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Chirurgia

χειρουργία). Surgery; a word meaning literally “handiwork.” The practice of surgery was at first considered by the ancients to be merely a part of a physician's duty; but, as in later times the two branches of the profession were to a great extent separated, it will perhaps be more convenient to treat of it under a separate head. Without touching upon the disputed question, which is the more ancient branch of the profession, or even trying to give such a definition of the word chirurgia as would be likely to satisfy both the physicians and the surgeons of the present day, it will be sufficient to determine the sense in which the word was used by the ancients; and then to give an account of this division of the science and art of medicine as practised among the Greeks and Romans, referring to the article Medicina for further particulars.

The word chirurgia is derived from χείρ, “the hand,” and ἔργον, “a work,” and is explained by Celsus (De Med. lib. vii. Praefat.) to mean that part of medicine quae manu curat, “which treats ailments by means of the hand”; in Diogenes Laertius (iii. 85) it is said to cure διὰ τοῦ τέμνειν καὶ καίειν, “by cutting and burning.” Omitting the fabulous and mythological personages, Apollo, Aesculapius, Chiron, etc., the only certain traditions respecting the state of surgery before the establishment of the republics of Greece, and even until the time of the Peloponnesian War, are to be found in the Iliad and Odyssey. There it appears that surgery was almost entirely confined to the treatment of wounds, and the imaginary power of enchantment was joined with the use of topical applications ( Il. iii. 218). The Greeks received surgery, together with the other branches of medicine, from the Egyptians; and from some observations made by the archæologists who accompanied the French expedition to Egypt in 1798, and by subsequent investigators, it appears that there are documents fully proving that in very remote times this extraordinary people had reached a degree of proficiency of which few of the moderns have any conception. Upon the ceilings and walls of the temples at Karnac, Luxor, etc., bas-reliefs are seen, representing limbs that have been cut off with instruments very similar to those which are employed for amputations at the present day. The same instruments are again observed in the hieroglyphics, and vestiges of other surgical operations may be traced, which afford convincing proofs of the skill of the ancient Egyptians in this branch of medical science.

The earliest remaining surgical writings are those in the Hippocratic Collection, where there are ten treatises on this subject, of which, however, only one is considered undoubtedly genuine. Hippocrates (B.C. 460-357?) far surpassed all his predecessors in the boldness and success of his operations; and though the scanty knowledge of anatomy possessed in those times prevented his attaining any very great perfection, still one should rather admire his genius, which enabled him to do so much, than blame him because, with his imperfect information, he could not accomplish more. (See Hippocrates.) The scientific skill in reducing fractures and luxations displayed in his works De Fracturis, De Articulis, excites the admiration of Haller (Biblioth. Chirurg.); and he was most probably the inventor of the ambe, an old surgical machine for dislocations of the shoulder, which, though now fallen into disuse, enjoyed for a long time a great reputation. In his work De Capitis Vulneribus he gives minute directions about the time and mode of using the trephine, and warns the operator against the probability of his being deceived by the sutures of the cranium, as he confesses happened to himself (De Morb. Vulgar. lib. v. tom. iii. p. 561, ed. Kühn). Amputation, in the modern sense of the word, is not described in the Hippocratic Collection; though mention is made of the removal of a limb at the joint, after the flesh has been completely destroyed by gangrene. The author of the “Oath” commonly attributed to Hippocrates binds his pupils not to perform the operation of lithotomy, but to leave it to persons specially accustomed to it (ἐργάτῃσι ἀνδράσι πρήξιος τῆσδε); from which it would appear as if certain persons confined themselves to particular operations.

The names of several persons are preserved who practised surgery as well as medicine in the times immediately succeeding those of Hippocrates; but, with the exception of some fragments, inserted in the writings of Galen, Oribasius, Aëtius, etc., all their writings have perished. Archagathus deserves to be mentioned, as he is said to have been the first foreign surgeon who settled at Rome, B.C. 219 (Plin. H. N. xxix. 12). He was at first very well received, the ius Quiritium was conferred upon him, a shop was bought for him at the public expense, and he received the honourable title of Vulnerarius; which, however, on account of his frequent use of the knife and cautery, was soon changed by the Romans, who were unused to such a mode of practice, into that of Carnifex. Asclepiades, who lived at the beginning of the first century B.C., is said to have been the first person who proposed the operation of tracheotomy ( Aurel. De Morb. Acut. i. 14.111; iii. 4.39). Ammonius of Alexandria, surnamed Λιθοτόμος, who is supposed to have lived rather later, is celebrated in the annals of surgery for having been the first to propose and to perform the operation of lithotrity, or breaking a calculus in the bladder when found to be too large for safe extraction. Celsus has minutely described his mode of operating (De Med. vii. 26.3, p. 436), which in some respects resembles that of Civiale and Heurteloup in the early part of the present century, and proves that, however much credit they may deserve for perfecting the operation and bringing it out of oblivion into public notice, the praise of having originally thought of it belongs to the ancients. “A hook or crotchet,” says Celsus, “is fixed upon the stone in such a way as easily to hold it firm, even when shaken, so that it may not revolve backward; then an iron instrument is used, of moderate thickness, thin at the front end, but blunt, which, when applied to the stone and struck at the other end, cleaves it: great care must be taken that the instrument does not come into contact with the bladder itself, and that nothing fall upon it by the breaking of the stone.” The next surgical writer after Hippocrates, whose works are still extant, is Celsus, who lived at the beginning of the first century A.D., and who has devoted the four last books of his work De Medicina, and especially the seventh and eighth, entirely to surgical matter. It plainly appears from reading Celsus that since the time of Hippocrates surgery had made very great progress, and had, indeed, reached a high degree of perfection. We find in him the earliest mention of the use of the ligature for the arrest of hemorrhage from wounded bloodvessels (v. 26.21, p. 262); and the Celsian mode of amputation was continued down to comparatively modern times (vii. 33, p. 451). He is the first author who gives directions for the operation of lithotomy (De Med. vii. 26.2, p. 432), and the method described by him (called the apparatus minor, or Celsus's method) continued to be practised till the commencement of the sixteenth century. It was performed at Paris, Bordeaux, and other places in France, upon patients of all ages, even as late as the latter part of the seventeenth century; and a modern author (Allan On Lithotomy, p. 12) recommends it always to be preferred for boys under fourteen. He describes (vii. 25.3, p. 428) the operation of infibulatio, which was so commonly performed by the ancients upon singers, etc., and is often alluded to in classical authors. (See Juv. vi. 73, 379; Seneca, in Lactant. Divin. Instit. i. 16; Epigr. vii. 82, 1; Epigr. ix. 28, 12; Epigr. xiv. 215, 1; Tertull. De Corona Mil. 11.) He also describes (vii. 25.1, p. 427) the operation of circumcision alluded to by St. Paul (1 Cor.vii. 18). Paulus Aegineta (De Re Med. vi. 53) transcribes from Antyllus a second method of performing the same operation.

The following description by Celsus of the necessary qualifications of a surgeon deserves to be quoted: “A surgeon,” says he (lib. vii. Praefat.), “ought to be young, or, at any rate, not very old; his hand should be firm and steady, and never shake; he should be able to use his left hand as readily as his right; his eyesight should be clear, and his mind not easily startled; he should be so far subject to pity as to make him desirous of the recovery of his patient, but not so far as to suffer himself to be moved by his cries; he should neither hurry the operation more than the case requires, nor cut less than is necessary, but do everything just as if the other's screams made no impression upon him.”

Omitting Scribonius Largus, Moschion, and Soranus, the next author of importance is Caelius Aurelianus, who is supposed to have lived about the beginning of the second century A.D., and in whose works there is much surgical matter, but nothing that can be called original. He rejected as absurd the operation of tracheotomy (De Morb. Chron. iii. 4.39). He mentions a case of ascites that was cured by tapping (ib. iii. 8.128), and also a person who recovered after being shot through the lungs by an arrow (ib. ii. 12.144).

Galen, the most voluminous and at the same time the most valuable medical writer of antiquity, is less celebrated as a surgeon than as an anatomist and physician. He appears to have practised surgery at Pergamus, but upon his removal to Rome (A.D. 165) he entirely confined himself to medicine (De Meth. Med. vi. in fine, tom. x. p. 455). His writings prove, however, that he did not entirely abandon surgery. His Commentaries on the treatise of Hippocrates De Officina Medici, and his treatise De Fasciis, show that he was well versed even in the minor details of the art. He appears also to have been a skilful operator, though no great surgical inventions are attributed to him.

Antyllus, who lived some time between Galen and Oribasius, is the earliest writer whose directions for performing tracheotomy are still extant, though the operation (as stated above) was proposed by Asclepiades about three hundred years before. Only a few fragments of the writings of Antyllus remain, and among them the following passage is preserved by Paulus Aegineta (De Re Med. vi. 33): “When we proceed to perform this operation, we must cut through some part of the windpipe, below the larynx, about the third or fourth ring; for to divide the whole would be dangerous. This place is commodious, because it is not covered with any flesh, and because it has no vessels situated near the divided part. Therefore, bending the head of the patient backward, so that the windpipe may come more forward to the view, we make a transverse section between two of the rings, so that in this case not the cartilage, but the membrane which unites the cartilages together, is divided. If the operator be a little timid, he may first stretch the skin with a hook and divide it; then, proceeding to the windpipe, and separating the vessels, if any are in the way, he may make the incision.”

This operation appears to have been very seldom, if ever, performed by the ancients upon a human being. Avenzoar tried it upon a goat, and found it might be done without much danger or difficulty; but he says he should not like to be the first person to try it upon a man.

Oribasius, physician to the emperor Julian (A.D. 361), professes to be merely a compiler; and though there is in his great work, entitled Συναγωγαὶ Ἰατρικαί (Collecta Medicinalia), much surgical matter, there is nothing original. The same may be said of Aëtius and Alexander Trallianus, both of whom lived towards the end of the sixth century A.D. Paulus Aegineta has given up the fifth and sixth books of his work De Re Medica entirely to surgery, and has inserted much useful matter, derived in a great measure from his own observation and experience. Albucasis translated into Arabic great part of these two books as the basis of his work on surgery. Paulus was particularly celebrated for his skill in midwifery and female diseases, and was called on that account, by the Arabians, Al-Kawábelí, “the Accoucheur” (Abulfaraj, Hist. Dynast. p. 181, ed. Pococke). He probably lived towards the end of the seventh century A.D., and is the last of the ancient Greek and Latin medical writers whose surgical works remain. The names of several others are recorded, but they are not of sufficient eminence to require any notice here. For further information on the subject both of medicine and surgery, see Medicina; and for the legal qualifications, social rank, etc., both of physicians and surgeons, among the ancient Greeks and Romans, see Medicus.

The surgical instruments from which the accompanying engravings (Nos. 1 to 19) are made were found by a physician of St. Petersburg (Dr. Savenko) in 1819, at Pompeii, in the Via Consularis (Strada Consulare), in a house which is supposed to have belonged to a surgeon. They are now preserved in the museum at Portici. The engravings, with an account of them by Dr. Savenko, were originally published in the Revue Médicale for 1821, vol. iii. p. 427, etc. They were afterwards inserted in Froriep's Notizen aus dem Gebiete der Natur- und Heilkunde for 1822, vol. ii. n. 26, p. 57, etc. The accompanying figures are copied from the German work, in which some of them appear to be badly drawn. Their authenticity was at first doubted by Kühn (De Instrumentis Chirurg. Veteribus Cognitis, et nuper Effossis, Leipzig, 1823), who thought they were the same that had been described by Bayardi in his Catal. Antiq. Monument. Herculani Effos. (Nap. 1754, fol., n. 236-294). When, however, his dissertation was afterwards republished (Opusc. Academ. Med. et Philol., Leipzig, 1827, ii. 309), he acknowledged himself to be completely satisfied on this point, and has given in the tract referred to a learned and ingenious description of the instruments and their supposed uses, from which the following account is chiefly abridged. It will, however, be seen at once that the form of most of them is so simple, and their uses so obvious, that very little explanation is necessary. Altogether they give a very high idea of both the science and the practice of surgery among the Romans.

1, 2. Two probes (specillum, μήλη) made of iron; the larger six inches long, the smaller four and a half. 3. A cautery (καυτήριον) made of iron, rather more than four inches long. 4, 5. Two lancets (scalpellum, σμίλη) made of copper; the former two inches and a half long, the other three inches. It seems doubtful whether they were used for blood-letting or for opening abscesses, etc. 6. A knife, apparently made of copper, the blade of which is two inches and a half long, and in the broadest part one inch in breadth; the back is straight and thick, and the edge much curved; the handle is so short that Savenko thinks it must have been broken. It is uncertain for what particular purpose it was used: Kühn conjectures that (if it be a surgical instrument at all) it may have been made with such a curved edge and such a straight thick back in order that it might be struck with a hammer, and so amputate fingers, toes, etc. 7. Another knife, apparently

Surgical Instruments.

made of copper, the blade of which is of a triangular shape, two inches long, and in the broadest part eight lines in breadth; the back is straight and one line broad, and this breadth continues all the way to the point, which, therefore, is not sharp, but guarded by a sort of button. Kühn thinks it may have been used for enlarging wounds, etc., for which it would be particularly fitted by its blunt point and broad back. 8. A needle, about three inches long, made of iron. 9. An elevator (or instrument for raising depressed portions of the skull), made of iron, five inches long, and very much resembling those made use of at the present day. 10-14. Different kinds of forceps (volsellae). No. 10 has the two sides separated from each other, and is five inches long. No. 11 is also five inches long. No. 12 is three inches and a half long. The sides are narrow at the point of union, and become broader by degrees towards the other end, where, when closed, they would form a kind of arch. It should be noticed that it is furnished with a movable ring, exactly like the tenaculum forceps employed at the present day. No. 13 was used for pulling out hairs by the roots (τριχολαβίς). No. 14 is six inches long, and is bent in the middle. It was probably used for extracting foreign bodies that had stuck in the œsophagus, or gullet, or in the bottom of a wound. 15. A male catheter (aenea fistula), nine inches in length.

Surgical Instruments.

The shape is remarkable from its having the double curve like the letter S, which is the form that was re-invented in the last century by the celebrated French surgeon J. L. Petit. 16. Probably a female catheter, four inches in length. Celsus describes both male and female catheters (De Med. vii. 26.1, p. 429). 17. Supposed by Froriep to be an instrument for extracting teeth (ὀδοντάγρα, Pollux, iv. 181); but Kühn, with much more probability, conjectures it to be an instrument used in amputating part of an enlarged uvula, and quotes Celsus (De Med. vii. 12.3, p. 404), who says that “no method of operating is more convenient than to

Surgical Instruments.

take hold of the uvula with the forceps, and then to cut off below it as much as is necessary.” 18, 19. Probably two spatulae. Nos. 20-23 are perhaps the most interesting of all, as showing the means employed by the Romans in the exploration of some of the internal cavities of the body, for the discovery and treatment of disease. They are taken from Bened. Vulpi, Illustraz. di tutti gli Strumenti Chirurgici, etc. (Naples, 1847), Mem. 4, p. 39, etc., where there is a detailed and learned description of them. Nos. 20, 21 are two views of the same kind of instrument—viz., a dilator vaginae (διόπτρα, Aegin. Paul. vi. 73). No. 22 is a dilator ani (ἑδροδιαστολεύς, id. vi. 78); and No. 23, nippers for compressing veins or extracting splintered bones.

See Pliny, Historia Naturalis, bks. xx.-xxxii.; Rénouard, Hist. of Medicine (Eng. trans. Philadelphia, 1867

Surgical Instruments.

); Ritter von Rittershain, Die Heilkünstler des alten Roms (Berlin, 1875); Coxe, The Writings of Hippocrates and Galen Epitomized (Phil. 1846); Watson, The Medical Profession in Ancient Times (N. Y. 1856); Dunglison, Hist. of Medicine (Phil. 1872); Daremberg, Hist. des Sciences Médicales (Paris, 1870-73); Garratt, Myths in Medicine (N. Y. 1884); and Müller, Handbuch, v. pp. 108 foll.

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