The treatment of “hernia” in the writings of Celsus (first century AD)

Niki S. Papavramidou1, MS, Helen Christopoulou-Aletras, PhD1

1. Division, School of Medicine, Aristotle University of

Thessaloniki, Thessaloniki, Greece

Correspondent author:

Helen Christopoulou-Aletra

Ass. Professor,

History of Medicine, School of Medicine,

Aristotle University of Thessaloniki, PO Box 356

Thessaloniki, Greece

Tel: +302310999136

Fax: +302310999139

Email: [email protected]

Running title: Celsus on “hernia”

1 Abstract:

Descriptions concerning “hernia” can be found from the early historical years and its’ treatment was a subject mentioned by numerous physicians of the Antiquity like

Hippocrates and Praxagoras of Kos. Yet, Aulus Cornelius Celsus, a very famous doctor and encyclopedist of the 1st century AD, was among the first to propose surgical treatment and carry it out successfully, according to his accounts. Many physicians attempted to treat several types of “hernia” before him but more “scientific” information, with details and complete descriptions could only be found in Celsus. In his book De

Medicina, Celsus describes eight types of “hernia”: bronchocele, umbilical hernia, intestinal and omental hernia, hydrocele, varicocele, sarcocele (hernia carnosa) and inguinal hernia. Among them, some retain their ancient nomenclature up till now though others have acquired gradually different terminology or are not recognized by the physicians today as “hernias” (e.g. bronchocele).

For each type of “hernia” Celsus provides his readers with an extremely detailed well-reasoned description of the execution of surgical procedures accompanied usually with pre and post-operative instructions. His innovations particularly concern the ligature of the vessels. He recommended that an injured vessel should be tied in two places with lint threads and then cut between them. Other pre and post-operative practices, such as the sterilization and bandaging of the incised aria, were all elements that helped in the advances of medicine and some of them still exist in modern Medicine.

2

As early as the 16th century BC hernia was identified and described in the texts as a diseased condition, which needed some sort of life-saving, treatment. The Egyptian papyrus of Ebers (circa 1552 BC) contains some observations on hernias [1]. Also, the mummy of Pharaoh Merneptah (1224-1214 BC) showed a large wound in the groin, with the scrotum separated from the body, where possibly might have been performed that was not part of the procedure of mummification [2].

Almost a thousand years later, in the Hippocratic Corpus very little was mentioned about the subject. Actually the Hippocratic texts mention that hernia is more frequent in people drinking water that originates from distant areas [3] and that groin hernia is not a dangerous condition while in contrast hernias originating near the navel can be painful and may provoke nausea. All those hernias may occur following injury or distension of the abdomen [4].

Praxagoras of Cos (circa 4th century BC) mentioned strangulated intestinal hernia and suggested a surgical operation for its treatment as it is reported by Caelius

Aurelianus. Thus, no direct reference can be found in the fragments left by Praxagoras’ work and Caelius does not mention any details about it [5, 6]. The Alexandrian physicians, described both hernia and their attempts to treat it but we don’t’ have as well direct references left. Thus, Celsus seems to be the father of treating hernia by surgical intervention.

(Figure 1) Cornelius Celsus lived in during the early 1st century AD (c. 25

B.C-A.D. 50). He wrote a general Encyclopedia (De artibus, Arts) dealing with several subjects, among which some of medical content (De Medicina, Medicine), an eight-

3 volume compendium. His medical works provide information for a period up to 300 years before his time, and in particular the surgical knowledge of the Alexandrian School.

De Medicina, was his only medical work that was preserved, and was composed of eight treatises [7]. Though De Medicina was the first book of medical “rational” content to be published in Latin, containing detailed descriptions of surgical operations, it was ignored for many centuries. After the 10th century, it was preserved and studied by the monks in the monasteries of the West. In 1443, Pope Nicolas V discovered in Milan a copy of the book and he appreciated its content; thus De Medicina regained its’ fame and value. Until the 19th century there were more than 60 editions of the book published in Latin as well as numerous translations in European languages [8].

In De Medicina Celsus describes the clinical manifestations of hernia and proposes several kinds of treatments for the following types of “hernia”: bronchocele, umbilical hernia, intestinal and omental hernia, hydrocele, varicocele, sarcocele (hernia carnosa) and inguinal hernia.

Bronchocele

Under the name “bronchocele”, Celsus describes the “enlargement of the thyroid gland, consisting of dark red soft material, which may have undergone cystic degeneration into a honey-like liquid, and also a dermoid cyst of the neck containing hair and calcified material” [9]. The contents of the swelling are enclosed in a coat [10].

Celsus suggests two kinds of treatment, either cauterization or surgery. If the physician chooses to use caustics, these will act by eating away the skin, along with the underlying tunic. In case there is fluid accumulated in, it will just flow out; however, if the content is

4 solid material, it can be extracted with the use of the fingers and the wound can be healed with lint dressings [11]. In the case where surgery is performed then the treatment will be shorter when compared to cauterization. “A linear incision is made over the middle of the tumor down to the tunic; then the morbid pouch is separated by the finger from the sound tissue, and the whole is removed along with its covering” [12]. Later, the wound should be washed with vinegar and salt or alternatively with vinegar and soda, and the margins should be brought together by a suture. The wound is then lightly bandaged so as not to trouble the throat. In case that it is impossible to take the tunic out, caustics should be dusted into its interior and the wound should then be covered with lint [13].

Umbilical hernia

In the eighth treatise of De Medicina Celsus provides information on hernia observations made by earlier physicians, such as Meges of Sidon (1st cent. BC), Heron of

Alexandria (3rd cent. BC), Gorgias of Alexandria (1st cent. AD) and Sostratus of

Alexandria (1st cent. BC). According to Celsus, all these physicians described umbilical hernia. Among them, only Heron described all of its four causes i.e. rupture of the intestine in the umbilicus, rupture of the omentum in the umbilicus, leak of fluid from the umbilicus or simultaneous rupture of the omentum and of the intestine in the umbilicus

[14]. In order for a physician to decide which of the aforementioned causes was responsible for the particular hernia in each case, he had to watch for the following indications: a) Intestinal prolapsus, where the swelling is “neither hard nor soft”; but it can be reduced by the application of anything cold and be increased under the application of heat or when the patient “holds his breath”; at intervals, the swelling rumbles and if the

5 patient lies down on his back then the swelling decreases, as the intestine slips back in its place [15]. b) If the umbilical hernia is caused by the omentum, the swelling is softer,

“broad at its base”, thinner towards its apex; “if anyone grasps it, it slips away” [16]. c)

When both intestines and omentum have prolapsed, the signs are mixed. In this case, the flesh is harder and even when the patient lies on his back the swelling is still there and it does not yield to pressure. If the swelling is “malignant”, the signs are those of ; humorous material fluctuates with palpation; “yields under pressure, but returns at once, also the swelling retains the same shape when the patient lies down on his back” [17].

As for the treatment of umbilical hernia, Celsus mentions that some physicians let the fluid out either by perforating the tissues with a needle or by cutting into the apex of the “tumor” and then dressing the wound with lint. He suggests that the patient should lie on his back, in order that the swelling, in both cases, may slip back into the abdomen.

The patient then has to hold his breath so that the “tumor” shows itself at its largest. Then its base should be marked with ink. The surgeon then has to compress the tumor with his fingers and drawn the umbilicus forward and tightly constrict it with flaxen thread along the marks of the ink. Afterwards, the part beyond the ligature should be burnt with caustics and the wound should be dressed like all other burns [18].

Celsus believes that this treatment is the best for all kinds of umbilical hernia but some precautions should be taken against any danger deriving from the ligature, because this treatment is suitable only to children between seven and fourteen years of age [19].

Furthermore, the patient should generally be in a good health condition. Additionally, hernias that are extremely large cannot be cured with this technique and the operation should be performed either during the spring or in early summer [20]. Finally, Celsus

6 advises fasting the day before the operation and enema for the evacuation of the bowels

[21].

Intestinal and omental hernia

Celsus believes that intestinal and omental hernia may occur underneath the scrotal covering after an inflammation, which in turn is followed by a rupture caused by the weight of the swelling. Otherwise, trauma may result in a direct rupture of the covering, which ought to separate the intestines from the parts below. Then, either the omentum or the intestine rolls down by its own weight. If the omentum comes down, the

“tumor” in the scrotum never disappears, irrespective of the position the patient is lying.

Furthermore, if the patient holds his breath, the tumor does not increase to any extend

[22]. In the case that the intestine has also come down, and is not inflamed, sometimes, either diminishes or increases in size and it is generally painless and soft [23]. In the case of constipation, feces are accumulated in the intestine and the “tumor” swells largely thus causing pain to the scrotum, the groin and the abdomen [24].

Hydrocele

Celsus comments also on how other physicians cannot make the distinction between hydrocele and intestinal or omental hernia. Sometimes, he explains, fluid distends the scrotum while the membranes remain intact. There are two kinds of this affliction: first, when fluid is accumulated between the coverings or second, when fluid is accumulated in the membranes surrounding the veins and the arteries become thickened and weighted down. Even when fluid lies between the membranes, it is not confined in

7 one place but it may lie between the scrotum and the tunica vaginalis or between the tunica vaginalis and the tunica albuginea. In both cases the hernia described is called hydrocele [25]. In order for the physician to detect the location of the fluid Celsus proposes the following: if the fluid lies between the scrotum and the tunica vaginalis, the physician has to press the area with two of his fingers so that the fluid gradually comes up, receding however, as the fingers are withdrawn; but if the fluid is accumulated between the tunica vaginalis and the tunica albuginea, the scrotum is stretched and more raised up, so that the root of the penis is concealed by the swelling [26].

In order to treat hydrocele, Celsus suggests again the use of surgery. “In boys an incision is to be made in the groin…; in men … a scrotal incision is made. So then if the incision is in the groin, when the tunics have been drawn forwards the humour must then be evacuated there; if in the scrotum, and if the trouble is immediately beneath, there is nothing to do but to let out the fluid and cut away any membranes which are keeping it in; then the incision is washed with water to which salt or niter has been added” [27].

Varicocele, sarcocele and inguinal hernia

The clinical manifestations of varicocele are numerous. While the tunics are intact, the veins become swollen and when twisted at the upper part of the area, they distend the scrotum [28]. Sometimes they grow even beneath the inner covering around the actual testicle and its cord. The veins in the scrotal wall are visible, though those situated in the middle or inner coverings are not equally visible; yet even these can be seen because of the swelling of the veins, which is more resistant to applied pressure

[29]. But when the disease has spread also over the testicle and its cord, the testicle

8 becomes smaller than the other one and its function becomes problematic. Sometimes, rarely though, flesh also grows between the tunics; this is what Celsus calls sarcocele

[30]. The testicle swells because of an inflammation accompanied by . Unless the inflammation subsides quickly, pain spreads in the inguinal region and the area swells.

The cord of the testicle becomes “fuller” and harder. Besides this, sometimes the groin is ruptured, a situation, which Celsus calls “bubonocele” (inguinal hernia) [31]. When inguinal hernia is diagnosed, several methods are used for its treatment; some of which are common practice while others are applied only in particular cases. As for the common treatment, there are two cases: when the inguinal region has to be incised or when the scrotum has to be incised. If the groin has to be incised, the scrotum has to be stretched and an incision is made below the abdominal cavity, deep enough to cut through the scrotum and reach the tunica vaginalis. When the incision has been made, an opening is created leading in the deeper structures. The surgeon then has to put his index finger of his left hand in this opening so as to free the hernial sac. The assistant surgeon has to grasp the scrotum and stretch it upwards as for the surgeon to cut away all the membranes lying above the tunica vaginalis. If the tunica vaginalis is also affected, it has to be excised as high as the groin [32]. But when an incision is required lower down, the surgeon has to press his left hand under the scrotum, grasp it firmly and make an incision; the more severe the disease, the larger the incision. “The scalpel at first should be held in a very light hand, with its edge vertical to the skin, until the wall of the scrotum has been divided; then the edge is sloped sideways so as to cut across the membranes between the scrotal wall and the middle tunic (tunica vaginalis). … The surgeon either with his finger, or with the handle of the scalpel, separates the middle tunic from its connection with the

9 scrotal wall, and brings it forwards; then with a knife, called from its shape ‘the raven’, he lays it open so that his index and middle finger can enter. With these fingers so introduced the remainder of the tunic should be brought forwards, and the knife inserted in between the two fingers, and any diseased matter taken away or let out”. After every affected part gets cleaned, the testicle should be again replaced inside the scrotum and the scrotal margins must be united with stitches [33].

As for the treatment of varicocele, if a varix is located in the scrotal skin, it must be cauterized at the place were the veins form a twisted mass [34]. When the veins overlying the tunica vaginalis swell, the groin should be incised, the tunic should be pressed out into the wound; then, the veins should be separated from it. At the “part” where they are still attached, the veins should be tied with linen thread both above and below that part. Then the surgeon should cut away just beyond the ligatures and replace the testicle in the scrotum [35]. But when the varix is situated upon the tunica albuginea, it is necessary to cut through the tunica vaginalis; then, if the disease is not so severe, the veins should be excised. When the disease has affected the entire testicle, the surgeon should use his index finger and draw the veins forward and up until the testicle of that side is in the same level as the opposite one. After that, “pins” are passed through the edges so that at the same time they take up the veins as well [36]. The time to remove the pins is when the inflammation calms down and the wound has been cleaned. However, if a varix has developed between the tunica albuginea and the testicle itself and its cord, the entire testicle has to be excised. In this case, “also the groin is to be cut into, the middle tunic (tunica vaginalis) pressed out and cut away, and the inner tunic (tunica albuginea) likewise. Then the cord by which the testicle is suspended is to be cut through. After this

10 the veins and arteries towards the groin are to be ligatured with linen thread, and cut away below the ligature [37].

Surgery is also advised for the treatment of sarcocele where an incision should be made through the scrotum. This practice helps only if the cord hasn’t become indurated.

Otherwise, the condition is characterized as incurable, since high fever and vomits are present, the patient cannot eat or digest his food and death usually follows [38].

Additional surgical practices and techniques

It is of great importance to note that for the majority of the proposed operations

Celsus orders pre- and post-operative treatment and care for the patients. As far the pre- operative care of inguinal hernia, the patient has to drink a lot of water for three days.

The last day he has to abstain from food and on the day of the surgery he must “lie on his back” [39]. On the day before the umbilical surgery Celsus orders once more fasting and the application of enema. During the operation, the patient has to hold his breath so that the swelling shows itself at its largest, then its base can be marked with ink [40]. With respect to post-operative care, Celsus seems to pay special attention to sterilization and bandaging of the wound. After a bronchocele operation, the wound is washed with vinegar to which either salt or soda is added [41]. Vinegar is also used after surgery of inguinal hernia where a sponge or wool had be soaked with vinegar and applied on the wound twice a day. In such cases and when pain was absent, the wound should not be bandaged until the fifth day after surgery. If pain is present, the wound should be dressed on the third day and if pins are inserted in the body they have to be taken out. If gauze is used for the bandage, a new one should be soaked with rose-oil and wine and placed on

11 the wound [42]. After hydrocele hernia surgery, it is used only water with salt or niter for the cleaning of the incision [43]. Finally, after cauterization of varicoceles, a solution of flour and water is applied on the wound and on the third day, lentil meal with honey. The final cleansing of the wound should be done with honey and rose-oil and bandage with dry lint should be applied [44].

Celsus also mentions in his texts the cooperation with an assistant surgeon, a tradition already known by the Hippocratic texts. He as well recognizes the usefulness of an extra hand [45], especially if was not applied. Finally, he is the first to talk about ligature in order to prevent hemorrhage [46].

Discussion

By Celsus’ time surgery had developed, as Celsus himself writes in his book VII in the Prooemium [47], with the contribution of Philoxenus in Egypt, Gorgias, Sostratus,

Heron and “the two Apollonii and Ammonius, the Alexandrians, and many other celebrated men, each found out something”. Celsus also mentions two more doctors who lived in Rome, Tryphon and Meges. However, Celsus’ innovations in the surgical treatment of hernia are numerous since no other physician before him described these types of surgery. It is important to also mention, though, that either he did not make use of any anesthetic or analgesic during the surgical operations for the treatment of hernias, or that some sort of anesthesia was so common at the time that he did not think it was necessary to mention. Anesthetic drugs and plants were already known to the physicians,

(hyoscyamus, wild lettuce, etc.), which the Hippocratic physicians believed to cool and anodyne [48]. Besides, only a few years after Celsus, Dioscorides (c. 100 AD), Gaius

12 Plinius Secundus (23-79 AD) and Apuleius (c. 123-170 AD) specifically mention the use of some substances for the relief of pain during surgery [49, 50, 51]. Actually, the value of diet and of medicaments, as Calsus points out, is in some cases doubted [52].

Celsus sets the base for the surgical treatment of hernia. Numerous writers and doctors after Celsus continued his work. , for instance, the most prolific writer of the antiquity, described inguinal hernia [53], intestinal hernia and umbilical hernia [54].

At the same time, in the 2nd century AD, Heliodorus proposes surgery with the use of ligature and excision of the freed sac in the case of inguinal hernia. Oribasius, followed him in the 4th century AD, by proposing ligature and excision of the freed sac and cauterization [55]. During the Byzantine times, numerous medical writers describe hernial surgery, among which Aetius of Amida and Paul of Aegina were the most precise and innovative [56].

From the point of view of medical terminology, several terms, concerning either anatomical structures or nomenclature of diseases have retained their meaning up till now. However, there are cases without equivalence like the use of the word “tumor” which in the texts of Celsus stands for the words “swelling” or “protrusion” of a structure. “Bronchocele” actually probably does not correspond to a hernia with its present meaning since it is neither the case of the protrusion of a structure nor of the malfunction of the thyroid gland; the description seems to refer to several kinds of cysts.

Additionally, it is made obvious in the texts that Celsus had good knowledge of

Αnatomy, by describing step by step the procedure of his operations. Furthermore, some observations concerning practical aspects of his surgery are in agreement with medical practices of our time; for instance, the supine position of the patient, which results in

13 decreased “swelling” as the structures recede in the cavities of the body. Another example is the expulsion of fluid, the excision of unnecessary membranes that are attached to the structures and, the excision of parts that may undergo necrosis etc.

It should be noted that some measures taken by Celsus before, during or after the operation of hernia still exist in modern medical practice. For example, fasting or the application of enema, which is still advised before the surgery of intestinal hernia.

Celsus’ proposed technique of ligature in order to prevent hemorrhage is also of great importance. He recommended that an injured vessel should be tied in two places with lint threads and then cut between them, but it was his younger contemporary, the surgeon Heliodorus who gave the first account of “terminal” ligature and torsion of damaged vessels [57].

As far as Celsus’ proposal to sterilize the wounds with the use of vinegar and wine, this was probably due to the observation of their preserving power of fruits and vegetables. However, long before, the Hippocratic physicians used wine and other plant extracts as antiseptics [58]. More over, one must pay attention to some other observations concerning the use of several substances used during or after the surgery. For instance ink is used by Celsus as a marker on the incised area because of its antiseptic properties since it contains tannin, which was broadly used so far by other physicians for the proper healing of wounds and burns59. A saline of water and either salt or netre, are probably used for the salting out of the tissues and consequently the prevention of their loosening.

The oily extracts from the roses are used as soothing agents, but at the same time the tannin they contain, may prevent inflammation. Wine alone that is used for the washing

14 of the injured tissues contains tannin but with the addition of soda it is achieved the beneficial action of carbon dioxide.

Finally, Celsus in his treatises describes a full surgical scheme, he explains with details the procedures, and provides all additional, necessary information (pre and post operative). He even adjusts the surgical procedures according to the age of the patient.

One can really appreciate Celsus, as a pioneer of his time, who not only described for the first time some surgical techniques, but he was also able and willing to write his experiences with details so that other physicians may profit by them.

15 Figure Legends

Figure 1: Cornelius Celsus as depicted in 1765*

*A. S. Lyons, R. J. Petrucelli, An illustrated history of medicine, New York,

Abradale Press, Harry N. Abrams, Inc., Publishers, 1978.

16 Acknowledgments:

We would like to thank Dr H. Tsoukali-Papadopoulou, Associate Professor,

School of Medicine, Aristotle University of Thessaloniki, for the information concerning the chemical properties of substances used by Celsus during surgical operations and

Emeritus Professor H. Aletras, for medical information and remarks on Anatomy and

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