Octobre 2012 André J. Fabre
The idea that splenic surgery might have been practiced in Antiquity will seem provocative. However, we do know that, as early as the first century A.D., existed some form of surgery for abdominal eventrations, inguinal hernias and, certainly, strangulated hernias . On splenectomies, the first records can be traced in Italy back to the start of XVIth century but several texts, all dated from the Ist to 4th century A.D., refer to a "splenic surgery" which would have been practiced in the times of greco-roman Antiquity. This corpus is given here together with a critical analysis of the assertions found in ancient texts.
MENTION OF A "SPLENIC SURGERY" IN CLASSICAL TEXTS
1. The concept of "splenic resection" is clearly mentioned in three classical texts :
Aristotle (384-322.B.C.) (Metaphysics. IV. 27. 1024-1028) : "Man is not mutilated to be deprived from his flesh or his spleen but if he has to be deprived from his extremities, and not any part of the body but the sort of flesh which will never grow again"
Pliny the Elder (23-79 A.D.) (The Natural History.XI.205) : "The spleen brings at times a special embarrassment. Thus is it necessary to reduce ("reminuitur") the spleen) on the sprinters who suffer from it. One reports also that animals which have lost their spleen from a wound ("adimi") go on living. Some think that in man, ablation of spleen gives a loss of laughter and that immoderate laugh is associated with an enlargement of the spleen.
Serenus Sammonicus (end of 2d century A.D.??) (Liber Medicinalis. XXII.29) : "Some say that ablation of spleen ("dicitur exsectus" ) suppresses any tendency to laugh and gives to people a serious look for the rest of their life "
In this text a reference to some form of ritual or symbolic shrinkage of spleen seems unlikely. The meaning of such words as "adimi" (passive voice of "adimere" : eradicate) is still open to discussion but "exsectus" (past participle of "exsecare" : amputate), as mentioned with precision by Serenus Sammonicus, gives obvious reference to surgery. The possibility of a congenital asplenia, as the "situs inversus syndrome", could also be discussed but knowing the importance given by the Ancients to all questions of laterality, such an hypothesis seems hardly thinkable. Many references show that the Ancient knew the possibility of asplenia said to be found in some animals as chameleon (Pliny. The natural history. VIII.122) or "warm belly birds" (Aristotle. Animals ("Peri zwiwn moriwn").III.7.(670a)
2. Another group of texts refer to a "cauterisation" of the spleen"
Hippocrates (460-370 B.J.C.) (On Diseases.VI.p.231) : "In other patients (presenting a splenic enlargement), the spleen suppurates, it becomes thus mandatory to cauterize this organ and the patient gets healed. In other cases, the spleen gets a hard consistency and becomes larger as disease is growing This type of ailment occurs when an inadequate treatment has been given, and bile or phlegm or both remain stuck in the spleen."
Caelius Aurelianus (Vth century A.D. ?) (On Chronic Diseases. III.4., "De "iecorosis et lienosis, de arquato morbo") : " In the second volume of his treaty on Chronic Diseases, Themison proposes a wide array of receipts in agreement with the principles of "Methodism". He agrees on the point that, because of splenic consistency, energic forms of treatment should then be considered such as plasters or cauterisations. In fact he goes so far as advise to puncture spleen with a cauter ("lienem igneo cautere transpungendum") in 3 or 4 places without admitting that strength of remedies must be adapted to the severity of illness and to the strength of the patient but not to the nature of illness. All this because this part of the body quasi insensitive to touch becomes, as disease progresses, more painful than all other organs."
Paulus of Aegina (VIIth century A.D. ?) (On surgery. XLVII. XLVIII. : Cauterisation of spleen) : In case of dropsy, make an incision on the right side... After lifting up the skin with a crook comes the membrane covering the spleen, we burn it with a long incandescent cauter to get two escarrs in a same stroke ("aÇto kaÂsomen" : a single burn). We repeat three times the same procedure for a total of six escarrs. Marcellus used a "trident" i.e. a cauter shaped as a trident to get six escarrs on a single stroke."
3. The concept of "removal" of the spleen is also mentioned by two classical authors :
Celsus (Ist century A.D.??)(De Medicina. V.26.24c.1.) : "[in case of abdominal wounds], there is no need to worry if a portion of liver, spleen or lung gets outside the belly ("dumtaxat extremo dependet"); in this case it becomes mandatory to practice a section ("praecidatu")."
Caelius Aurelianus (Vth century A.D. ?) (On chronic diseases, III.4) : "Some have gone so far as to advise to cut or remove the spleen ("decidendum vel auferendum") but this we don't take as concrete fact but only as words ("voce dictum, non officio completum accipimus")".
PHYSIOPATHOLOGICAL CONCEPT OF SPLEEN IN ANTIQUITY
Many references are available, in ancient treaties of medecine, on splenic anatomy, physiology and pathology. Of interest is the fact that the Latin names given to spleen, "lien" and "splen" originate both from Greek. In fact, "splÐn" and its derivative"spl€gcna" are on center of a semantic ensemble merging together heart, viscers and moral features as pity and courage. In addition, it is important to take notice, as expressed in a study from Jacques Andre , that "splen" belongs from the start to a group of words dedicated to veterinarian art, in direct reference to animal sacrifices and sciences of divination.
1. Anatomy of spleen in Ancient texts
The Ancients were certainly aware of many anatomic details concerning the spleen : its colour, consistency and "honey bee cake" structure. There are ample comments on the subject in Galen (On the Usefulness of the Parts of the Body : IV.IX., XI, XV and XVI)"
2. Ancient concepts on the physiological role of spleen.
A long tradition considers spleen as "emunctory" ("depurative") organ to which is given, for that function, a "porous" structure. Aristotle in Animals (III.VII.) gives lengthy details on the complex mechanism depurating spleen from "black bile" coming from liver to stomach.
The spleen, as organ of "good temper"
The "depurative" theory gives to the spleen an important function in sanitising blood and mind. A long tradition gave to each visceral organ a specific role in the control of personality : kidneys for wisdom, liver for courage and anger, spleen for laughter. This is thus summarized by Isidore in the VIth century A.D. : "with spleen, laughter, with bile, anger, with heart, knowledge and with liver, love" (Etymologia. XI.123). Such concepts are still alive in popular locutions such as "desopilate" and "dilate spleen". On the opposite, melancholy as state of sadness called "spleen" in English (long time before coming of common use in France) was interpretated by Galen (De locis affectis.VI.I-II.) as a state of "splenic atony" due to a nocive accumulation of black bile. It should be matched with a statement from Serenus Sammonicus (Liber Medicinalis XXII.29.) stating that patients with enlargement of spleen have a "strange laugh".
3. Splenic diseases in classical texts
The spleen as a cause of disease
Splenic enlargement is frequently reported in Ancient texts as a disease entity, often associated, as asserted by Celsus, to periodic fever and diffuse ache : "erratic fevers, splenic ache and hydrops are mainly observed in autumn (De Medicina. II.I.8.1.), "abdominal pain is beneficial to splenomegalies and so are fevers" (II.VIII.17.1.). In itself the assertion expressed by Celsus in De Medicina (5.28."2a".1) that "carcinoma" has its origin in spleen could justify ample developpements .
A palpable spleen ("splenic tumour") was, without any doubt, for the Ancients the sign of some pathologic condition. This is fully in agreement with modern definitions, stating that in normal individuals, spleen should never be palpable under the lower costal edge. Numerous mentions of the clinical importance of splenomegalies can be found in ancient medical treaties. Thus, Serenus Sammonicus in Liber Medicinalis.XXII.29 : "splenic tumour is harmful for health". Hence, a great number of appellations for the concept of "spleen enlargement" : splenemphraxy , "splenoncy" "splenoparectamy". A citation from Aurelius Victor, a roman historian of the Vth century, clearly expresses the belief of the Ancients on the prognosis related to splenomegalies : " "[Trojan] compared taxes to the spleen, saying that excessive enlargement could only lead to illness." (Ps.Aur.Victor.Epitoma.42.21.)
SPLENIC SURGERY IN ANTIQUITY : CAN IT BE TRUE ?
The idea that some form of anaesthesia could have been in practice at the times of Antiquity lies beyond all limits of credibility. In fact, ancient pharmacopoeia used a few drugs which could be called "pre-anaesthetics" mainly solaneas as belladona and opiates as opium or poppies, the basic medication in Antiquity for any type of pain. Caelius Aurelianus, as we quoted, referred to the spleen as a quasi insensitive organ. Could it mean thet patients, in that time, were given higher tolerance for pain? We shall not give a stand on the subject.
2. Surgical procedures
Cauterisations were, in Antiquity, a common mode of treatment in all sorts of diseases skin ulcers, chronic amygdalatis, perineal lesions among others. Could it be common practice, in the ancient times, to cauterize spleen ? It remains difficult to assess in retrospect the depth given to the cauter. The possibility of a direct access to the spleen might be however considered for very voluminous splenomegalies, combining lignification and diffuse sclerosis. Such splenic tumours could be easily identified from the presence of characteristic crenels on their anterior edge. This procedure was certainly associated yo a major risk of thrombosis : but this might have been the real purpose of such cauterisations. Anyway, some patients did survive, as stated by Hippocrates (On Affections.VI.231.) : "(in some patients), the spleen suppurates, thus cauterisation is mandatory and they heal..."
On evidence, the idea that splenectomies could have been performed in Antiquity remains highly questionable. It will seem difficult to believe that Ancient physicians could have the technical skill to safely perform a dissection of splenic vessels and their ligature. On this point, we share the polite disbelief expressed, as we mentioned, by Caelius Aurelianus in Tardarum Passionum (III.4).
However a recent review of abdominal surgery in Antiquity gives ample references on the subject. Very suggestive of such techniques is the De Medicina of Celsus (VII.4.3.) ("On penetrating abdominal wounds") : "After reduction of intestinal exteriorisation, the edges of the wound will be sutured. However, inside the abdomen, suture of peritoneum will cause many problems". Galen, a few decades later at the end of 2d century, states (On the usefulness of the Parts of the Body .I.209.) to have performed a quasi complete ablation of the epiploon on a severely wounded gladiator. The patient survived but became "so sensitive to external cold and so easily harmed by it that he could not bear to have his abdomen uncovered and kept himself wrapped in wool. His whole body, however, was naturally thin, particularly in the region of the stomach and I have thought that this was the reason why he was easily chilled." Our comments would be in first place to discuss the meaning of "epiploon", very likely to have been the epiploic "apron" which covers abdominal viscers. We should, however, take note that for Aristotle (I.17.16-21) "liver and spleen are attached to the lower part of stomach by the epiploon.".
2.) Post operative course
Acute hemorragia is clearly the most imminent risk for splenic surgery but a wide array of post-operative complications has to be mentioned : mesenteric thrombosis, hemorrhagic or infectious complications following splenectomy However we have seen that, following Pliny, Celsus and Galen some patients could survive the gruesome abdominal surgery of the Ancient times.
Remains to be cited the post splenectomy syndrome and the chronic susceptibility to infections but this is far beyond the scope of this study...
SPLENIC SURGERY IN ANTIQUITY : MYTH OR REALITY ?
1. Legends, sayings and tales on the "doping" effect of splenectomy
A belief was present among the Ancients that spleen, "cleaning" organ, but also receptacle for the "thick humours" coming from liver, could be responsible for some of the painful symptoms observed during violent muscular efforts, mainly stitches and feeling of heaviness in the left flanks. Hence, a removal of the spleen seemed to be a logical procedure to give some sort of "doping action" to the sprinters. Such statements, supported by all major authors, including Pliny (Natural History. XI.205.), is still alive in our times as expressed by the French saying "courir comme un derate" On this subject, we have to quote Rosner  and his comments on Talmudic texts : "The Talmud (Tractate Sanhedrin 21b) questions : What was so remarkable about those fifty men (runners before the chariots of Adonijah) ? :The answer given is that they had all their spleen removed".
2. surgery of abdominal trauma
This is the only domain attested without any doubts : Celsus, in four chapters of "De Medicina" (V.26.3, 12, 24 and VIII.IV.3.) comments symptoms of penetrating abdominal wounds and gives some therapeutic guidelines on splenic traumas : "In splenic wounds there is issue of brown, black blood, and contracture of abdominal wall. The pain diffuses to the clavicular area". Another passage of De Medicina (V.26.24c.1) is quite explicit : "If spleen goes outside the abdomen , better section it "
3. Chronic splenomegalies
Ancient pharmacopoeia gives a major place to the treatment of splenic diseases with a large choice of vegetal medications : Ceterach officinarum (spleenwort : the phytonymic appellation clearly refers to its properties), Iris pseudo-acorus (yellow Iris), burnet (Pimpinella saxifraga ) and many other substances, most often given as local ointments It seems likely that therapeutic failures could lead to some attempts of surgical cure.
A discussion on the main causes of chronic splenomegalies in the Mediterranean world cannot find place here. Obviously, a very large number of diagnosis could come into discussion : we mentioned the possible relations between "splenic tumour" and "muscular fatigue" or "strange laughter" : in retrospect, malaria comes in first place on the list with many other infectious diseases as melitococcia ("Maltese fever" still commonly observed in Greece or Italy), splenic tuberculosis or a wide array of parasitic diseases.
Still remain to be discussed the so-called "mediterranean splenomegalies" :
. hemoglobinopathies, and most of all, thalassemia, a genetic disease specific to the Mediterranean world, frequent cause of voluminous splenic enlargements and, even in our times, potential indication for splenectomy.
The splenic surgery of antiquity will probably remain an unsolvable mystery. Myth or reality ? Shall we ever know the truth ?
Our personal interpretation of the texts presented in this paper goes to some form of "hoaxing" arranged by highly skilled manipulators. A comparable situation was recently displayed on television screens showing quacks, "extracting flesh" "from the belly of their patients". Should we admit, for conclusion, that the quest for truth is always doomed to end up, with some kind of disappointment ?
Whatever the truth may be, we should give homage to the greatness of Antique medecine, fallen after a long period of glory in undeserved oblivion, and also homage to the temerity of our remote predecessors and the courage of their patients ...
TEXTS REFERRING TO SPLENIC SURGERY IN ANTIQUITY
"ablation" of the spleen
Aristotle (384-322 B.J.C.), Metaphysics, IV, 27, 1024-1028 (Trad. : H. Tredennick :. Loeb Classical Library 1971)
Pliny the Elder (23-79), Natural History. XI.205 Natural history (English translation by H. Rackham), London : W. Heineman Ltd., 1949-
" Peculiare cursus impedimentum aliquando in eo quam ob reminuitur cursorum laborantibus et per vulnus etiam exempto vivere animalia tradunt.Sunt qui putent adimi  simul risum homini intemperantiamque eius constare lienis magnitudine"
Serenus Sammonicus (v. 250 ??) Liber Medicinalis, XXII.29 :
Liber Medicinalis (Trad. Pépin R.), Paris : Presses Universitaires de France 1950
Liber Medicinalis (Trad. Ruffato C.) Turin : UTET, 1996
" Dicitur exsectus faciles auferre cachinnos perpetuoque aeuo frontem praestare severam "
Hippocrates (460-370 B.J.C.) : Œuvres complètes.VI.p.230-231 (Trad. E. Littré), Amsterdam : Ed. Hakkert 1962)
Caelius Aurelianus (v. 450), Tardarum Passionum, III.4 (Trad. Drabkin I.E.), Chicago : Chicago U. Press, 1950
Paulus of Aegina (v. 650) (On surgery) (XLVII)(Trad. R. Briau), Paris : Ed. V. Masson 1855Medical Works of Paulus Aegineci (F. Adams’s” Commentary “)London and Aberdeen, 1834
Celsus (14 B. J.C.??-37??) (De Medecina. V.26.24c.1.) (Trad. W.G. Spencer) London : W. Heinemann, 1935-1938 (Loeb classical library)
V.26."24c".1 "In visceribus nihil movendum est, nisi ut, si quid ex iocinere aut liene aut pulmone dumtaxat extremo dependet, praecidatur . Alioqui volnus interius ea victus ratio eaque medicamenta sanabunt, quae cuique visceri convenire superiore libro posui."
8. Caelius Aurelianus (v. 450), Tardarum Passionum, III.4(" De lienosis quos Graeci splenicos dicunt ")  "Quidam etiam decidendum  vel auferendum  lienem ordinare aussi  sunt, quod quidem voce dictum, non officio completum accipimus "
Aurelius Victor, Roman historian of Vth century (Ps.Aur.Vict.Epit.42.21. "(Trajanus) fiscum lienem vocavit, quod eo crescente artus reliqui tabescunt"
Surgery of splenic traumas
Celsus (14 B. J.C.??-37??) (De medicina)
5.26."3a".1 "Vix autem ad sanitatem pereniunt, quibus ulla parte aut pulmo aut iocineris crassum aut membrana, quae continet cerebrum, aut lienis aut vulva aut uesica aut ullum intestinum aut saeptum transversum vulneratum est. Li quoque in praecipiti sunt, in quibus usque ad grandes intusque conditas venas in alis vel poplitibus mucro desedit. Periculosa etiam ulnera sunt, ubicumque venae maiores sunt, ..."
220.127.116.11 "At liene icto sanguis niger a sinistra parte prorumpit; praecordia cum ventriculo ab eadem parte indurescunt; sitis ingens oritur; dolor ad iugulum sicut iocinere vulnerato venit."
5.26."24c". "Illo neminem decipi decet, ut propriam viscerum curationem requirat : de quibus supra posui. Nam plaga ipsa curanda extrinsecus uel sutura uel alio medicinae genere est: in visceribus nihil mouendum est, nisi ut, si quid ex iocinere aut liene aut pulmone dumtaxat extremo dependet, praecidatur. Alioqui vlnus interius ea victus ratio eaque medicamenta sanabunt, quae cuique visceri convenire superiore libro posui."
Surgery for penetrating abdominal wounds
Celsus (14 B. J.C.??-37??) (De Medecina. (VII.4.3 )
VII.4."3a".1 "Ventri nullum os subest, sed ibi perniciosae admodum fistulae fiunt, adeo ut Sostratus insanabiles esse crediderit. Id non ex toto ita se habere usus ostendit. Et quidem, quod maxime mirum videri potest, tutior fistula est contra iecur et lienem et ventriculum quam contra intestina, non quo perniciosior ibi sit, sed quo alteri periculo locum faciat. Cuius experimento moti quidam auctores parum modum rei cognoverunt. Nam uenter saepe etiam telo perforatur, prolapsaque intestina conduntur, et oras vulneris suturae conprehendunt;"
7.4."3b".1 "Quod quemadmodum fiat, mox indicabo. Itaque etiam ubi tenuis fistula abdomen perrumpit, excidere eam licet suturaque oras coniungere. Si vero ea fistula intus patuit, excissa necesse est latius foramen relinquat, quod nisi magna ui, utique ab interiore parte, sui non potest; qua quasi membrana quaedam finit abdomen, quam peritonaeon Graeci vocant. Ergo ubi aliquis ingredi ac moveri coepit, rumpitur illa sutura, atque intestina solvuntur; quo fit, ut pereundum homini sit. Sed non omni modo res ea desperationem habet, ideoque tenuioribus fistulis adhibenda curatio est."
Galien (131? - 201? A.D.) (De usu partium corporis human) (Liber I., Cap.I) )
(Claudius Galeni Opera Omnia (Ed. Carolus Gottlieb Kühn, Leipzig:Officina Libraria Car. Cnoblochii, 1822. Tomus 3, liber 1, Cap.1, p. 287
On the usefulness of the Parts of the Body (Trad. Arthur John Brock)(New York : D. Appleton and Company, 1916
 Mazzini I. La chirurgia di Celso (De Medicina VII e VII). Macerata : Istituti Editoriali e Polygrafici Internazionali 1999
 Jackson R. The surgical instruments, appliances and equipment in Celsus' De Medicina (in «Médecins et médecine dans l'antiquite», (Ed. Sabbah G.) St Etienne. St Erienne : Publ. de l'Universite de St Etienne 1982
 Pieri G. Una splenectomia nel cinquecento. Chirugia Italiana, 1, 1949:204-208
 Des animaux III.VII p. 89 (Ed. P. Louis). Paris Belles Lettres 1968
 Aristotle states that in some kinds of animals, feathers or scales have the same "emunctory" function than spleen.
 Marcellus : another physician living at the same period without any relation with Marcellus Burdigalensis.
 Possible interpretation : "we have no official sources on that fact"
 Gourevitch D. Bibliographie du vocabulaire de la pathologie en latin ancien ('in Mémoire XVII du Centre Jean Palerne« "Nommer la maladie : Recherche dans le lexique greco-latin de la pathologie, édité sous la direction de A.Debru et G.Sabbah). St Etienne : Publications de l’Universite de St Etienne 1998.
 J. André. Andre J. Note sur "ˆsplÐnon", Revue de Philologie. 1978; 52:252-253
 "emunctere" : to wipe out
 Late latin for "unblock" ("oppilare" giving here reference to some form of "obstruction"
 "dark bile"
 Galen (De locis affectis.VI.I-II.) states that, in absence of depuration, blood is loaded with dark bile : thus, comes a state of sadness and "melancholy"
 See further comments on "splenic surgery in Antiquity : myth or reality ?"
 "Non idem periculum carcinoma adfert...et in vlcere autem aut splene hoc nascitur".
 "splenemphraxy" (Hellenism derived from "mfr€ssein", to obstruct)
 "ígkos" : tumefaction
 "parektama": enlarged spleen.
 "Trajanam uxor talem reddidit, ut...exactiones improbas detestans fiscum lienem vocaret, quod eo crescente artus reliqui tabescunt" (Ps.Aur.Vict.epit.42.21.)
 Piperno D. La chirurgie dans le De Medicina de Celse. Annales de Chirurgie 1998;52(6) : 568-570
 "Run flat out" as a man without spleen.
 Rosner F. The spleen in the Talmud and other early Jewish Writings. Bulletin, History of Medicin 1972 46(1); P 82-5
 The german name ("milzkraut") also refers to the spleen.
 Ancient phytonym :"ˆspljnon"
 Fabre A.J. Utilisation médicinale des épices dans l'Empire romain (Thèse de Doctorat présentée le 2 novembre 2001 at the Universite Paris IV-Sorbonne)
 Delaveau P. Les plantes médicinales depuis la nuit des temps jusqu'à l'horizon 1990. Journal de la Pharmacie de Belgique (Supplement) 1986; 5:11-21
 The greek name for spleen, "splÐn" is likely to be apparented with the word "splÐnon" ("splenium"), refering to dressings or plasters used for local ointments (cf Chantraine : Dictionnaire etymologique de la langue grecque. Klincksieck 1968
 Battin J. Genetic diseases in the Mediterranean region : a historical perspective. Arch. Fr. Pediatr. 1998; 5 Suppl. 4 : 397S-406S
 Rawashdeh M.O., Majeed H.A. Familial Mediterranean fever in Arab children : the high prevalence and gene frequency. Eur. J. Pediatr. 1996 155 (7) : 540-4
 adimi, derived from "ademo" : to get rid of
 "firmitatem" : strength, solidity, possibly refering to some degree of splenic insensitivity ?
"Praecido" : cut down, fell a tree (derived from "prae, caedo")
 Caelius Aurelianus is known to have given a traduction from the wodks of Soranos
 "decido" : to slit, to section...
"aufero" : to remove
"audeo" : to venture to
 See facsimile in annex
Date de dernière mise à jour : 29/07/2013