the tremendous conditions of
surgically treated and wounded patients, emphasizing that
almost all great wounds suppurated. The hospital envi-
ronment, the patients own skin bacteria, and the surgeons
hands concurred to determine poor wound healing and a
poor prognosis for the patient [31].
The Hungarian obstetrician Ignaz Semmelweiss (1818
1865) was the first but unheard promoter of a new clean capability of the organism.
way in the surgical maneuvering [32], but it was Joseph
Lister (18271912), chairman of surgery and head of the
Royal Infirmary of Glasgow, who highlighted the evidence
of bacterial growth in wounds, and its role in sepsis and
gangrene [33].
On the basis of the discoveries by Pasteur (18221895)
concerning micro-organisms, he suggested a new way to
manage wounds by the use of carbolic acid (phenol). To
kill the bacteria and protect the injured part from infec-
tions, Lister recommended the application on the wound of
a piece of lint soaked in carbolic acid, covering also a little
part of healthy skin, and placing over this tissue a thin vault
that could be removed everyday to imbue the lint with
phenol [34, 35]. The early reports of Listers works were
published by The Lancet in 1867 [36]. Beginning the era of
antisepsis, suppuration is now regarded as an accident, and
not a normal and necessary event in the natural history of
wound healing. The fall of the infection rate and mortality
in wounded and surgically treated patients after the intro-
duction of antisepsis quickly gave support to Listers
reform [37].
2119
This was the true turning point of 19th century surgery:
the discovery of anesthesia deeply transformed the scenery
in the operating room, but did not immediately affect the
patients postoperative survival as did the introduction of
antisepsis [38, 39]. The fall in mortality rates for amputa-
tion in Listers clinic closely follows the adoption of
antiseptic procedures [21], whereas ether and chloroform
had been in use for more than 20 years. At the same time
the pathological mechanisms of diseases were investigated
at the physiological and cellular levels [40].
Rudolf Virchow (18211912) was the pioneer of the
investigations on cellular pathology, and he systematized
the study of pathological events in the tissue environment
[41]. His discoveries of the role of white blood cells in
inflammation and the origin of suppurative processes led to
the correct interpretation of tissue reaction to trauma and
infection.
Biological pathways were gradually replacing the
empiricism in surgical practice, and surgeons adapted their
methods to make an environment beneficial to the natural
mechanisms of tissue repair.
Crossing the threshold of the 20th century, the land-
marks are clearly outlined. The improvement in wound
management was first of all the history of a progressive
comprehension of the tasks of nature and the tasks of the
surgeon that must be blended and balanced to obtain
effective cooperation. The major tasks of nature, such as
angiogenesis, cell migration and proliferation, collagen and
noncollagenous protein synthesis, and tissue remodelling,
can be improved by the surgeon, especially in patients with
biological drawbacks or where the wound size exceeds the
An example of this cooperation can be found in the
procedures used to enhance the biological pathways
involved in tissue repair. New technologies support some
of these procedures, based on biophysical stimulation, such
as pulsed electromagnetic fields and laser irradiation, or
exploiting a controlled environment, such as vacuum-
assisted closure and hyperbaric oxygen [42, 43]. Thanks to
the strong development in biomaterial science, medical
device technology, and biotechnology, many wound
dressings and innovative treatments have been developed.
The capability of absorbing exudates, protecting the
wound, and preventing bacterial invasion are still the
required characteristics for an ideal wound dressing.
Moreover, the promotion of angiogenesis, cell migration
and proliferation, and extracellular matrix protein synthesis
is now possible thanks to tissue engineering and bioactive
materials [44].
Tissue engineering is an interdisciplinary field of
regenerative medicine that applies the principles of biology
and engineering to the development of substitutes able to
replace temporarily tissue function (thus organs) partially
123
2120
damaged to favor regeneration, such as both the structural
and functional properties of the wounded tissues are
restored at the level before surgery [45, 46]. This procedure
is primarily enabled by using scaffolds (i.e., fibrin matrix),
growth factors and cells (i.e., cultured keratynocites, mes-
enchymal stem cells) [47]. There are three general
strategies in the development of tissue-engineered prod-
ucts: 1) the use of cells, which are transplanted to restore
function in an injured organ; 2) the development of syn-
thetic polymers or other biomaterials with or without the
addition of proteins, such as growth factors and cytokines;
and 3) the use of cells within a three-dimensional matrix,
i.e., bilayered skin substitutes composed of keratinocytes
and fibroblast incorporated into biologic or synthetic bio-
absorbable scaffolds [4850].
Engineered tissues can be obtained in vitro, before their
transfer to the living organism, by using plates or bioreactors
[51], but in vivo or in situ tissue engineering is now also
performed by a method in which scaffolds are tailored and
inserted to define and maintain an adequate space to guide
regenerating tissue, to supply temporarily functional features
in which the tissue is lacking during the repair time, and to
help the cell growth also by incorporating biological factors
injected into it [52]. By this procedure, peripheral nerve and
guided bone regeneration are now obtained [53, 54]. Another
simpler approach in tissue regeneration is to design a
reliably bioactive scaffold capable of increasing angiogen-
esis and recruiting and stimulating the patients own cells
[55]. Many biological membranes simulating skin extracel-
lular matrix (ECM) are now available for wound healing
[56]. Collageneous and not collageneous proteins and
growth factors native to the ECM materials can modulate
host cell adhesion, migration, proliferation, and synthetic
activity and, consequently, accelerate the biology of tissue
repair [57]. The advantages of this approach compared with
in vitro tissue engineered is that one step surgery is per-
formed in the absence of the need of cell manipulation.
As Naughton observed, tissue engineering has moved in
the last decade from science fiction to science fact 13. Caldwell MD (1990) Topical wound therapy: an historical per-
[58]. In the theater of wound healing, this transition is
especially outstanding. Starting in the wounded body, the
cooperation between man and nature is verified and
improved in the laboratory, to redirect at last toward the
damaged tissues and organs.
Literally this cooperation was formerly defined by the
distinguished Italian clinician Giorgio Baglivi (16681707)
[59] as the core of his doctrine: Medicus naturae minister
et interpres, quicquid meditetur et faciat, si naturae non
obtemperat naturae non imperat [The physician, who is a
minister and an interpreter of the nature, whatever he think
or do, if doesnt comply to the nature, doesnt command to
the nature] [60]. Baglivi meant and disclosed in this way
the idea that a successful practice (medicus minister)
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World J Surg (2008) 32:21142121
resulted from the knowledge of biological events (medicus
interpres). The relationship between medicus and natura
medicatrix was by that time forever defined.
With regards to wounds, this concept was earlier well
exposed in a short but expressive comment by the
Renaissance physician Paracelsus (14931541): A phy-
sician who thinks that he heals does not understand the art.
You may understand for what purpose there is a physician.
He provides a shield for Nature, and protects the injured
parts against its enemies so that the foe may not retard,
poison or injure the forces of Nature, but may preserve its
vital power. He who takes good care of wounds is a good
surgeon [18].
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