SURGERY 



817 



tion, volvulus, and such abdominal lesions they 

 practised laparotoray, while fistula in ano (diag- 

 nosed hy the speculum ) they treated with the knife 

 and corrosives. Lithotomy, in no case performed 

 without the sanction of the rajah, they practised 

 on the method (sectio lateralis) described by Celsus. 

 The claim asserted for them of having independently 

 of the Greeks devised the operation of rhinoplasty 

 ( constructing a nose from the neighbouring tissue 

 in this case from the cheek), and also that for 

 cataract, has still to be made good. 



As to the surgery of the other orientals we 

 possess but obscure notices. Among the Persians 

 we. find Greeks in general practice under King 

 Cambyses. The Chinese six centuries B.C. per- 

 formed surgical operations ( castration, for example ) 

 in the rudest fashion, and placed much reliance 

 on acupuncture and the moxa. Japanese surgery 

 betrays similar features. 



In Greece surgery had attained high develop- 

 ment before Hippocrates put medicine on a rational 

 ba.-is, and in the Hippocratic books we find a rich 

 collection of surgical doctrine and practice drawn 

 from centuries of experience. The treatise called 

 Jatreion contains a description of the practitioner's 

 room, its lighting, the instruments and appliances 

 necessary, the duties of assistants, the accommoda- 

 tion of the patients, the position of the operator, 

 the use of the hands, of water, of bandages, of 

 founds manufactured from tin or lead, &c. A full 

 account of wounds and their treatment is given, 

 haemorrhage being arrested by cold, by compression, 

 and styptics, the wounds themselves healed by 

 primary union or through suppuration. Cata- 

 plasms cold and warm and plasters are also 

 described in this connection. Lesion of the joints 

 and its manifold consequences, and injuries to 

 the medulla spinalis (paraplegia, &c.) are also 

 dealt with. Dislocations and fractures have special 

 treatises devoted to them. On the battlefield, on 

 shipboard, in building operations, gymnastic and 

 athletic contests the Greek surgeon lost no oppor- 

 tunity of perfecting the knowledge to which the 

 latter-day world has surprisingly little to add. 

 Medical scholarship has proved that many of the 

 rarest forms of dislocation had not escaped Hippo- 

 crates. Even modern appliances were in great 

 part anticipated by him splints, for example, and 

 bandages of various kinds. The gem of the Hippo- 

 cratic surgery (according to Haser)is the treatise 

 on injuries of the cranium fractures, fissures, and 

 contusions with or without depression. For such 

 cases trepanning is the sovereign operation, to be 

 performed as early as possible, less to get rid of 

 effused blood, pus, &c. than, by removal of the 

 injured osseous structure, to prevent inflammation 

 of the scalp. This l>old and circumspect practice 

 creates surprise that the greater operations (extir- 

 pation of tumours, aneurisms, amputations, &c.) 

 were ignored, till we remember that in their 

 meagre knowledge of anatomy Hippocrates and 

 bin school were slow to risk section of the more 

 important vessels and nerves. The removal of 

 extremities which had become gangrenous shows 

 again the Hippocratic surgery in a wonderfully 

 favourable light. Hernias, haemorrhoids, fistula 

 are also described and treated with a judgment 

 and skill remarkable for the time. 



The post- Hippocratic school ( its greatest surgeon 

 being Praxagoras of Cos, noted for his cure of 

 volvulus) has little to detain us ; but the Alexan- 

 drians left a distinct mark on every branch of the 

 healing art^-surgery included. Our best know- 

 ledge of them comes from Celsus, who names as the 

 most celebrated surgeon of Alexandria Philoxenus, 

 a voluminous writer on the subject. Ammomus, 

 the lithotomist, is another light of the school, litdo- 

 trity being his special contribution to practice. 

 468 



Roman surgery can hardly claim M. Porcius Cato 

 (234-149 B.C.) as more than a shrewd amateur who 

 left some handy rules for the treatment of fractures, 

 ulcers, nasal polypi, fistulse, strangury, &c., having 

 doubtless drawn on his experience as a slave-owning 

 patrician. Archagathiis (218 B.C.) was a regular 

 practitioner, known, for his skilful handling of dis- 

 locations, fractures, and particularly wounds, as 

 the ' Vulnerarius. ' The senate confirmed the popular 

 appreciation by providing him with a ' taberna ' in 

 a much frequented thoroughfare. But when from 

 such practice lie proceeded to operate with the 

 knife his popularity Hed, he was nicknamed the 

 ' Carnifex,' and had to leave the city. Celsus, the 

 patrician dilettante in medicine, is really the 

 highest name in Roman surgery, though it is 

 doubtful whether he ever operated. Of the eight 

 books of his admirably written work the last two 

 treat of surgery, including plastic replacement of 

 defects in the outer ear, the nose, and the lips ; 

 lithotomy as practised on boys (a celebrated 

 chapter); amputation, previously described by 

 no other author ; diseases of the bones, with the 

 operation of trepanning, fractures simple and com- 

 pound, and dislocations. 



Galen, though a master of surgery and, before 

 his settling in Rome under M. Aurelius, a practi- 

 tioner of it, seems to have contributed nothing of 

 bis own to its doctrine or practice. As he found 

 it (with some notable additions) it remained to the 

 close of the Byzantine period. An intimate know- 

 ledge of its modus operandi during these centuries 

 may be inferred from the collection of surgical in- 

 struments dug up at Pompeii and now on view at 

 Naples. These are about 300 in number, consist- 

 ing of some sixty different kinds : needles, hollow 

 probes (straight, curved, and toothed ), catheters, 

 specula vaginae, pincers, cauteries, bistouries, 

 lancets, scissors, &c. , mostly of bronze, many of the 

 cutting ones of iron. To sum up : blood-letting 

 was practised in antiquity by venesection, arterio- 

 tomy, cupping, and (later) by leeches. Haemor- 

 rhage was checked by cold water, styptics, cauteris- 

 ing, ligature, and torsion the two latter not men- 

 tioned by Hippocrates, the ligature being a device of 

 the Alexandrians, as torsion was of the empire, after 

 which time it fell into desuetude. The treatment of 

 fractures and dislocations was practically the same 

 from Hippocrates to Paulus ^igineta (650 A.D.). 

 Trepanning received several modifications in 

 practice up to Galen's time, while tracheotomy 

 (introduced by Asclepiades, 1st century) was by 

 Paulus restricted to cases of choking, when the 

 deeper air-passages were free. The evacuation 

 of pus in empyema, frequently mentioned by 

 Hippocrates, was seldom performed in later times 

 Paulus recommending, instead of the knife, the 

 application of the actual cautery to the wall of the 

 thorax. The operation for hernia, perfunctorily 

 dealt with by Hippocrates, had by the epoch of 

 Celsus assumed the practical development in which 

 it is found during the later empire, Heliodorus, 

 under Trajan, being noted for his radical cure of the 

 scrotal form. Lithotomy, in the Hippocratic period 

 confined to specialists, was by the Alexandrian 

 school raised to full surgical honours, to be supple- 

 mented under the Byzantine empire again by htho- 

 trity. In Paulus we find 'a well-nigh exhaustive 

 list of operations for disease or malformation of the 

 genitals, even including syphilis (Hiiser), while 

 rectal and anal affections (haemorrhoids, fistula, 

 &c.) were skilfully treated by Leonides (200 A.D.), 

 who seems to have used the ecraseur as well as 

 the knife and the cautery. Large tumours in the 

 neighbourhood of great vessels were untouched by 

 Hippocrates or Celsus, though the latter makes 

 mention of the surgical cure of goitre. On the 

 other hand, Leonides extirpated the cervical glands; 



