Surgery in all countries is as old as human needs. A certain skill in the stanching of blood, the extraction of arrows, the binding up of wounds, the supporting of broken limbs by splints, and the like, together with an instinctive reliance on the healing power of the tissues, has been common to men everywhere. In both branches of the Aryan stock surgical practice (as well as medical) reached a high degree of perfection at a very early period. It is a matter of controversy whether the Greeks got their medicine (or any of it) from the Hindus (through the medium of the Egyptian priesthood), or whether the Hindus owed that high degree of medical and surgical knowledge and skill which is reflected in Charaka and Susruta (commentators of uncertain date on the Yajur-Veda; see Sanskrit, vol. xxi. p. 294) to their contact with Western civilization after the campaigns of Alexander. The evidence in favour of the former view is ably stated by Wise in the Introduction to his History of Medicine among the Asiatics (London, 1868). The correspondence between the Susruta and the Hippocratic Collection is closest in the sections relating to the ethics of medical practice; the description, also, of lithotomy in the former agrees almost exactly with the account of the Alexandrian practice as given by Celsus. But there are certainly some dexterous operations described in Suśruta (such as the rhinoplastic) which were of native invention; the elaborate and lofty ethical code appears to be of pure Brahmanical origin; and the very copious materia medica (which included arsenic, mercury, zinc, and many other substances of permanent value) does not contain a single article of foreign source. There is evidence also (in Arrian, Strabo, and other writers) that the Last enjoyed a proverbial reputation for medical and surgical wisdom at the time of Alexander’s invasion. We may give the first place, then, to the Eastern branch of the Aryan race in a sketch of the rise of surgery, leaving as insoluble the question of the date of the Sanskrit compendiums or compilations which pass under the names of two representative persons, Charaka and Suśruta (the dates assigned to these ranging as widely as 500 years on each side of the Christian era).

The Suśruta speaks throughout of a single class of practitioners who undertook both surgical and medical cases. Nor were there any fixed degrees or orders of skill within the profession; even lithotomy, which at Alexandria was assigned to specialists, was to be undertaken by any one, the leave of the rajah having been first obtained. The only distinction recognized between medicine and surgery was in the inferior order of barbers, nail-trimmers, ear-borers, tooth-drawers, and phlebotomists, who were outside the Brahmanical caste.

Suśruta describes more tha,n one hundred surgical instruments, made of steel. They should have good handles and firm joints, be well polished, and sharp enough to divide a hair; they should be perfectly clean, and kept in flannel in a wooden box. They included various shapes of scalpels, bistouries, lancets, scarifiers, saws, bone-nippers, scissors, trocars, and needles. There were also blunt hooks, loops, probes (including a caustic-holder), directors, sounds, scoops, and forceps (for polypi, &c.), as well as catheters, syringes, a rectal speculum, and bougies. There were fourteen varieties of bandage. The favourite form of splint was made of thin slips of bamboo bound together with string and cut to the length required. Wise says that he has frequently used “this admirable splint,” particularly for fractures of the thigh, humerus, radius, and ulna, and it has been subsequently adopted in the English army under the name of the “patent rattan-cane splint.”

Fractures were diagnosed, among other signs, by crepitus. Dislocations were elaborately classified, and the differential diagnosis given; the treatment was by traction and countertraction, circumduction, and other dexterous manipulation. Wounds were divided into incised, punctured, lacerated, contused, &c. Cuts of the head and face were sewed. Skill in extracting foreign bodies was carried to a great height, the magnet being used for iron particles under certain specified circumstances. Inflammations were treated by the usual antiphlogistic regimen and appliances; venesection was practised at several other points besides the bend of the elbow; leeches were more often resorted to than the lancet; cupping also was in general use. Poulticing, fomenting, and the like were done as at present. Amputation was done now and then, notwithstanding the want of a good control over the haemorrhage; boiling oil was applied to the stump, with pressure by means of a cup-formed bandage, pitch being sometimes added. Tumours and enlarged lymphatic glands were cut out, and an arsenical salve applied to the raw surfaces to prevent recurrence. Abdominal dropsy and hydrocele were treated by tapping with a trocar; and varieties of hernia were understood, omental hernia being removed by operation on the scrotum. Aneurisms were known, but not treated; the use of the ligature on the continuity of an artery, as well as on the cut end of it in a flap, is the one thing that a modern surgeon will miss some what noticeably in the ancient surgery of the Hindus; and the reason of their backwardness in that matter was doubtless their want of familiarity with the course of the arteries and with the arterial circulation. Besides the operation already mentioned, the abdomen was opened by a short incision below the umbilicus slightly to the left of the middle line, for the purpose of removing intestinal concretions or other obstruction (laparotomy). Only a small segment of the bowel was exposed at one time; the concretion when found was removed, the intestine stitched together again, anointed with ghee and honey, and returned into the cavity. Lithotomy was practised, without the staff. There was a plastic operation for the restoration of the nose, the skin being taken from the cheek adjoining, and the vascularity kept up by a bridge of tissue. The ophthalmic surgery included extraction of cataract. Obstetric operations were various, including caesarean section and crushing the foetus.

The medication and constitutional treatment in surgical cases were in keeping with the general care and elaborateness of their practice, and with the copiousness of their materia medica. Ointments and other external applications had usually a basis of ghee (or clarified butter), and contained, among other things, such metals as arsenic, zinc, copper, mercury, and sulphate of iron. For every emergency and every known form of disease there were elaborate and minute directions in the śâstras, which were taught by the physician-priests to the young aspirants. Book learning was considered of no use without experience and manual skill in operations; the different surgical operations were shown to the student upon wax spread on a board, on gourds, cucumbers, and other soft fruits; tapping and puncturing were practised on a leathern bag filled with water or soft mud; scarifications and bleeding on the fresh hides of animals from which the hair had been removed; puncturing and lancing upon the hollow stalks of water-lilies or the vessels of dead animals; bandaging was practised on flexible models of the human body; sutures on leather and cloth; the plastic operations on dead animals; and the application of caustics and cauteries on living animals. A knowledge of anatomy was held to be necessary, but it does not appear that it was systematically acquired by dissection. Superstitions and theurgic ideas were diligently kept up so as to impress the vulgar. The whole body of teaching, itself the slow growth of much close observation and profound thinking during the vigorous period of Aryan progress, was given out in later times as a revelation from heaven, and as resting upon an absolute authority. Pathological principles were not wanting, but they were derived from a purely arbitrary or conventional physiology (wind, bile, and phlegm); and the whole elaborate fabric of rules and directions, great though its utility must have been for many generations, was without the quickening power of reason and freedom, and became inevitably stiff and decrepit.

The Chinese appear to have been far behind the Hindus in their knowledge of medicine and surgery, notwithstanding that China profited at the same time as Tibet by the missionary propagation of Buddhism. Surgery in particular had hardly developed among them beyond the merest rudiments, owing to their religious respect for dead bodies and their unwillingness to draw blood or otherwise interfere with the living structure. Their anatomy and physiology have been from the earliest times unusually fanciful, and their surgical practice has consisted almost entirely of external applications. Tumours and boils were treated by scarifications or incisions. The distinctive Chinese surgical invention is acupuncture, or the insertion of fine needles, of hardened silver or gold, for an inch or more (with a twisting motion) into the seats of pain or inflammation. Wise says that “the needle is allowed to remain in that part several minutes, or in some cases of neuralgia for days, with great advantage , rheumatism and chronic gout were among the localized pains so treated. There are 367 points specified where needles may be inserted without injuring great vessels and vital organs.

Cupping-vessels made of cow-horn have been found in ancient Egyptian tombs. On monuments and the walls of temples are figures of patients bandaged, or undergoing operation at the hands of surgeons. In museum collections of Egyptian antiquities there are lancets, forceps, knives, probes, scissors, &c. Ebers interprets a passage in the papyrus discovered by him as relating to the operation of cataract. Surgical instruments for the ear are figured, and artificial teeth have been found in mummies. Mummies have also been found with well-set fractures. Herodotus describes Egypt, notwithstanding its fine climate, as being full of medical practitioners, who were all “specialists.” The ophthalmic surgeons were celebrated, and practised at the court of Cyrus.

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 restoration 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 Hippocratic Collection (age of Pericles) bears every evidence of finish and elaboration. The two treatises on fractures and on dislocations 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 (φυματα ) 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 excellence 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 undertaken so freely as in Hindu surgical practice; nor was lithotomy 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 anatomy—there are allegations also of vivisection—at the hands of Herophilus and Erasistratus. 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 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 quae rat sine corde balantes et muscas suas abigat sine capite volantes” (De anima, 15). The next figure in the surgical history is Celsus, who 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 Brahmanical śâstras and the maxims and rules of Greek surgery. Plastic operations for the restoration 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 same 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 131 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. 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, Leonides, Rufus, and Heliodorus. Antyllus (300) is claimed by Häser 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. Häser 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 Leonides and Antyllus removed glandular swellings of the neck (strumae) ; 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 Leonides 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.

Whatever progress or decadence surgery may have experienced during the next three centuries is summed up in the authoritative treatise of Paulus of Aegina (650). Of his seven books the sixth is entirely devoted to operative surgery, and the fourth is largely occupied with surgical diseases. The importance of Paulus for surgical history during several centuries on each side of his own period will appear from the following remarks of Francis Adams in his translation and commentary (vol. ii. p. 247).

“This book (bk. vi.) contains the most complete system of operative surgery which has come down to us from ancient times. . . . Haly Abbas in the 9th book of his Prαctica copies almost everything from Paulus. Albucasis [Abulcasis] gives more original matter on surgery than any other Arabian author, and yet, as will be seen from our commentary, he is indebted for whole chapters to Paulus. In the Continens of Phases, that precious repository of ancient opinions on medical subjects, if there be any surgical information not to be found in our author it is mostly derived from Antyllus and Archigenes. As to the other authorities, although we will occasionally have to explain their opinions upon particular subjects, no one has treated of surgery in a systematical manner; for even Avicenna, who treats so fully of everything else connected with medicine, is defective in his accounts of surgical operations; and the descriptions which he does give of them are almost all borrowed from our author. The accounts of fractures and dislocations given by Hippocrates and his commentator Galen may be pronounced almost complete; but the information which they supply upon most other surgical subjects is scanty.”

It is obviously impossible in a brief space to convey any notion of the comprehensiveness of the surgery of Paulus; his sixth book, with the peculiarly valuable commentary of Adams, brings the whole surgery of the ancient world to a focus; and it should be referred to at first hand. Paulus himself is credited with the principle of local depletion as against general, with the lateral operation for stone instead of the mesial and with understanding the merits of a free external incision and a limited internal, with the diagnosis of aneurism by anastomosis, with an operation for aneurism like that of Antyllus, with amputation of the cancerous breast by crucial incision, and with the treatment of fractured...

Surgery in all countries is as old as human needs. A certain skill in the stanching of blood, the extraction of arrows, the binding up of wounds, the supporting of broken limbs by splints, and the like, together with an instinctive reliance on the healing power of the tissues, has been common to men everywhere. In both branches of the Aryan stock surgical practice (as well as medical) reached a high degree of perfection at a very early period. It is a matter of controversy whether the Greeks got their medicine (or any of it) from the Hindus (through the medium of the Egyptian priesthood), or whether the Hindus owed that high degree of medical and surgical knowledge and skill which is reflected in Charaka and Susruta (commentators of uncertain date on the Yajur-Veda; see Sanskrit, vol. xxi. p. 294) to their contact with Western civilization after the campaigns of Alexander. The evidence in favour of the former view is ably stated by Wise in the Introduction to his History of Medicine among the Asiatics (London, 1868). The correspondence between the Susruta and the Hippocratic Collection is closest in the sections relating to the ethics of medical practice; the description, also, of lithotomy in the former agrees almost exactly with the account of the Alexandrian practice as given by Celsus. But there are certainly some dexterous operations described in Suśruta (such as the rhinoplastic) which were of native invention; the elaborate and lofty ethical code appears to be of pure Brahmanical origin; and the very copious materia medica (which included arsenic, mercury, zinc, and many other substances of permanent value) does not contain a single article of foreign source. There is evidence also (in Arrian, Strabo, and other writers) that the Last enjoyed a proverbial reputation for medical and surgical wisdom at the time of Alexander’s invasion. We may give the first place, then, to the Eastern branch of the Aryan race in a sketch of the rise of surgery, leaving as insoluble the question of the date of the Sanskrit compendiums or compilations which pass under the names of two representative persons, Charaka and Suśruta (the dates assigned to these ranging as widely as 500 years on each side of the Christian era).

The Suśruta speaks throughout of a single class of practitioners who undertook both surgical and medical cases. Nor were there any fixed degrees or orders of skill within the profession; even lithotomy, which at Alexandria was assigned to specialists, was to be undertaken by any one, the leave of the rajah having been first obtained. The only distinction recognized between medicine and surgery was in the inferior order of barbers, nail-trimmers, ear-borers, tooth-drawers, and phlebotomists, who were outside the Brahmanical caste.

Suśruta describes more tha,n one hundred surgical instruments, made of steel. They should have good handles and firm joints, be well polished, and sharp enough to divide a hair; they should be perfectly clean, and kept in flannel in a wooden box. They included various shapes of scalpels, bistouries, lancets, scarifiers, saws, bone-nippers, scissors, trocars, and needles. There were also blunt hooks, loops, probes (including a caustic-holder), directors, sounds, scoops, and forceps (for polypi, &c.), as well as catheters, syringes, a rectal speculum, and bougies. There were fourteen varieties of bandage. The favourite form of splint was made of thin slips of bamboo bound together with string and cut to the length required. Wise says that he has frequently used “this admirable splint,” particularly for fractures of the thigh, humerus, radius, and ulna, and it has been subsequently adopted in the English army under the name of the “patent rattan-cane splint.”

Fractures were diagnosed, among other signs, by crepitus. Dislocations were elaborately classified, and the differential diagnosis given; the treatment was by traction and countertraction, circumduction, and other dexterous manipulation. Wounds were divided into incised, punctured, lacerated, contused, &c. Cuts of the head and face were sewed. Skill in extracting foreign bodies was carried to a great height, the magnet being used for iron particles under certain specified circumstances. Inflammations were treated by the usual antiphlogistic regimen and appliances; venesection was practised at several other points besides the bend of the elbow; leeches were more often resorted to than the lancet; cupping also was in general use. Poulticing, fomenting, and the like were done as at present. Amputation was done now and then, notwithstanding the want of a good control over the haemorrhage; boiling oil was applied to the stump, with pressure by means of a cup-formed bandage, pitch being sometimes added. Tumours and enlarged lymphatic glands were cut out, and an arsenical salve applied to the raw surfaces to prevent recurrence. Abdominal dropsy and hydrocele were treated by tapping with a trocar; and varieties of hernia were understood, omental hernia being removed by operation on the scrotum. Aneurisms were known, but not treated; the use of the ligature on the continuity of an artery, as well as on the cut end of it in a flap, is the one thing that a modern surgeon will miss some what noticeably in the ancient surgery of the Hindus; and the reason of their backwardness in that matter was doubtless their want of familiarity with the course of the arteries and with the arterial circulation. Besides the operation already mentioned, the abdomen was opened by a short incision below the umbilicus slightly to the left of the middle line, for the purpose of removing intestinal concretions or other obstruction (laparotomy). Only a small segment of the bowel was exposed at one time; the concretion when found was removed, the intestine stitched together again, anointed with ghee and honey, and returned into the cavity. Lithotomy was practised, without the staff. There was a plastic operation for the restoration of the nose, the skin being taken from the cheek adjoining, and the vascularity kept up by a bridge of tissue. The ophthalmic surgery included extraction of cataract. Obstetric operations were various, including caesarean section and crushing the foetus.

The medication and constitutional treatment in surgical cases were in keeping with the general care and elaborateness of their practice, and with the copiousness of their materia medica. Ointments and other external applications had usually a basis of ghee (or clarified butter), and contained, among other things, such metals as arsenic, zinc, copper, mercury, and sulphate of iron. For every emergency and every known form of disease there were elaborate and minute directions in the śâstras, which were taught by the physician-priests to the young aspirants. Book learning was considered of no use without experience and manual skill in operations; the different surgical operations were shown to the student upon wax spread on a board, on gourds, cucumbers, and other soft fruits; tapping and puncturing were practised on a leathern bag filled with water or soft mud; scarifications and bleeding on the fresh hides of animals from which the hair had been removed; puncturing and lancing upon the hollow stalks of water-lilies or the vessels of dead animals; bandaging was practised on flexible models of the human body; sutures on leather and cloth; the plastic operations on dead animals; and the application of caustics and cauteries on living animals. A knowledge of anatomy was held to be necessary, but it does not appear that it was systematically acquired by dissection. Superstitions and theurgic ideas were diligently kept up so as to impress the vulgar. The whole body of teaching, itself the slow growth of much close observation and profound thinking during the vigorous period of Aryan progress, was given out in later times as a revelation from heaven, and as resting upon an absolute authority. Pathological principles were not wanting, but they were derived from a purely arbitrary or conventional physiology (wind, bile, and phlegm); and the whole elaborate fabric of rules and directions, great though its utility must have been for many generations, was without the quickening power of reason and freedom, and became inevitably stiff and decrepit.

The Chinese appear to have been far behind the Hindus in their knowledge of medicine and surgery, notwithstanding that China profited at the same time as Tibet by the missionary propagation of Buddhism. Surgery in particular had hardly developed among them beyond the merest rudiments, owing to their religious respect for dead bodies and their unwillingness to draw blood or otherwise interfere with the living structure. Their anatomy and physiology have been from the earliest times unusually fanciful, and their surgical practice has consisted almost entirely of external applications. Tumours and boils were treated by scarifications or incisions. The distinctive Chinese surgical invention is acupuncture, or the insertion of fine needles, of hardened silver or gold, for an inch or more (with a twisting motion) into the seats of pain or inflammation. Wise says that “the needle is allowed to remain in that part several minutes, or in some cases of neuralgia for days, with great advantage , rheumatism and chronic gout were among the localized pains so treated. There are 367 points specified where needles may be inserted without injuring great vessels and vital organs.

Cupping-vessels made of cow-horn have been found in ancient Egyptian tombs. On monuments and the walls of temples are figures of patients bandaged, or undergoing operation at the hands of surgeons. In museum collections of Egyptian antiquities there are lancets, forceps, knives, probes, scissors, &c. Ebers interprets a passage in the papyrus discovered by him as relating to the operation of cataract. Surgical instruments for the ear are figured, and artificial teeth have been found in mummies. Mummies have also been found with well-set fractures. Herodotus describes Egypt, notwithstanding its fine climate, as being full of medical practitioners, who were all “specialists.” The ophthalmic surgeons were celebrated, and practised at the court of Cyrus.

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 restoration 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 Hippocratic Collection (age of Pericles) bears every evidence of finish and elaboration. The two treatises on fractures and on dislocations 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 (φυματα ) 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 excellence 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 undertaken so freely as in Hindu surgical practice; nor was lithotomy 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 anatomy—there are allegations also of vivisection—at the hands of Herophilus and Erasistratus. 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 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 quae rat sine corde balantes et muscas suas abigat sine capite volantes” (De anima, 15). The next figure in the surgical history is Celsus, who 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 Brahmanical śâstras and the maxims and rules of Greek surgery. Plastic operations for the restoration 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 same 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 131 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. 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, Leonides, Rufus, and Heliodorus. Antyllus (300) is claimed by Häser 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. Häser 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 Leonides and Antyllus removed glandular swellings of the neck (strumae) ; 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 Leonides 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.

Whatever progress or decadence surgery may have experienced during the next three centuries is summed up in the authoritative treatise of Paulus of Aegina (650). Of his seven books the sixth is entirely devoted to operative surgery, and the fourth is largely occupied with surgical diseases. The importance of Paulus for surgical history during several centuries on each side of his own period will appear from the following remarks of Francis Adams in his translation and commentary (vol. ii. p. 247).

“This book (bk. vi.) contains the most complete system of operative surgery which has come down to us from ancient times. . . . Haly Abbas in the 9th book of his Prαctica copies almost everything from Paulus. Albucasis [Abulcasis] gives more original matter on surgery than any other Arabian author, and yet, as will be seen from our commentary, he is indebted for whole chapters to Paulus. In the Continens of Phases, that precious repository of ancient opinions on medical subjects, if there be any surgical information not to be found in our author it is mostly derived from Antyllus and Archigenes. As to the other authorities, although we will occasionally have to explain their opinions upon particular subjects, no one has treated of surgery in a systematical manner; for even Avicenna, who treats so fully of everything else connected with medicine, is defective in his accounts of surgical operations; and the descriptions which he does give of them are almost all borrowed from our author. The accounts of fractures and dislocations given by Hippocrates and his commentator Galen may be pronounced almost complete; but the information which they supply upon most other surgical subjects is scanty.”

It is obviously impossible in a brief space to convey any notion of the comprehensiveness of the surgery of Paulus; his sixth book, with the peculiarly valuable commentary of Adams, brings the whole surgery of the ancient world to a focus; and it should be referred to at first hand. Paulus himself is credited with the principle of local depletion as against general, with the lateral operation for stone instead of the mesial and with understanding the merits of a free external incision and a limited internal, with the diagnosis of aneurism by anastomosis, with an operation for aneurism like that of Antyllus, with amputation of the cancerous breast by crucial incision, and with the treatment of fractured...