PART I. HISTORY OF SURGERY
Part 2. Ancient Greece. Ancient Rome.
Greek. As in the case of the Sanskrit medical writings, the earliest Greek compendiums on surgery bear witness to a long organic growth of knowledge and skill through many generations. In the Homeric picture of society the surgery is that of the battlefield, and it is of the most meagre kind. Achilles is concerned about the restora-tion to health of Machaon for the reason that his skill in cutting out darts and applying salves to wounds was not the least valuable service that a hero could render to the Greek host. Machaon probably represents an amateur, whose taste had led him, as it did Melampus, to converse with centaurs and to glean some of their traditional wisdom. Between that primitive state of civilization and the date of the first Greek treatises there had been a long interval of gradual progress.
The surgery of the Hippocrotic Collection (age of Pericles) bears every evidence of finish and elaboration. The two treatises on fractures and surgery. Qn disioc.ations respectively are hardly surpassed in some ways by the writings of the present mechanical age. Of the four dislocations of the shoulder the displacement downwards into the axilla is given as the only one at all common. The two most usual dislocations of the femur were backwards on to the dorsum ilii and forwards on to the obturator region. Fractures of the spinous processes of the vertebrae are described, and caution advised against trusting those who would magnify that injury into fracture of the spine itself. Tubercles (phemata) are given as one of the causes of spinal curvature, an anticipation of Pott's diagnosis. In all matters of treatment there was the same fertility of resource as in the Hindu practice; the most noteworthy point is that shortening was by many regarded as inevitable after simple fracture of the femur. Fractures and dislocations were the most complete chapters of the Hippocratic surgery; the whole doctrine and practical art of them had arisen (like sculpture) with no help from dissection, and obviously owed its ex-cellence to the opportunities of the palaestra. The next most elaborate chapter is that on wounds and injuries of the head, which refers them to a minute subdivision, and includes the depressed fracture and the contrecoup. Trephining was the measure most commonly resorted to, even where there was no compression. Numerous forms of wounds and injuries of other parts are specified. Ruptures, piles, rectal polypi, fistula in ano, and prolapsus ani were among the other conditions treated. The amputation or excision of tumours does not appear to have been under-taken so freely as in Hindu surgical practice; nor was litho-tomy performed except by a specially expert person now and then. The diagnosis of empyema was known, and the treatment of it was by an incision in the intercostal space and evacuation of the pus. Among their instruments were forceps, probes, directors, syringes, rectal speculum, catheter, and various kinds of cautery.
Between the Hippocratic era and the founding of the school of Alexandria (about 300 B.C.), there is nothing of surgical progress to dwell upon. The Alexandrian epoch stands out prominently by reason of the enthusiastic cultivation of human anatomythere are allegations also of vivisectionat the hands of Herophilus and Erasistra-tus. The sum and substance of this movement appears to have been precision of diagnosis (not unattended with pedantic minuteness), boldness of operative procedure, subdivision of practice into a number of specialities, but hardly a single addition to the stock of physiological or pathological ideas, or even to the traditional wisdom of the Hippocratic time. " The surgeons of the Alexandrian school were all distinguished by the nicety and complexity of their dressings and bandagings, of which they invented a great variety." Herophilus boldly used the knife even on internal organs such as the liver and spleen, which latter he regarded "as of little consequence in the animal economy." He treated retention of urine by a particular kind of catheter, which long bore his name. Lithotomy was much practised by a few specialists, and one of them (Ammonius) is said to have used an instrument for breaking the stone in the bladder into several pieces when it was too large to remove whole. A sinister story of the time is that concerning Antiochus, son of Alexander, king of Syria, who was done to death by the lithotomists when he was ten years old, under the pretence that he had stone in the bladder, the instigator of the crime being his guardian and supplanter Diodotus.
The treatise of Celsus De re medica, (reign of Augustus) reflects the state of surgery in the ancient world for a period of several centuries: it is the best record of the Alexandrian practice itself, and it may be taken to stand for the Roman practice of the period following.
Great jealousy of Greek medicine and surgery was expressed by many of the Romans of the republic, notably by Cato the Elder (234-149 B.C.), who himself practised on his estate according to Major, the native traditions. His medical observations are given in De re rustica. In reducing dislocations he made use of the following incantation: "Huat hanat ista pista sista damiato damnaustra. The first Greek surgeon who established himself in Rome is said to have been Archagathus, whose fondness for the knife and cautery at length led to his expulsion by the populace. It was in the person of Asclepiades, the contemporary and friend of Cicero, that the Hellenic medical practice acquired a permanent footing in Rome. This eloquent and plausible Greek confined his practice mostly to medicine, but he is credited with practising the operation of tracheotomy. He is one of those whom Tertullian quotes as abandoning themselves to vivisections for the gratification of their curiosity: "Asclepiades capras suas quaerat sine corde balantes et muscas suas abigat sine capite volantes" (De anima, 15).
The next figure in the surgical history is Celsus, who Celsus. devotes the 7th and 8th books of his De re medica exclusively to surgery. There is not much in these beyond the precepts of the Bralimanical sastras and the maxims and rules of Greek surgery. Plastic operations for the restora-tion of the nose, lips, and ears are described at some length, as well as the treatment of hernia by taxis and operation; in the latter it was recommended to apply the actual cautery to the canal after the hernia had been returned,. The celebrated description of lithotomy is that of the operation as practised long before in India and at Alexandria. The treatment of sinuses in various regions is dwelt upon, and in the case of sinuses of the thoracic wall resection of the rib is mentioned. Trephining has the came prominent place assigned to it as in the Greek surgery. The resources of contemporary surgery may be estimated by the fact that subcutaneous urethrotomy was practised when the urethra was blocked by a calculus. Amputation of an extremity is described in detail for the first time in surgical literature. Mention is made of a variety of ophthalmic operations, which were done by specialists after the Alexandrian fashion.
Galen's practice of surgery was mostly in the early part of his career (born 130 A.D.), and there is little of special surgical interest in his writings, great as their importance is for anatomy, physiology, and the general doctrines of disease. Among the operations credited to him are resection of a portion of the sternum for caries and ligature of the temporal artery.
Under the Roman Empire
It may be assumed that surgical practice was in a flourishing condition all through the period of the empire from the accounts preserved by Oribasius of the great surgeons Antyllus, Leónides, Rufus, and Heliodorus. Antyllus (300) is claimed by Háser as one of the greatest of the world's surgeons; he had an operation for aneurism (tying the artery above and below the sac, and evacuating its contents), for cataract, for the cure of stammering; and he treated contractures by something like tenotomy. Rufus and Heliodorus are said to have practised torsion for the arrest of haemorrhage; but in later periods both that and the ligature appear to have given way to the actual cautery. Hiiser speaks of the operation for scrotal hernia attributed to Heliodorus as "a brilliant example of the surgical skill during the empire." The same surgeon treated stricture of the urethra by internal section. Both Leónides and Antyllus removed glandular swellings of the neck (strumse); the latter ligatured vessels before cutting them, and gives directions for avoiding the carotid artery and jugular vein. The well-known operation of Antyllus for aneurism has been mentioned before. Flap-amputations were practised by Leónides and Heliodorus. But perhaps the most striking illustration of the advanced surgery of the period is the freedom with which bones were resected, including the long bones, the lower jaw, and the upper jaw.
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