Ancient surgery
Rome
Alexander the Great had encouraged his physicians to expand the limits of their science, and from the time of Hippocrates, Greek doctors were recognised as the best in the world. The Romans admired them, too, and when they conquered the Greeks in about 100 BC, the physicians were allowed to continue to practise, now as Roman subjects.
The Executioner
However, the first Greek doctor/surgeon that the Romans encountered was almost their last. According to the naturalist Pliny the Elder, Arcagathus arrived from Greece in 219 BC. He was made a citizen, and a medical shop was set up for him at state expense. Because he was an expert wound surgeon (uulnerarius), he immediately became popular, but this did not last.
His enthusiastic use of the knife and cautery – that is, cutting and sealing tissue with high heat – soon earned him the title ‘Executioner’ (Carnifex). More than 100 years elapsed before another Greek physician, Asclepiades of Bithynia, took up residence in Rome.
Sophisticated
In 46 BC, Julius Caesar granted citizenship to all foreigners teaching a liberal art in Rome. This included the Greek doctors, most of whom were slaves or freed men. When, in 23 BC, Antonius Musa, once Mark Antony’s slave, cured the emperor Augustus of a serious illness, he was richly rewarded and won immunity from taxation for all doctors. Later, during the reign of Vespasian (AD 69-79), physicians were also freed from military service.
‘It’s not at all surprising that the Romans used Greek physicians,’ says Andrew Wallace-Hadrill, director of the British School at Rome and professor of classics at Reading University. ‘Greek medicine was incredibly sophisticated.’
The demand for Greek physicians continued to grow, and many Roman cities devised tax incentives to get them to stay. But this was strictly private medicine, with no set pay scale. Only reputation determined prosperity.
‘In general, Romans are very superstitious,’ continues Wallace-Hadrill, ‘and to them the borderline between medicine and magic was very unclear. So powerful Romans paid a lot of money to the great Greek physicians, they gave them a lot of respect, but at the same time, they wanted to distance themselves from them.’
Surgical instruments
In the ruins of Pompeii, turned into a time capsule by a volcanic eruption in AD 79, is a house that belonged to a Greek surgeon. It was identified, in 1887, by its large stores of surgical equipment – more than 100 instruments. Since there was relatively little innovation in these tools from the time of Hippocrates in the 5th century BC, instruments like these remained typical of surgical practice for nearly a millennium. In fact, some of them, such as the vaginal speculum, did not change significantly until the 20th century.
The instruments found at Pompeii represent the normal range that a surgeon of the time would have needed. They were mostly bronze, brass or copper, but blades and needles were almost invariably made of iron or steel. Most of the instruments could be heated up and used for cautery. By heating the instruments, the surgeons were, without realising it, sterilising them.
Circumcision, scars and brands
What sorts of things would these instruments have been asked to do?
The Romans distrusted most of the foreigners they had conquered, and foreigners who wanted to fit in would try to hide telltale differences. That wasn’t always easy, especially in the public baths that every respectable Roman visited every day.
The Romans, who celebrated the nude body in art and sport, viewed any abnormal appearance of the genitals with distaste, even amusement. The Jews were well known for their insistence on male circumcision, but they were not the only circumcised men known to the Romans. Egyptian priests also practised it, as did Arabs, Ethiopians and Phoenicians.
Certain scars were despised. The manly thing was to have battle scars on the front. To have scars on your back was a mark of shame – it showed that you had turned your back in battle and run away or, worse, that you had been whipped – only slaves were whipped. Brands were also hated, as they, too, revealed that you had once been (or still were) a slave, someone who could never enjoy respect.
So it was very important to these residents of Rome – foreigners who wanted to fit in and former slaves on the make – to find ways of abolishing these signs. And they turned to the Greek surgeons for solutions.
Removing the marks
There is some evidence from the poet Martial (AD 40-c. 104) – himself a foreigner, a Spaniard – that some slaves at that time had their brands removed by surgeons. Unfortunately he gives no details of exactly how it was done.
The area of branded skin might have been cut out and the edges sewn back together, so that the ex-slave would have been left with a long linear scar. Alternatively, the top layer of skin might simply have been shaved off to remove the brand. This would have left the poor ex-slave with a wide scar that he could then have said was caused by having accidentally burned his arm. Both these procedures (which could equally have been used for removing tell-tale scars) would have been excruciating, so the reasons have them done would have had to be extremely important.
Reversal and reduction
Celsus, writing during the reign of the emperor Tiberius (AD 14-37), must have witnessed a lot of experimental operations. This is his rather detached report of the reversal of a circumcision.
The prepuce [foreskin] is to be raised from the underlying penis mound the circumference of the glans by means of a scalpel. This is not so very painful, for once the margin has been freed, it can be stripped up by hand as far back as the pubes ... The prepuce, thus freed, is again stretched forwards beyond the glans ... For the following days the patient is to fast until nearly overcome by hunger, less satiety excite that part ...
Celsus also describes a procedure to reduce the breasts of an obese man because, he says, ‘they looked unsightly and shameful’. In Roman society, being fat was, apparently, as bad as being an ex-slave or a Jew and well worth the pain to have the stigma erased.
Cheerful countenance and entertaining talk
The physician himself, of course, had to be sympathetic and considerate. It was part of a code of conduct dating from Hippocrates. As Celsus wrote:
A practitioner of experience does not seize the patient’s forearm with his hand as soon as he come in but first sits down and, with a cheerful countenance, asks how the patient finds himself. And if the patient has any fear he calms him down with entertaining talk, and only after that moves his hand to touch the patient.
All eight volumes of Celsus’s work De Medicina (On Medicine) have survived intact. In them, he shows that he knew the difference between fresh wounds and ulcers that were slow to heal, and about clamping blood vessels to prevent haemorrhage. He describes complex surgical operations, including goitre and cataract removal, as well as plastic surgical procedures such as ‘counter-circumcision’ and gynaemastia (breast reduction).
Pain relief
These types of surgery were very sophisticated but quite invasive. How did surgeons help their patients cope with the pain?
They wouldn’t have had anaesthetics in the modern sense, but various plant extracts with analgesic (painkilling) properties would have helped. The healers probably grew some of these plants in their own gardens, as the surgeon did in Pompeii. For pain relief, there were four important plants: opium, poppy, white mandrake and henbane. Pliny the Elder (who died near Pompeii as it disappeared under the ash of Vesuvius) said of white mandrake that you only need a sniff of it before an operation to send you to sleep. But it was probably more like ‘pre-medication’ – a drug that would make patients drowsy but not completely asleep.
If they weren’t completely asleep, they could move around, and so the surgeons must have been quite skilled and fast. They needed a small number of instruments that covered most eventualities. And to help them, these tools were double-ended so that they could be turned round and used very quickly before the patients died of surgical shock.
Deceit and cunning
Like surgery, drugs were a speciality of the Greeks. The flourishing of their medicine had coincided with the expansion of their civilisation throughout Asia Minor and beyond, and they had access to narcotic plants from all over the known world. And now, under the Romans, they were careful to keep their formulae secret.
Then as now, there was a lot of money to be made in the drugs trade. Pliny the Elder complained:
The deceit of men and cunning profiteering led to the invention of quack laboratories. A small sore is charged with the cost of medicine from the Red Sea, although the genuine remedies form the daily dinner of even the very poorest.
The ancients had a huge range of pharmacopoeia to help with pain relief and use as anaesthetics in the operations. Much of our pain relief nowadays, such as aspirin and opiate-based medicines such as codeine, is based on herbs and the knowledge of them that was gained in the past.
