Historical medicine: Biblical and talmudic surgery and surgical practice

The legacy of surgery in ancient Jews included those who cared for the wounds and injuries. In light of this they were awarded the title of experts, ummanim. The aim of the paper is to introduce the history of the craft of surgery from biblical times throughout the talmudic period focusing on historical and medical perspectives. Along the way, the surgical progress made a creative advancement of anatomical studies.


Introduction
The main sources of our knowledge of ancient Jewish medicine are the Bible and the talmudic corpus. The Talmud is a compendium of commentaries and elaborations on biblical teachings. It includes snatches on jurisprudence, history, ethics, mathematics, philosophy, astronomy, theology, medicine, and botany. It was compiled by a number of Jewish scholars as a tradition transmitted orally for centuries and fi nally placed in defi nite literary form at the end of the 5th century as a collective labour of many generations. In contradistinction to the written Mosaic Law in the fi ve books of the Pentateuch (Torah) [1], the talmudic corpus consists of the law as transmitted by verbal tradition (Mishnah), with its several interpretations and commentaries (Gemara). The Mishnah, comprised of an annotated version of the Oral Law, was fi rst put into editing around 200 CE [2], and was followed by the Tosefta [3], which was a further expansion on the Mishnah.
Together, the Mishnah and the Gemara are referred to as the Talmud. There are two Talmuds. The Jerusalem Talmud [JT] was created around 400 CE in the Land of Israel under Roman and Byzantine rule [4], while the Babylonian Talmud  The author checked the original texts in biblical Hebrew and Aramaic as she is expert in these ancient languages. In addition, the author also checked all translations from these languages into English. These checked translations appear in references [1][2][3][4][5][6].

Discussion
Surgery was commonly practised throughout the ancient world, and it was not isolated from practical medicine in ancient Jewish lore. A search of the Bible brings to light occasional references to surgery, but the authors of the Scriptures evidently had no intent to instruct or expand knowledge in the art, and produced nothing resembling a surgical treatise [12,13].
In Genesis 50:2, Joseph commanded his Egyptian servants the physicians to embalm his father Jacob for burial. The Ebers Papyrus (1550 BCE) [14], reinforced by other authentic records, demonstrates that the Egyptians had specialists, who had studied anatomy and practised human dissection for preparation of mummies. Embalming was just one step in the careful process of preserving a body. The key steps of mummifi cation were removal of the brain, the internal organs, putting the body into a natural salt to dry it out, coating the body in the embalming recipe to kill bacteria and to seal it and wrapping the body in linen [15][16][17].
The only surgical operations mentioned in the Bible are circumcision and castration, the former being mandatory -a covenant made with Abraham (Genesis 17:10-11), and the latter being forbidden (Deuteronomy 23:2). Moses, when in Egypt, probably gained knowledge of Egyptian surgery and health customs, which he subsequently imparted to the Hebrews. In Perhaps he had been given dose of pain reliever before his surgery [17]. Surgeons may have performed this procedure as well as priests, but not always. In Exodus 4:25, we have the fi rst biblical record of a fl int used in circumcision, 'to cut off the foreskin of her son'. Flint, however, was not necessarily the usual instrument of circumcision, for Zipporah was forced to act quickly to stave off God's wrath and she probably availed herself of whatever was handiest. It is highly probable that metal knives were also employed. It should be remembered that the manufacture and use of brass and iron implements were known (Genesis 4:22). That it was a painful operation can readily be discerned, for so great was the weakness and pain of the circumcised adults even on the third day following circumcision (Genesis 34:24-25). In another occasion, when God was referring to those males recently born in the desert who had not been circumcised, he ordered Joshua: 'Make fl int knives and circumcise the Israelites again' (Joshua 5:2).
The technique practised is unknown. In addition, the text of (II Kings 8:29) [22]. The resulting conclusion is that wounds themselves were rarely described, and when they were it was because the individual was a central fi gure in the event [23].
Surgical cases then, as now, were considered more dangerous and, consequently, brought greater fame to the successful physician. The woman bound by the spirit of her infi rmity (Luke 13:11-17),was a case of senile kyphosis; while Lazarus was the typical beggar outcast from society, who can be seen at any of our city dispensaries suffering from varicose ulceration (Luke 14 :20). That the priests possessed some accurate surgical knowledge cannot be disputed, for the rite of circumcision was delayed if the child was jaundiced, a fact that would indicate that they appreciated the danger of haemorrhage in such conditions. The Hebrew materia medica consisted of balm of Gilead, myrrh, cinnamon, aloes, spikenard, calamus, camphor, cassia, and mandrake. Folklore medicine attributed healing virtues to saliva, and the fi rst aid to the injured rendered by the good Samaritan, when he poured oil and wine into the sufferer's wounds, was certainly surgically orthodox [24]. A further instance of surgical accident may be seen in the case of Malcus, whose right ear was cut off (John 18:10). No doubt, Peter aimed the sword at the head of the high priest's servant with the intention of doing more serious damage, but in the event only the pinna was severed. If complete from the adjacent tissues took place, the healing which ensured was strictly miraculous, since neither ancient nor modern surgery would avail under such circumstances [25]. Surgery in the time of the talmudic era was not considered to be its own subspecialty and was practiced by general physicians.
The high degree to which surgery had been developed may be seen both from operations and their modus operandi [26]. The Among ancient surgical procedures is trephination, also known as craniotomy, in which part of the skull is removed without penetrating the underlying soft tissue of the brain.
Various techniques included scraping the bone, cutting a rectangular hole, or boring a hole. The operation was performed to relieve pressure caused by intracranial infection, to extract an object imbedded in the skull, or to provide evil spirits with a means of escape. Evidence is that the patient could survive for some time after the surgery, since there are indications of healing. If necessary, the procedure could be repeated [22,37,38]. The most detailed report of a surgical procedure is that of cranial surgery performed to remove a disease called ra'atan (BT, Ketuboth 77b), which is unknown to us [27,39]. The Talmud clearly describes a growth or organism present upon the lining membranes of the brain. There is no mention of the intracranial location of the lesion. The marble house was preferred location for the operation. Three hundred cups of a presumable anesthetic solution were then poured over the skull. A drill was then used to open the skull. Four myrtle leaves were added to separate the organism, which could then be removed with forceps. The use of leaves and forceps illustrates the knowledge that damage to the brain itself would result in probable death so that care was taken to leave both the brain and meninges intact [29,31,40] [13,29,40,43]. Based on the weight and size of such a mass, the differential diagnosis would include a hemangioma, meningioma, and acoustic neuroma [7, 29,31].

Conclusion
The familiarity of the ancient Jews with anatomy, physiology, surgery, sleeping draughts, and disinfectants is indeed remarkable. There were operating places with marble-