Surgery involved, as Celsus reported at the beginning of his seventh book, cures effected by the doctor’s hands, and what the surgeon accomplished was more visible than in the other two branches of medicine. This comment highlighted the fact that the much of ancient surgery was performed on the surface of the body or on areas available to the touch, with medical instruments extending and facilitating what the surgeon could accomplish. Accidents, of course, confronted the physician with interior parts that were normally hidden within. In the seventh book of On Medicine Celsus described surgical procedures in the soft parts of the body in the usual head-to-toe arrangement, while the eighth book concentrated on wounds and injuries to bones. Considerable progress had been made in surgical techniques in Hellenistic Alexandria and late republican Rome, and these are on display in Celsus’ account, especially in operations on the surface of the eyeball and on the eyelids, including couching a cataract (Med. 7.7). Still, in his catalogue Celsus jumped from tumors in the neck between skin and trachea to the lower body, skipping for the most part surgical interventions in the central trunk. He did describe procedures for the drainage of retained fluids through insertion of a bronze tube in cases of dropsy and for prolapse of the intestine (Med. 7.14-17). Reversing the effects of circumcision was probably a procedure originally developed in the Hellenistic world of the eastern Mediterranean, when those who had been circumcised wished to participate in Greek gymnastic contests performed in the nude. Celsus reported that the prepuce was to be raised from the penis with a scalpel and the foreskin fastened to its proper place by a threaded needle (Med. 7.25). The procedure was in his view neither very painful nor did it result in profuse bleeding, two of the worries that punctuated most surgical accounts along with the fear of infection (Salazar 2000: 43-4).
In the eighth book Celsus seems to have been somewhat more dependent upon surgical treatises in the Hippocratic Corpus than in his other discussions, for not only was the greatest period in Roman surgical experimentation just getting underway in the early first century, but techniques Hippocratic doctors employed for dealing with fractures clearly remained useful. Hippocratic knowledge of the larger bones of the human skeleton and their crucial joints was relatively sophisticated, when compared with their knowledge of organ anatomy and general physiology, although their nomenclature for individual bones was closer to ‘‘the knee-bone connected to the thigh-bone’’ than was the case in Hellenistic times and in Celsus, when specific bones were increasingly likely to have individual names. In a similar vein, the Hippocratic author of ‘‘Wounds in the Head’’ spoke of the act of trephination only through the verb meaning ‘‘saw’’ and its compounds ‘‘saw through,’’ and ‘‘saw out’’ (priein, diapriein, ekprien), cautioning that when trepanning, it was frequently necessary to stop, ‘‘for sawing heats because of the rotation, and by heating and drying the bone, scorches it and causes more of the bone surrounding the site to separate than would normally do so’’ (Cap. vuln. 21). While Celsus was likewise concerned that instruments employed to penetrate the skull in the treatment of head wounds be kept cool by dipping them in water, his description proceeded in terms of the two instruments employed, the ‘‘crown trephine’’ (modiolus, choinikis), which bored through the bone, and the ‘‘perforator’’ (terebra), which chiseled and separated bone segments for subsequent excising. Celsus’ language implied that both instruments were in use in contemporary Rome, as was the meningophylax, a metal plate to protect the dura mater during surgery on the head (Med. 8.3). A treatise in the Galenic corpus, but clearly not by Galen, claimed that surgeons no longer used the crown trephine, but by the early second century ce were content solely to perforate and chisel their way through the skull (Introd. 19).
The works of the important surgeons at Rome, such as Heliodorus and Antyllus, have largely been lost, except for excerpts in Oribasius’ massive collection and in later compendia by Aetius of Amida in the early sixth century, and Paul of Aegina, who lived to see the Arab conquest of Alexandria in the seventh century; fragments from Heliodorus have also been preserved on papyrus. Heliodorus was a contemporary of the social critic and poet Juvenal (early second century ce), as we know from
Heliodorus’ appearance in the misogynist sixth Satire, in which Juvenal called Helio-dorus a castrator of young slave boys, asserting that he did so for the sexual pleasure of their Roman mistresses (6.366-73). Castration, after all, removed the possibility of an unwanted pregnancy as the result of intercourse. Heliodorus’ seriousness as a surgeon can be observed in his discussion of treatments for intestinal incontinence with which the fourth book of his Surgery closed (Marganne 1998: 96-109). Although little more than a single column of the treatise survived on the fragmentary papyrus, it is clear that Heliodorus was concerned with etiology and he distinguished three causes for the fact that an anal sphincter was no longer functioning properly, but continuously discharged excrement: either the sphincter had been incised by mistake, or a pathologic condition had eroded its musculature, or paralysis impeded its functioning. Oribasius relied heavily on Heliodorus for his excerpts on surgical topics and a brieflook at Heliodorus’ directions for examining head wounds dispels any notion that he was merely a society doctor catering to the whims of an elite clientele. ‘‘Every wound is to be subjected to personal inspection and probing, discovering thereby whether it is simple, or if there is bruising of the entire mass; probing ascertains its depths, whether superficial or deep’’ (Heliodorus apud Orib. Co//. 46.7). Or again, when Heliodorus confronted distension of the skull’s sutures after a blow or a fall:
Use your hands immediately, pressing on either side in order to reunite the separated skull bones at the suture; then dry out the entire head and apply a plaster with noninflammatory, fastening properties; finally tie with a bandage capable of complementing the closure of the sutures, the bunny bandage; untie it during the first day, or the second, and introduce a drying vapor bath, subsequently reapplying the same plaster and bandaging. The skull usually reunites and solidifies..., although occasionally suppuration ensues. (Heliodorus apud Orib. Co//. 46.26)
Heliodorus was apparently the inventor of the bunny bandage, used for wounds in the head, sometimes ‘‘without ears’’ and sometimes ‘‘with ears,’’ with the ears apparently providing the means by which greater or lesser pressure was to be exerted on the skull through the bandaging. When treating the head fracture called rhogme, Heliodorus acknowledged how dreadful an experience surgery on the skull was for the patient: he used restraints to hold the patient down during the surgery, as well as an assistant to keep his head motionless. When removing bone from the skull by chiseling and chipping, he plugged the patient’s ears lest echo from the chisel terrify him (apud Orib. Co//. 46.11). The surgeon Antyllus practiced at Rome subsequent to Heliodorus and he observed with regard to penetrating the skull in cases of hydrocephalus:
If the fluid collects under the skull, whether the sutures distend or not, we forswear surgery, for the dura is impossible to manage when it lies in a sorry state surrounded by fluid; distension of the sutures cannot then be treated at all. If the skull is swollen even without distension, surgery is useless, for while we displace the fluid when we perforate through, how could anyone dissipate the deformity caused by the skull’s upward movements? If someone wants to chisel out a skull that has separated upward, he will totally denude the dura and abandon his patient to spasm. (Antyllus apud Orib. Co//. 46.28)
Expressing concern for the patient’s comfort, as well as his survival, was present already in Celsus’ discussion of surgery, and the thought punctuated later surgical practice at Rome, for Heliodorus too repeatedly spoke of abandoning the knife when there was no hope of the patient’s recovery, because this brought only additional suffering. In common with his Hippocratic predecessors Celsus was also concerned that the surgeon be youthful and strong, with steady and ambidextrous hands and sharp vision; at the same time, Celsus’ surgeon was also to be filled with pity, because his greatest desire was to make the patient well. Nonetheless, he must not be so moved by the patient’s cries that he rush along and cut less than necessary, ever reacting to cries of pain without emotion (Med. 7 proem. 4). The emphasis on concern for the patient found echo in a fragmentary papyrus from the Egyptian town of Oxyrhynchus, copied in the third century ce: ‘‘... The best surgeon needs at times to be one who consoles’’ (P. Oxy. 3.437.12-13). Galen was certainly one of the most accomplished of the surgeons at Rome, yet once he left his position in the gladiatorial school at Pergamum, he seldom operated on human beings, except in emergencies, and perfected his skills largely by cutting open and stitching up the animals he vivisected (Meth. med. 6.4).
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