John Raffensperger
Fort Meyers, Florida, United States

 

Two methods of lithotomic position recommended by Sushruta. From Mukhopadhyaya G. The surgical instruments of the Hindus. (vol 2) Calcutta University Press 1914 pp 79 – 80 [public domain]

Physicians who take The Oath of Hippocrates swear not to perform abortions or operate for bladder stones: Similarly, I will not give to a woman a pessary to cause abortion. But I will keep pure and holy both in my life and art. I will not use the knife, not even verily, on sufferers from stone, but will give place to such as are craftsmen. Does the phrase to “keep pure and holy” suggest a moral or religious objection to abortion? Did Hippocrates object to using a pessary to insert dangerous drugs into the vagina, or as with cutting for stone, was he leaving abortion to others who had more skill? Who were the craftsmen?

Socrates, in his introductory dialogue with Theaetetus, said, “How absurd of you, never to have heard that I am the son of a midwife, a fine buxom woman called Phaenarete!” Socrates explains that midwives are women who are past the age of childbearing. Then he says, “Moreover with drugs and incantations they administer, midwives can either bring on the pangs of travail or alleviate them at their will, make a difficult labor easy and at an early stage cause a miscarriage if they so decide.”¹ This statement by Socrates is good evidence that midwives were the “craftsmen” who performed abortions. There are also references to abortion in the Corpus Hippocraticum, most likely written by authors other than Hippocrates.^2,3 The ancient Greeks committed infanticide by exposing “puny or malformed infants” to die.⁴ An example is in the tragedy of Oedipus Rex when King Laius and Queen Jocasta abandoned their newborn baby to die with the tendons of his feet pierced and fettered because the king had dreamed his son would one day kill him.⁵

Hippocrates described symptoms of bladder stones in children: Calculous children rub their privy parts and tear at them, as supposing the obstruction of urine is situated there. He treated bladder stones with diluted wine but advised against surgery.⁶ This is perplexing since the Corpus Hippocraticum describes operations for empyema, fractures, rectal prolapse, and recurrent dislocation of the shoulder.⁷ His reluctance to operate on bladder stones may have been due to a lack of knowledge of internal anatomy because the ancient Greeks did not allow human dissection.

A description of vesicolithotomy is in the Samhita Sushruta, a treatise on medicine and surgery written before 600 BC in India, well before Hippocrates.⁸ According to Hindu tradition, bodies were incinerated but an exception was made for dead newborn male infants. Anatomical studies in these infants were likely the basis for the skill of ancient Indian surgeons.⁹

Sushruta performed perineal lithotomy with the patient resting on an assistant’s lap with his hips and knees strongly flexed and secured with cloths. The surgeon anointed the patient’s abdomen and perineum with oil and pressed down on the bladder to deliver the stone to the perineum. He then placed two fingers in the rectum and secured the stone so it pressed against the perineum. The incision was made lateral to the midline raphe, large enough to deliver the stone. The surgeon applied poultices of vinegar and salt to stop the bleeding, then the patient was placed in a tub of warm water.¹⁰

Knowledge of the operation, or Indian surgeons themselves, could have reached Greece by land or sea routes that existed in ancient times.¹¹ Other avenues for the transfer of information could have been the Greeks who accompanied Darius, the Persian who invaded the Indus valley in 538 BC, or in 326 BC by Alexander the Great’s surgeons when he invaded India.^12,13

Alexander the Great founded Alexandria, the cultural and scientific center of Greece, in 322 BC. After his death, Ptolemy developed a medical school at Alexandria in 276 BC.¹⁴ There Ammonius Lithotomos, a Greek surgeon, became famous for this skill in operating for bladder stones. His method was essentially the same as that described in the Samhita Sushruta, suggesting that he learned the technique from Indian surgeons.¹⁵

Hippocrates’ advice against abortion and operating on bladder stones can be interpreted in many ways, but he may have advised his students to leave these procedures to “craftsmen” such as midwives and to surgeons trained in the Indian method of perineal vesicolithotomy.

 

References

1. Theaetetus, Plato; Dover Thrift Edition, translated by Francis M. Cornford, edited by Janet B. Kopito; Dover Publications, Inc. Mineola New York, 2018
2. Loyd, G.E.R., editor, Chadwick, J., Mann, W.N., Lonnie, I.M., Withington, C., translators; Hippocratic Writings; Penguin Books, 1983, London, New York, pgs. 325-26
3. Hanson, A. E. Hippocrates, Diseases of Women; Journal of Culture and Society, published by the University of Chicago, Vol.1, #2, 1975, pg. 567
4. Abt, I.A. and Abt, A. F., in Garrison’s History of Pediatrics, W. B. Saunders, Philadelphia, London, 1965; page 35
5. Sophocles, Oedipus the King; The Great Books Reading and Discussion Program, Fifth series, Vol. one, The Great Books Foundation, Chicago, Ill. 1985, page 50
6. Hippocrates on Airs, Waters and Places, in Adams, F. The Genuine works of Hippocrates, [Vol.I] London Sydenham Society, 1829, 201
7. Hippocrates, vol. I-VIII: translated by W.H.S. Jones, Loeb Classic Library, Harvard University Press, Cambridge, MA, 1923
8. Singh, V. Sushruta, the Father of Surgery; Natl. J. Maxillofacial Surgery 2017; 8, 1-3
9. Bishagratna, K.K. An English Translation of the Sushruta Samhita, based on the original Sanskrit Text, Calcutta, Self-Published, 1907, vol. I pp1-67
10. Bishagratna, K.K. [ed. and tr.] An English Translation of the Sushruta Samhita, based on the original Sanskrit text; Calcutta, Self-pub., 1911, Vol. II, pp. 329-337
11. Rawlinson, H.G. Intercourse between India and the Western World from the earliest times to the fall of Rome: Cambridge University Press, 1916, pg. 24
12. Adamson, P.B. The Military Surgeon; His Place in History; Journal of the Army Medical Corps, 1982, 128; 43-50
13. Machowiak, P.A. “Postmortem Solving Histories Great Medical Mysteries”; College of Physicians, Philadelphia, 2007, pg. 60
14. Fraser, P.M. Ptolemaic Alexandria. [3 vols.] Oxford, Clarendon Press, 2001
15. Tsoucalas, G.Sgantos, M.: Ammmonius Lithotomos, [3rd cent. B.C.], The Alexandrian Innovative Surgeon Who Introduced Lithoclastic Cystotomy; Surg. Innov. 2017, 24; pgs. 183-185

 

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JOHN RAFFENSPERGER, MD, graduated from the University of Illinois in 1953, interned at the Cook County Hospital, served in the U.S. Navy and returned to Cook County for training in surgery. He was on the attending staff at Cook County until 1970 when he went to the Children’s Memorial Hospital. He is the author of surgical texts, novels, and works of medical history, including, “The Old Lady on Harrison Street, History of the Cook County Hospital, 1883 to 1995.”

 

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