Surgical History

Surgery for Inguinal Hernia in Byzantine Times (A.D. 3241453): First Scientific
Descriptions
John G. Lascaratos, M.D., Ph.D.,
1
Constantine Tsiamis, M.D.,
1
Alkiviadis Kostakis, M.D.
2
1
Department of History of Medicine, National Athens University, Greece, M. Asias 75 Str., Goudi, Athens, Greece
2
2nd Department of Propedeutic Surgery, Medical School, National Athens University, Greece, M. Asias 75 Str., Goudi, Athens, Greece
Published Online: August 21, 2003
Abstract. The aim of this article is to present the techniques applied by
Byzantine physicians for inguinal hernia repair and to note their influence
on the development of surgery after that time. A study and analysis of the
original texts of the Byzantine medical writers, written in Greek, and con-
taining the now mostly lost knowledge of the ancient Hellenistic and Ro-
man periods, was undertaken. Two Byzantine physicians, Aetius of Amida
(6th century A.D.) and Paul of Aegina (7th century A.D.), described two
techniques for confrontation of inguinal hernia, namely the surgical re-
moval of the prolapsed peritoneum and the cauterization of the groin.
These methods were probably derived from the texts of earlier Greek sur-
geons to which they added their own keen observations. The study of Byz-
antine medical and literary texts proves that the surgical techniques for
inguinal hernia were practiced in Byzantine times and influenced later
Arabian and European surgery, thus constituting significant roots of sur-
gery.
The history of the Byzantine Empire commenced in A.D. 324 with
the ascent of Constantine the Great to the Roman throne. The new
emperor transferred the capital of the empire from Rome to By-
zantium, a small town on the Bosporus with great strategic signifi-
cance because it was situated at the crossroads of two continents,
Europe and Asia. This new state, a natural continuation of the Ro-
man Empire, constituted the greatest political, cultural, and scien-
tific center of the world until 1453, when it fell to the Turks.
In Byzantium, a group of talented physicians was established;
among them the most eminent were Oribasius of Pergamum (4th
century A.D.), Aetius of Amida (6th century A.D.), Alexander of
Tralles (6th century A.D.), and Paul of Aegina (7th century A.D.).
These men studied medicine in Alexandria, followed Hippocratic,
Hellenistic, Roman, and Galenic traditions, and enriched medical
science from their wealth of experience.
Thus, the main characteristic of Byzantine medicine is that it was
a continuation of ancient medicine and is the vital link with western
European medicine, which it influenced directly or indirectly via
works of Arab physicians, later spreading to the entire world. Ex-
amination of the medical knowledge of the Byzantines is of signifi-
cant interest because the majority of them, in their writings, pre-
serve the knowledge of the ancient Greek physicians, many of
whose works are now lost, adding their own personal experience
[1, 2].
The practice of surgery in particular was considerably developed
owing to the advances in anatomic knowledge gained during the
Hellenistic period, when dissection of the human body was permit-
ted. Then skilled surgeons dared to carry out complex procedures
such as lithotripsy in the bladder [3], tracheotomy [4], separation of
Siamese twins [5], and to apply special techniques for plastic and
reconstructive surgery of the face [6], aneurysms [7], and varices
[8].
Byzantine physicians knewinguinal hernia, which was called bu-
bonokele (in Greek , fromthe words bubon =groin
and kele = hernia), and several forms of scrotal hernia. The former
was considered to be a prior stage of the latter; the Byzantine phy-
sicians stress that the two conditions differ only in location, for
when the intestine remains in the groin it is called bubonocele but
when it falls down into the scrotumit is named enterocele. They also
recommend conservative treatment in the first stages of the dis-
ease, consisting of poultices of a variety of drugs, cold baths, and
bandaging [9, 10].
Materials and Methods
The first description of the surgical techniques for confronting in-
guinal hernias in that era was that of Aetius of Amida [11] (Fig. 1),
a talented physician who wrote a medical compendium in sixteen
books, called Tetrabiblos. It covers many surgical topics, quoted
fromthe works of two eminent ancient surgeons, Leonides (1st cen-
tury A.D.) and Antyllus (2nd century A.D.).
Aetius maintains that inguinal hernia is very often found in
women to the right of the genital area. It is a protrusion that causes
intestinal rumbling, mainly when it is squeezed, or when the women
open their legs, or when they rest horizontally.
At the beginning, treatment consisted of application of a suitable
bandage and poultices of a variety of drugs; in case there is no ef-
fective result, Aetius recommends surgery. The woman is placed
horizontally with her feet high up. The surgeon presses the protru-
Correspondence to: John G. Lascaratos, M.D., Ph.D.,164b Hippocratous
Str., 11471 Athens, Greece e-mail: giannop@power.ece.ntua.gr
WORLD
Journal of
SURGERY
2003 by the Societe
Internationale de Chirurgie
World J. Surg. 27, 11651169, 2003
DOI: 10.1007/s00268-003-7123-4
sion so that the intestines will be pushed back to their regular po-
sition. After that, an oblique incision is made in the groin area and
the subcutaneous membranes are pushed away, thus preparing the
hernial sac. Then, lifting the peritoneum, the surgeon pushes any
intestines contained in that area; after that, he ties and tightens a
thread around the base of the loose peritoneum and cuts and re-
moves the peritoneumexactly above the tightened thread. The skin
incision is then sutured with two or three stitches. There follows
application of unwashed sheepswool containing its natural fat, im-
pregnated with vinegar and olive oil, and then bandaging. The sur-
geon follows the three treatments aiming at producing pus, heal-
ing and maintaining cleanliness of the area with appropriate
poultices and sprinkling of suitable medicines until the inflamma-
tion ceases and the healing is complete.
A century later, Paul of Aegina [12] (Fig. 2), the last of the emi-
nent early Byzantine physicians, gives detailed descriptions both of
the surgical method and cauterization. Born on the island of Ae-
gina, Paul studied and practiced medicine at Alexandria, where he
remained after the Arab invasion. He was occupied with surgery in
particular. Paul was not simply a compiler but also a competent
physician and skilled surgeon. His work Epitome consisted of seven
books, the sixth of which, the best section, was exclusively devoted
to surgery [13].
Paul of Aegina [12] attributes inguinal hernia to a loosening of
the peritoneum into which intestines drop, thus creating hernia in
the groin. Paul describes two techniques, an operation that earlier
surgeons had performed and the method of cauterization carried
out by his contemporary surgeons.
The former method was performed using an oblique incision of a
length of three fingers to the highest area of the protrusion of the
groin. Then the surgeon separated the subcutaneous membranes
and fat. After that, in the middle of the peritoneum, which had
already been exposed, an olivary probe was applied on the top (on
the hernial sac) and was pressed, pushing the intestines inwards.
Then, the parts of the peritoneum protruding on either side of the
probe were approached with needle and thread and stitched. After
that the probe was removed. Paul writes that with this method the
peritoneum was not removed, neither were the testicles endan-
gered, nor was there any other risk. Then the usual treatment for a
fresh wound ( , in Greek) followed.
The second method, preferred by most of the contemporary sur-
geons, was carried out as follows:
We place the patient upright and instruct him to cough violently and
stretch, holding his breath. In this way the protrusion in the groin area
appears and then with ink or collyrium we mark a triangle around the
protrusion with its base towards the groin; then we mark the center of the
triangle. After that, we cauterize all the area of this triangle. This is per-
formed as follows. The patient is placed horizontally and after we have
heated up the cauteries, we cauterize the central mark of the triangle
firstly with nail-shaped cauteries, then the sides of the triangle with
gamma - shaped cauteries, and then all the surface of it with cauteries
shaped like bricks or lentils. During this operation an assistant, with the
fluff of some material, wipes away the liquids resulting from the burns.
As regards the depth of the burn, in those of normal physical
build we cauterize until the layer of fat is reached. In slightly-built
persons, we must take care to cauterize slowly and with caution, as
there is a risk of burning the peritoneum accidentally. In over-
weight persons, more cauterization is necessary. The happy me-
diumcan be judged with the experience and technical instinct of the
surgeon.
After the procedure, we apply to the eschar salt and leeks
pounded into an ointment, then a special X-shaped bandage for
inguinal hernias. In the days that follow we use medicines, such as
lentils and honey and the like; these assist in the easy falling of the
eschar and its healing [12].
Discussion
Hernia was a disease that had attracted attention from ancient
times, due to its protrusion and symptoms. In the Talmud, some
forms of scrotal hernia are referred to without any mention of pos-
sible surgical reconstruction [14]. The termhernia (kele in Greek) is
referred to in the book of the Corpus Hippocraticum Airs Waters
Places. The Hippocratic physician attributes hernia, as other dis-
eases like lithiasis, to the bad quality of water [15]. No description,
or hint of any possible surgical treatment, is contained in the books
of the Hippocratic School.
Fig. 1. Aetius of Amida showing his text. Women patients are coming to
consult him (Miniature reproduced from the fourteenth century Biblioteca
Universitaria of Bologna [BUB ms.] Code 3632, 97. (Reprinted with per-
mission of Biblioteca Universitaria of Bologna. Reproduction or duplica-
tion by any means is not allowed.)
Fig. 2. Paul of Aegina (left) and Menemachus, ancient physician (right)
(Miniature reproduced from the fourteenth century Biblioteca Universi-
taria of Bologna [BUBms.] Code 3632, 90. (Reprinted with permission of
Biblioteca Universitaria of Bologna. Reproduction or duplication by any
means is not allowed.)
1166 World J. Surg. Vol. 27, No. 10, October 2003
The flourishing of anatomical studies in the Hellenistic period,
when necrotomies were permitted, seems to have helped the un-
derstanding of the etiology and improved the surgical confronta-
tion of hernias.
Soranus from Ephesus [16] (1st century A.D.) was the first an-
cient physician to give a rational etiology of scrotal hernia, main-
taining that in the newborn, when crying too long due to hunger, a
slipping-down of the intestines into the scrotum is provoked. He
further refers to an operation on a woman suffering from an in-
testinal hernia, to which he was a witness.
The encyclopedist Cornelius Celsus [17] (1st century A.D.)
writes that on the first appearance of groin hernias in young chil-
dren, poultices are used and then bandaging, before considering a
surgical procedure. For the bandaging, a strip of linen is used; one
end of this is formed into a ball that is placed on the prolapse so that
the intestines can be pushed back. The rest of the linen strip is then
tied firmly all around. In this way, the intestines are often forced
back inside and the tunics adhere immediately. The writer, in cases
of very large or strangulated hernias in older patients, recommends
avoidance of surgery. When the groin hernias have advanced they
form scrotal hernias, and Celsus describes a detailed surgical tech-
nique for sparing the testicles. The Latin writer obviously had seen
these operations in Alexandria.
Galen [1820] (2nd century A.D.) classifies hernias as bubono-
cele (when located in the groin), enterocele (scrotal hernia), and
omphalocele (umbilical hernia). He gives a clear definition of the
hernia, writing that it is a tumor containing intestines, peritoneum,
omentum, liquids, dilated vessels, and the like. He further classifies
scrotal hernias into nine types, according to their contents; for ex-
ample, enteroceleif containing intestines (entera in Greek), hy-
droceleif containing water (hydor in Greek), epiploceleif con-
taining omentum (epiploon in Greek).
The writer [18, 19] provides a plausible explanation for the eti-
ology of inguinal hernia. He writes that in the groin area there is
formed a strong membranoid tenon that is the aponeurosis of the
abdominal muscles, which is attached to the pubic bones. The loos-
ening of this is essential for the creation of inguinal hernia, in com-
bination with injury to or loosening of the peritoneum. The result of
these two factors is the slipping (either slowly or abruptly after
stretching) of the intestines, peritoneum, or omentum and the cre-
ation of the hernial sac.
The author [21] recommends, when groin hernias first appear,
poultices with various drugs and bandaging; but in cases of failure
of this treatment, surgical intervention is suggested. This consists of
the pressing of the intestines contained in the hernial sac into the
abdominal cavity, the surgeon then raising the peritoneum and, af-
ter tightening it at its base, cuts it off [22, 23]. The author gives no
detailed description, which might have been provided in his lost
book On Surgery.
Galen [22, 23] also advises surgical intervention in all cases of
inguinal hernias but his description is not extant. After surgical in-
tervention, he recommends the application of poultices of fresh
palm leaves, finely cut and boiled, and sprinkling of the incision
with a variety of drugs [21].
From Galens text, although it provides us with no complete de-
scription, it appears that the surgical method of Aetius and Paul of
Aegina is the same. Perhaps the Byzantine physicians had in mind
the now-lost Galenic text on surgery or some other common Hel-
lenistic source.
It is likely that similar techniques were set out in the books of
Oribasius [24], the celebrated physician and talented surgeon of the
fourth century A.D., because, as appears from his texts, there were
great gaps in the manuscripts of the relevant chapters concerning
hernias. This viewis reinforced by the fact that there has survived in
Oribasius text a detailed description, unique in Byzantine bibliog-
raphy, of the confrontation of scrotal hernia aimed at saving the
testicles, with reference to the severe complications following such
an operation [24]. Consequently, the techniques obtained fromAe-
tius and Paul are the first detailed descriptions in the history of
groin hernias.
It is possible that the surgical method described by Aetius and
Paul was associated with frequent recurrence and for that reason
younger physicians at that time preferred the method of cauteriza-
tion. The latter obviously left an ugly scar, but perhaps it had fewer
relapses without indeed being a completely sure method, since the
scar tissue would consist of a locus minoris resistentiae.
Later physicians followed the methods described by the two emi-
nent Byzantine doctors, Aetius and Paul. The surgical method was
in use during the seventh century in Byzantium, as a reliable literary
source, the Miracula Sancti Artemii, states that many doctors oper-
ate on bubonocele making an incision of the folded skin in women
suffering from groin hernia after the command of the doctors to
stretch so that the peritoneum will be protruded [25].
Leo, the philosopher and physician [26] (9th century A.D.), fol-
lows the Galenic definition of groin hernia and recommends, dur-
ing the first stages, conservative treatment by applying styptic or dry
drugs, such as the poultice called barbara (which contained tar), or
else the bark of willow (salix). Then the application of bandaging
shaped like the Greek (deltotos) followed. If the condition has
deteriorated due to a greater loosening of the peritoneum, Leo sug-
gests cauterization (the second method described by Paul of Ae-
gina).
Theophanes Chryssobalantes (incorrectly known as Nonnus,
10th century A.D.), court physician to Constantine VII Porphyro-
genitus, wrote his Epitome at the command of the emperor in the
course of the latters campaign for development of scientific knowl-
edge. This contains pharmaceutical rather than surgical informa-
tion, and an entire chapter [27] is devoted to inguinal and scrotal
hernias in particular. He recommends poultices of pounded pome-
granate peel with powdered Cytinus hypocistis, an herb that sprouts
under the cistus (rock-rose), and wine. This poultice is applied after
the intestines have been pressed back and then a triangular-shaped
bandage is applied for five days. His treatment of the early stages of
groin hernias obviously follows that of Celsus, Galen, and earlier
Byzantine physicians; the bandaging is the same as that used by
Leo. Theophanes also provides prescriptions for many other poul-
tices containing bull-glue (taurocolla), frankincense, fruits from
the cypress tree, aloe, tar, glue, snails with their shells, wine, niter,
wax, and olive oil, among others, but he does not recommend sur-
gical intervention.
The last eminent Byzantine physician, Ioannes Actuarius [28]
(14th century A.D.), defines several forms of hernia and gives the
full description of the disease, writing that injury to or loosening of
the peritoneum comes from a great jump or fall from a cliff, a loud
voice or lifting a heavy weight or intensive running, the result being
the falling of the intestines or the omentum. Certain forms of scro-
tal hernia, such as hydrocele, are imaginary hernias because they
contain only water, concludes the writer.
1167 Lascaratos et al.: Surgery for Inguinal Hernia in Byzantine Times
The fact that the two latter great Byzantine physicians do not
refer to surgical confrontation of groin hernias, must not lead to the
view that the physicians had neglected surgery in their epoch;
rather, their books were written as a vade mecum for general phy-
sicians.
Throughout the Byzantine era hernias were operated on in hos-
pitals, known as Xenones. A special category of lower surgeons
called celotome (= surgeon for hernias, oO

) dealt exclu-
sively with this kind of operation. The famous eleventh century
Pantocrator Hospital (Fig. 3) rules, titled Typicon [29], provided for
the staffing of the hospital with two chief surgeons, a number of
official surgeons, and a surgeon for hernias, indicating that the of-
ficial surgeons of that time were not occupied with hernia opera-
tions. After the fall of Constantinople, similarly, special empirical
practitioners carried out hernia operations all over the Greek ter-
ritory, following the techniques of Paul of Aegina [30]. They per-
formed this operation, passing on the technique from father to son
and did not know the techniques for other operations, for example
cataract or bone setting, which were the work of other such empiri-
cal specialists.
The techniques of Byzantine physicians were adopted by later
Arab physicians, among them Rhazes, Haly Abbas, Avicenna, and,
particularly, Abulcasis; through their translations these methods
spread to the Western world [9, 13, 31]. Fabricius ab Aquapendente
in the middle ages adopted many of Pauls concepts, as did Fried-
rich Trendelenburg as late as the nineteenth century [8, 13]. The
techniques for inguinal hernia described by Aetius and Paul were
copied by the European bather surgeons of the middle ages and the
Renaissance, because another ancient source, Celsus, had minimal
influence on later practitioners. His first century A.D. de medicina
had been lost and was only rediscovered in the fifteenth century by
Pope Nicholas V [1, 32, 33].
Re sume . Le but de cette e tude a e te de pre senter les techniques de cure de
hernie inguinale par les me decins byzantins et de noter leur influence sur le
de veloppement de la chirurgie de cette e poque. On a entrepris une e tude
et une analyse des textes originaux des e crivains me dicaux de le poque
Byzantine, re dige engrecque, et contenant des connaissances, actuellement
perdues pour la plupart, des pe riodes anciennes, helle nistique, et romaine.
Deux me decins Byzantins, Aetius dAmide (6e ` sie `cle apre `s je sus) et Paul
dAegine (7e `sie `cle apre `s je sus) ont de crit deux techniques de cure de hernie
inguinale, notamment une comportant lexe re `se du pe ritoine prolabe dans
le sac et lautre la caute risation de laine. Ces me thodes ont e te probablement
de rive es des textes des chirurgiens plus anciens auxquels ils ont rajoute
leurs propres observations. Le tude des textes byzantins me dicaux et
litte raires prouve que les techniques chirurgicales ont e te pratique es aux
temps des Byzantins et ont influence plus tard la chirurgie arabe et
e gyptienne, jetant ainsi des bases importantes de la chirurgie moderne.
Resumen. El proposito de este trabajo es presentar la te cnica utilizada por
los cirujanos bizantinos en el manejo de la hernia inguinal y su influencia
para el posterior desarrollo de la cirug a. Se emprendio el estudio y analisis
de los textos originales de los autores bizantinos, escritos en griego, que
contienenel conocimiento, actual-mente perdido, de los periodos helen stico y
romano. Dos me dicos bizantinos, Aecio de Amida (siglo VI A.D.) y Pablo de
Egina (siglo VII A.D.) describieron dos te cnicas para el tratamiento de
la hernia inguinal, mediante la reseccion del peritoneo prolapsado y la
cauterizacion de la ingle. Estos me todos probablemente se derivaron de los
textos de cirujanos griegos anteriores, a los cuales ellos anadieron sus
propias y muy precisas observaciones. El estudio de los textos me dicos y
literarios bizantinos comprueba que las te cnicas quirurgicas para el
tratamiento de la hernia inguinal fueron practicadas en los tiempos
bizantinos y luego ejercieron influencia sobre la cirug a arabe y europea,
por lo cual deben ser considerados como ra ces de la cirug a.
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