The Contribution of Aulus Cornelius Celsus (25 B.C.–50 A.D.) to Eyelid Surgery

Abstract

An accurate study of ancient medicine reveals that our forebears developed a large number of surgical ideas and techniques considered to be quite modern. Although the contribution of Aulus Cornelius Celsus to the development of several branches of surgery has already been celebrated, scant attention has been focused on his description of eyelid surgery in the seventh book of his encyclopedia, De Medicina octo libri. Although the practice was quite advanced by that time, the first century A.D., Celsus was the first among the Greco-Roman authors to deal systematically with ophthalmology and oculoplastic surgery. He was a compiler, and many of his "innovations" were in fact done in principle by others. Yet it is almost certain that the surgical procedures presented were introduced more than 15 centuries before the time of Celsus by Egyptians, Indian surgeons, and Greek and Alexandrian doctors. The burning of the Ancient Library of Alexandria as well as the perishing of many writings of pioneer physicians resulted in a tragic loss of ancient knowledge for posterity. Celsus, whose work has been preserved in our time, helped to publicize this ancient knowledge, and perhaps because of the loss of so much early medical literature, became one of the most influential experts on ancient medicine. An analysis of how previous authors have influenced Celsus' description of eyelid surgery and reflections on how modern his ideas (or those of his time) were are presented in the paper.

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Author(s): D. Lazzeri et al.
Article title: The Contribution of Aulus Cornelius Celsus (25 B.C.–50 A.D.) to Eyelid Surgery
Article no: NORB 648816
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2 Tommaso Agostini
3 Michele Figus
4 Marco Nardi
5 Marcello Pantaloni
6 Stefano Lazzeri
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1
INTRODUCTION
A true insight into the medicine of ancient Egypt
has been possible only after the original Egyptian
documents (The Ebers Papyrus and the Edwin Smith
Papyrus)1,2 were found and elegantly translated by
Edwin Smith and George Ebers at the end of the 19th
century. Nevertheless, plastic surgery of the face
can probably make a claim to being one of the old-
est surgical specialties by referring to descriptions of
rudimentary surgical procedures performed to repair
facial trauma, including mandibular and nasal frac-
tures described in the Egyptian Edwin Smith Surgical
Papyrus,1 which may date back to the third millen-
nium B.C. (2600–2200 B.C.).2 The Ebers Papyrus3 rep-
resents the most important document about medicine
(written between 1553 and 1550 B.C.) from ancient
Egypt and includes chapters on ocular diseases.4
This papyrus also describes with medications for the
treatment of eyelid diseases. The epilation of hair in
the eye (“trichiasis”), however, remains the only ocu-
lar operation mentioned in the document.3,4
Nothing is known about ophthalmic plastic surgery
operations of the Babylonians and Assyrians and very
little is known about their medicine in general. In con-
trast, Indians bequeathed abundant historical records
by way of a Sanskrit text entitled Sushruta Samhita. This
encyclopedic volume (samhita is Sanskrit for encyclope-
dia) was written by a renowned Indian surgeon named
Sushruta, who lived during the 6th century B.C. In his
book, he described over 120 surgical instruments and
300 surgical procedures and classied human surgery
into eight categories.5 Among all achievements of
Indian medicine, the art and science of restoring facial
injuries, in particular total nasal reconstruction, and
the cataract operation (all of which were described by
Sushruta) constitute important chapters in the history
of plastic surgery5–8 and ophthalmology.4,7,8 About 20
Orbit, 00(00), 000–000, 2011
Copyright © 2011 Informa Healthcare USA, Inc.
ISSN: 0167-6830 print/1744-5108 online
DOI: 10.3109/01676830.2011.648816
Received 12 October 2011; accepted 05 December 2011
Correspondence: Dr. Davide Lazzeri, M.D., Unità Operativa di Chirurgia Plastica e Ricostruttiva, Ospedale di Pisa, Via Paradisa 2,
Cisanello, 56100 Pisa, Italy. Tel: +39 050 996879, Mobile: +39 3476675673. Fax: +39 050 996845. E-mail: davidelazzeri@gmail.com
12 October 2011
00 00 0000
05 December 2011
© 2011 Informa Healthcare USA, Inc.
2011
Orbit
0167-6830
1744-5108
10.3109/01676830.2011.648816
00
000
000
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648816
NORB
ORIGINAL ARTICLE
The Contribution of Aulus Cornelius Celsus
(25 B.C.–50 A.D.) to Eyelid Surgery
Davide Lazzeri1, Tommaso Agostini2, Michele Figus3, Marco Nardi3,
Marcello Pantaloni1, and Stefano Lazzeri3
1Plastic and Reconstructive Surgery Unit, Hospital of Pisa, Pisa, Italy, 2Burn Center Unit, Hospital of Pisa,
Pisa, Italy, and 3Ophthalmology Unit, University Hospital of Pisa, Pisa, Italy
ABSTRACT
An accurate study of ancient medicine reveals that our forebears developed a large number of surgical ideas
and techniques considered to be quite modern. Although the contribution of Aulus Cornelius Celsus to the
development of several branches of surgery has already been celebrated, scant attention has been focused on
his description of eyelid surgery in the seventh book of his encyclopedia, De Medicina octo libri. Although the
practice was quite advanced by that time, the rst century A.D., Celsus was the rst among the Greco-Roman
authors to deal systematically with ophthalmology and oculoplastic surgery. He was a compiler, and many of
his “innovations” were in fact done in principle by others. Yet it is almost certain that the surgical procedures
presented were introduced more than 15 centuries before the time of Celsus by Egyptians, Indian surgeons,
and Greek and Alexandrian doctors. The burning of the Ancient Library of Alexandria as well as the perishing
of many writings of pioneer physicians resulted in a tragic loss of ancient knowledge for posterity. Celsus,
whose work has been preserved in our time, helped to publicize this ancient knowledge, and perhaps because
of the loss of so much early medical literature, became one of the most inuential experts on ancient medicine.
An analysis of how previous authors have inuenced Celsus’ description of eyelid surgery and reections on
how modern his ideas (or those of his time) were are presented in the paper.
Keywords: Surgery, celsus, eyelid, romans, history
AQ1
AQ2

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2 D. Lazzeri et al.
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diseases of the lids are mentioned in the treatise. Lid
abscesses were rst approached with warm compresses
and then opened and expressed.4 Entropion was restored
by excising a strip of skin that should be 3 lines wide and
should involve the lower third of the upper lid (Sushruta
underlined brilliantly how an excision involving the
upper part of the lid would likely fail). Hair sutures
were used to close the wound. If this operation was not
successful, the hair follicles had to be destroyed by heat
or by cauterisation.4,7,8 Pterygium removal was another
well-described operation. Many stages of pterygia were
described as distinct diseases.7,8 Surgical removal of the
inamed pterygium was the choice of treatment once
eye-drops and salves had failed. With the eyelids held
wide apart by the surgeon, the pterygium was grasped
with a hook and held with a threaded needle and then
excised at its base while the patient was obliged to rotate
his affected eye medially toward his internal canthus. The
root of the pterygium was pushed asunder from the black
outline (cornea) of the eye to the medial canthus and then
removed.7,8 The eye was then protected for 3 days with
eye patches and dressed with various salts. Adequate
excision of the pterygium prevented any recurrence.7,8
Hippocratic surgery never went beyond what we
now call minor surgery; however, Hippocratic teach-
ings remain extremely relevant in the surgical context10
outlining brilliant measures to treat and restore facial
injuries.11 Twenty different eye diseases or symptoms are
described by Hippocrates, including lid diseases; not-
withstanding, operations on the eye are not mentioned
in the authentic books by Hippocrates. This, of course,
does not mean that they were completely unknown.
Even in the unauthenticated Hippocratic books, few
ocular operations are mentioned.4 Of interest among
these we found the treatment of trichiasis performed
by extraction with needle and thread.4
The School of Alexandria (third century B.C.) should
get credit for the following minor eyelid operations:4
incision of a sty; excision of chalazia, pterygia, tumor of
the caruncle, pustules and dermoids; and excision of a
stulae of the lacrimal sac with burning of the bone. The
separation of adherent lids and of lids adherent to the
eyeball was described.4 Alexandrian surgeons further
adopted several approaches for the treatment of patho-
logic lashes: a red hot iron was used to cauterise lashes
as an alternative to the removal of pathologic lashes
with a thread. Other interesting procedures elegantly
proposed by Alexandrian surgeons to treat trichiasis
included the transplantation of lashes with the excision
of skin and suturing and incision into the palpebral con-
junctiva close to the lid margin.4 The approach used to
treat lagophtalmus involved a semilunar incision (the
same operation was used against ectropion). Recurrent
ectropion was treated with a hot iron (also used to burn
the everted mucosa of the lid).4
We have to wait three centuries and reach Imperial
Rome to meet one of the greatest sources of ancient
surgery, the Roman medical writer Aulus Cornelius
Celsus (25 B.C.–50 A.D.) (Figure 1). With his pioneer-
ing work, De medicina, known also as De Re Medica
(Figure 2), Celsus earned a reputation as one of the most
important contributors to medicine and scientic thought
during the Roman Empire, and the most important
source of present-day knowledge on Alexandrian medi-
cine (Celsus did not change the Greek and Alexandrian
anatomical terminology used in writing about the eye).
Although the practice was quite advanced by that time,
the rst century A.D., Celsus is the rst among the
Greco-Roman authors to deal systematically with oph-
thalmology and eyelid surgery, with related manuscripts
preserved to the present day. The preceding Hippocratic
writings are silent on the subject, and therefore the
Alexandrian school mainly inuenced by the knowledge
inherited by Indians must have developed the teachings
to the advanced level recorded by Celsus.
Having analyzed the contribution of Celsus’work
in the development of several branches of surgery, we
focused our attention on his real contribution: ophthal-
mic plastic surgery. The question we tried to answer
was whether he was an innovator, a brilliant physician
or just a methodic compiler.
FIGURE 1 The famous Roman medical writer Aulus Cormelius
Celsus (25 B.C.–50 A.D.). (Courtesy of Biblioteca Antiqua, Aboca
Museum, Sansepolcro (AR), Italy).

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History of Eyelid Surgery 3
© 2011 Informa Healthcare USA, Inc.
CELSUS’S DESCRIPTION OF
EYELID SURGERY
Because eyelid surgery is extremely risky for the prac-
titioner and potentially perilous for the patient, it was
avoided wherever possible.4,12–14 Thus the recourse to
surgery was necessary only when all the non-surgical
procedures performed by the eye doctors had failed.
Indications for surgery were in this way acute, and
chronic infections or dysfunction was often caused by
improper or failed medical treatment. Celsus’ chapter on
eye surgery was organized accordingly: diseases of the
periocular tissues were followed by those involving the
eyelids and, lastly, the eyeball. Concerning eyelid surgery
Celsus began with minor afictions, small tumour or
cysts. A transverse incision in the eyelid was described as
the best approach with which to remove intact encysted
tumours and enlarged sebaceous glands as well as
chalazia and dermoid cysts. Mature Meibomian cysts
in which fomentations had failed to disperse pus were
incised and squeezed. The practice of surgical removal
of the pterygium was well known. Ancyloblepharus, a
frequent consequence of inadequate treatment of an ulcer
resulting in adhesion between the eyelids or the eyelids
and the eyeball, was approached with the reverse end of
a probe followed by the insertion of pledgelets of wool
and vigilant after-care to avoid re-adhesion.
With respect to diseases of the lashes, trichiasis which
involves “a second row of lashes growing beneath the rst
one” and eyeball irritation by eyelashes caused by entro-
pion (“the lashes turn against the eyeball because the skin
of the upper lid becomes loose, relaxes and droops down”)
were common conditions.12 Celsus did not distinguish
these two conditions as we do in modern medicine.
Three different operations were described according to
the precise manifestation and severity of the condition.
The rst was cauterisation of the hair follicles with a
red hot needle; the second involved the extraction of
the hair with needle and thread; and the third was
the cutting and suturing of a relaxed eyelid. Although
Celsus did not despise the rst method, he undoubtedly
preferred the last method and certainly disapproved of
the second, especially when many eyelashes were to
be removed, as the repeated perforation of an already
affected eyelid could dramatically exacerbate pain and
cause potentially troublesome inammation. The third
method involved re-shaping of the eyelid by removing
excess skin (the term blepharoplasty was coined in 1818
by Karl Ferdinand Von Graefe15 to describe a technique
for repairing deformities caused by resection of cancer
in the eyelids) from the upper and/or lower eyelid that
was causing entropion-related eyelash irritation. Upper
and lower eyelid skin is grasped with the ngers and
then lifted upward to estimate how much of the skin
has to be excised so that the normal lid position will be
regained. Celsus described how to plan the operation
as follows: ‘…to seize a fold of skin between a nger and
thumb…then consider how much must be removed so that the
lid will be in a natural position for the future.’ He brilliantly
advised the creation of deliberate incisions with ink tak-
ing care ‘…that between the margin holding the eyelashes,
and the marked line adjacent, there remains skin enough for
a needle afterwards to take up.’ The Roman author further
indicated which direction to take and how deep the inci-
sion should be, emphasizing the placement of sutures
(no more than three) at intervals. Perceptively, the
Roman author suggested an additional linear incision
under the row of eyelashes itself of the upper eyelid in
order to draw them superiorly. He further indicated the
need for proper distance of the suture from the wound
edge (thus preventing tension and tissue strangulation)
and described when the suture should be removed
(after 4 days, similar to modern concepts). The position
and the size of the excised strip were critical to a suc-
cessful result, though adjustment was possible at the
suturing stage. With his modern approach to surgery,
he underlined that complications should be considered
in advance, that common iatrogenic mistakes should
AQ3
FIGURE 2 Frontispiece of Celsus “De Re Medica libri octo” from
Lugduni, apud Sebastianum Gryphum edition, published in 1542.
(Courtesy of Biblioteca Antiqua, Aboca Museum, Sansepolcro
(AR), Italy).

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4 D. Lazzeri et al.
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be avoided and how mistakes should be managed if
they do occur. Celsus specically stated that condi-
tions such as ptosis, eyelid retraction, entropion and
ectropion occurred sometimes as a consequence of an
imperfect operation performed to treat trichiasis and
gave an accurate report about the technical details
for preventing such complications; he also described
detailed procedures for treatment. For lagophthalmus
Celsus advised incision of the skin of the upper lid just
below the eyebrow in the gure of a crescent with the
horns pointing downwards and allowing the wound to
heal by second intention inserting a lint in the gap “…
both to prevent the separated edges from reuniting, and to
help the growth of the esh between, so that the eyeball comes
to be properly covered when the gap has lled up.” When
ectropion occurred after defective lower lid surgery, it
was managed in the same way, but the horns of the
incision were directed ‘towards the jaws not towards the
eyeball’, and the wound was closed with ne cautery.
Finally, the entire everted mucosa of ectropion caused
by old age was to burned with a thin, hot iron.
DISCUSSION
According to Ebers,3 the Egyptians knew conditions
such as blepharitis, chalazion, ectropion, entropion,
trichiasis, granulations, chemosis, pinguecula, ptery-
gium, leucoma, staphyloma, iritis, cataract, hyphaema,
inammation, ophthalmoplegia and dacryocystitis. No
trace or evidence of marked advances in surgery made
by Egyptians exists. The only procedure that could be
considered “a form of surgery” is epilation of hair, men-
tioned in the Eber papyrus.3 The numerous epilation
forceps found among the relics suggest how widespread
this method was.
Some centuries later, the brilliant Indian surgeon
Sushruta recognized and named 76 different diseases
affecting the eye, dedicating 18 chapters of his work
Sushruta Samhita to them.7 It becomes immediately
obvious that surgery in the wider sense played an
important role in the ophthalmology and ophthalmic
plastic surgery of ancient India. It was more important
in India than among the Arabs and certainly played a
greater role in India than in ancient Greece.4 Cataract,
pterygia and trichiasis were commonly treated diseas-
es.
7
The widespread incidence of trachoma in India may
explain the high incidence of trichiasis as a secondary
consequence of it. The description of this procedure is
one of the highest merits reached by Indian surgery and
has inuenced all oculoplastic surgeons up to modern
times. A barleycorn-sized incision was made horizon-
tally and parallel to the eyelashes in the distal third of
the lid and then sutured with horse’s hair. A piece of
linen was tied around the forehead, and the horse’s hair
used to sew up operated parts, was attached thereto.
Once the adhesion of the two margins was obtained,
the sutures were removed. When this approach failed,
salvage procedures included cauterisation of the upper
lid or complete epilation.7,8
FIGURE 3 “De Pilis palpebrarum oculum iritantibus”. From Celsus’ “De Re Medica libri octo”, Lugduni, apud Sebastianum Gryphum
edition, 1542, page 334. The method involved re-shaping of the eyelid by removing excess skin from the upper and/or lower eyelids to
treat trichiasis. (Courtesy of Biblioteca Antiqua, Aboca Museum, Sansepolcro (AR), Italy).
AQ4

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History of Eyelid Surgery 5
© 2011 Informa Healthcare USA, Inc.
Nothing produced by Greek and Hippocratic medi-
cine in the eld of surgery could be comparable with the
brilliant innovations and ideas developed by Sushruta.16
Nevertheless, it has been shown that Hippocrates bor-
rowed much of his medical material from the Indians.
It is likely to the Indians that we owe the rst system of
medicine; thus, the literature suggests that Greek medi-
cine adopted Indian medicaments and methods.17 To
date, it is not still conrmed whether the secrets of plastic
surgery practiced by Indian surgeons diffused rapidly
to the western world or remained hidden for centuries
until later connections were established between the
Indians and the ancient world. Although likely, there is
no documentation about the transfer of reconstructive
procedures prior to the 7th century B.C., whereas it is
historically proven that a substantial medical knowl-
edge was shared by the two civilisations even before
the expedition of Greeks to India guided by Alexander
the Great (4th century B.C.). The answer to this intrigu-
ing question may explain how many Greek and Roman
authors provided the care and surgical restoration of
various facial defects with methods and approaches so
similar to those of their Indian counterparts.
Despite the claims of some historians, it does not
appear that Celsus performed nose reconstructions
using skin aps. However, the detailed descriptions
in De Medicina leave no doubt that he successfully
repaired lips and ears after trauma by surgical means
adopting techniques extremely similar to Indian meth-
ods.13 The advancement ap described so clearly by
Celsus did not differ greatly from Sushruta’s proce-
dure, even though Celsus introduced one important
improvement to the procedure, in recommending that
the surgeon modify the defect whenever possible,
imposing a geometric (preferably quadrangular or
triangular) outline so that it could be more easily cov-
ered by a matching ap. Concerning eyelid surgery,
the techniques reported by Celsus in his seven books
resemble those described by Sushruta (mainly ptery-
gium removal and re-shaping of the relaxed eyelid) in
the sixth century A.D.
7
The similarities between these
techniques reported by Sushruta and Celsus indicate
that the Roman author probably had a source that
described Indian surgical practices. This source might
have been the text of an ancient Greek physician of
the Alexandria School, both because it is known that
Celsus also used many Alexandrian sources to write
his works and because ancient Greeks were silent on
the subject.18
Interestingly, pterygium removal as described
by Celsus is similar to that described by Sushruta.
Regarding the treatment of trichiasis by eyelid tight-
ening, one of the innovations introduced by the
Roman writer that should be considered vital is the
preoperative marking of the quantity of lid skin that
has to be removed. However, in correcting entropion,
Sushruta recommends excising the third of the skin
closer to the lid margin, emphasizing how an excision
involving the upper part of the lid would remain
unsuccessful. Celsus also advises the use of this exci-
sion without, however, specically making a record of
it.
4
In discussing the restoration of the lagophthalmus,
Celsus does not provide any approach when extreme
lagophthalmus occurs due to excessive skin removal.
4
Celsus, therefore, did not know much about oculoplas-
tic surgery; the knowledge of Indian physicians was
superior to that of the Greeks and other Europeans
until the1800s.4 The Roman author provided a detailed
account about the surgical treatment of minor afic-
tions of the eyelid, small tumour or cysts, whereas
Sushruta advocated scarication in the treatment of
chalazia and styes.
Works from the Alexandrian school may have been
the source through which Celsus and all who have
been later inuenced by the Roman’s book inherited
the secrets and techniques of ophthalmologic surgery,
including eyelid surgery.
CONCLUSION
There is no doubt that Celsus is one of the most impor-
tant contributors to surgery and medicine. The descrip-
tion of ophthalmology and ophthalmic plastic surgery
is the oldest one available. This contribution by Celsus
merits our closest scrutiny, though we should not over-
look certain defects and some real errors because of
blind admiration for antiquity. However, it is indeed
necessary to read his work with a critical eye so as to
relate it to a historical context and better understand
his contribution as a physician and innovator, to be dis-
tinguished from his contributions as an encyclopedist
and compiler.
De Medicina, the form and proportion of which
seems to be almost perfect, comes in all probability
from the hand not of a physician but of a layman.
However, these books are far more than just simple
translations of Greek writings. Celsus clearly formu-
lated his own opinion from the collected knowledge
till his time and wrote down his independent theories,
involving one that ultimately became − and remains −
the basic principle in medicine: “accurate diagno-
sis must precede treatment.” Celsus was extremely
methodical in approaching every aspect of all the
eyelid surgery procedures known up to his time. He
innovated slightly eyelid surgery, but mainly helped
to publicise approaches and techniques inherited from
Indian and Alexandrian surgeons to the West. Perhaps
due to the loss of so much early medical literature, he
became one of the most inuential sources of ancient
medicine.
The form in which the material is presented, par-
ticularly in oculoplastic surgery chapter, deserves the
highest praise for being extremely adaptable for use in
teachings and instruction.

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6 D. Lazzeri et al.
Orbit
ACKNOWLEDGEMENTS
We wish to express our gratitude to the Aboca Museum
(www.abocamuseum.it) in Sansepolcro, Arezzo, Italy
for permitting reproduction of the gures from Celsus’
book. In particular, we feel indebted to Miss Anna
Zita Di Carlo (director of the museum) and Mister
Michelangelo Rossi of the Aboca Museum for their
help.
Declaration of interest: The authors report no conicts
of interest.
REFERENCES
1. Breasted JH. Edwin smith surgical papyrus. In: Facsimile
and Hieroglyphic Transliteration with Translation and
Commentary. Chicago: University of Chicago Press; 1930
2. Majno G. The Healing Hand, Man and Wound in the Ancient
World. Cambridge, MA: Harvard University Press; 1975
3. Corleto LM. Pharmacopoeia in ancient Egypt. Med Secoli
1993;5:1–18.
4. Hirschberg J. The History of Ophthalmology, Vol. 1: antiquity.
(Blodi FC, transl), Bonn, Germany, Verlag JP Wayenborgh;
1982. pp 7, 12, 33, 43, 44, 47, 122, 130, 215–256.
5. Rana RE, Arora BS. History of plastic surgery in India.
J Postgrad Med 2002;48:76–78.
6. Nichter LS, Morgan RF, Nichter MA. The impact of Indian
methods for total nasal reconstruction. Clin Plast Surg
1983;10:635–647.
7. Raju VK. Susruta of ancient India. Indian J Ophthalmol
2003;51:119–122.
8. Kansupada KB, Sassani JW. Sushruta: the father of Indian sur-
gery and ophthalmology. Doc Ophthalmol 1997;93:159–167.
9. Garrison FH. History of Medicine. Philadelphia: W.B.
Saunders Company; 1966. pp 92–93.
10. Major RH. Classic Descriptions of Disease, 3rd Edition.
Springeld, Illinois: Charles C Thomas Pub Ltd; 1945.
11. Adams F. The Genuine Works of Hippocrates, Vol. 2, 1st
Edition. New York: William Wood & Company; 1886.
12. Spencer WG. De Medicina By Celsus. Edited by: (trans.).
Cambridge: Massachusetts Harvard University Press; 1935,
Book VII.
13. Santoni-Rugiu P, Sykes PJ. A History of Plastic Surgery.
Germany: Springer-Verlag Berlin and Heidelberg GmbH &
Co. KG; 2007. pp 9, 49, 63, 65, 67, 75, 173, 189, 202, 215, 220,
254, 256, 273.
14. Jackson RPJ. Rise and Decline of the Roman World. Vol 37,
Part 2, cap. V. p 2243.
15. Von Graefe KF. Rhinoplasty or the Art to Replace the Loss
of the Nose Organically [in German]. Berlin: Realschulbuch;
1818. p 13.
16. Thorwald J. Science and Secrets of Early Medicine. (Translated
by Winston R, Winston C). New York: Harcourt, Brace &
World, Inc; 1963. p 194.
17. Neuburger M. History of Medicine. [Translated by E. Playfair].
London: Oxford University Press; 1910. Vol. 1, p 60.
18. Mettler CC. History of Medicine. Philadelphia: The Blakiston
Co.; 1947. pp 332–337, 853.
AQ5
AQ6
AQ7

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ORIGINAL ARTICLE
Recto: History of Eyelid Surgery
Verso: D. Lazzeri et al.
The Contribution of Aulus Cornelius Celsus (25 B.C.– -
50 A.D.) to Eyelid Surgery
Davide Lazzeri
1
, M.D.;, Tommaso Agostini
, M.D.*2
; , Michele Figus
, M.D.§3
; , Marco Nardi
,
M.D.§3
; , Marcello Pantaloni
, M.D.;1
, and Stefano Lazzeri
3
, M.D.
§
;
1
Plastic and Reconstructive Surgery Unit, Hospital of Pisa, Pisa, Italy
2
Burn Center Unit, Hospital of Pisa, Pisa, Italy
3
Ophthalmology Unit, University Hospital of Pisa, Pisa, Italy[AU: Please carefully check the
authors’ names and affiliations.]
Plastic and Reconstructive Surgery Unit and *Burn Center Unit, Hospital of Pisa,
§
Ophthalmology Unit, University Hospital of Pisa, Italy.
DL is plastic surgeon at the Plastic and Reconstructive Surgery, Hospital of Pisa, Italy. MP is
the Chief of the Unit.
TA is plastic surgeon at the Burn Center Unit, Hospital of Pisa, Italy.
SL and MF are ophthalmologists at the Ophthalmology Unit, University of Pisa Hospitals,
Italy. MN is full professor of Ophthalmology, director of the Specialization School and
director of the Unit.
Address Correspondence to:: Dr.
Davide Lazzeri, M.D.,
Unità Operativa di Chirurgia Plastica e Ricostruttiva, Ospedale di Pisa,
Via Paradisa 2, Cisanello – , 56100 Pisa (, Italy)
. Phone numberTel: +39 050 996879, Mobile: +39 3476675673.
Fax number: +39 050 996845
Mobile phone number: +39 3476675673.

- 10 -
E-mail address: davidelazzeri@gmail.com
Running head: History of eyelid surgery
ABSTRACT
An accurate study of ancient medicine reveals that our forebears developed a large number of
surgical ideas and techniques considered to be quite modern. Although the contribution of
Aulus Cornelius Celsus to the development of several branches of surgery has already been
celebrated, scant attention has been focused on his description of eyelid surgery in the
seventh book of his encyclopedia, De medicina Medicina octo libri. Although the practice
was quite advanced by that time, the first century A.D., Celsus was the first among the
Greco-Roman authors to deal systematically with ophthalmology and oculoplastic surgery.
He was a compiler, and many of his “innovations” were in fact done in principle by others.
Yet it is almost certain that the surgical procedures presented were introduced more than
fifteen 15 centuries before the time of Celsus by Egyptians, Indian surgeons, and Greek and
Alexandrian doctors. The burning of the Ancient Library of Alexandria as well as the
perishing of many writings of pioneer physicians resulted in a tragic loss of ancient
knowledge for posterity. Celsus, whose work has been preserved in our time, helped to
publicisepublicize this ancient knowledge, and perhaps because of the loss of so much early
medical literature, became one of the most influential experts on ancient medicine. An
analysis of how previous authors have influenced Celsus’ description of eyelid surgery and
reflections on how modern his ideas (or those of his time) were are presented in the paper.
KEYWORDS : Surgery; , Celsus; , Eyelid; , Romans; , History
INTRODUCTION
A true insight into the medicine of ancient Egypt has been possible only after the original
Egyptian documents (The Ebers Papyrus and the Edwin Smith Papyrus)
1,2
were found and
elegantly translated by Edwin Smith and George Ebers at the end of the 19th century.
Nevertheless, plastic surgery of the face can probably make a claim to being one of the oldest
surgical specialties by referring to descriptions of rudimentary surgical procedures performed
to repair facial trauma, including mandibular and nasal fractures described in the Egyptian
Edwin Smith Surgical Papyrus,
1
which may date back to the third millennium B.C. (2600– -
2200 B.C.).
2
The Ebers Papyrus
3
represents the most important document about medicine
Formatted: kwd, English (U.S.)

- 10 -
(written between 1553 and 1550 B.C.) from ancient Egypt and includes chapters on ocular
diseases.
4
This papyrus also describes with medications for the treatment of eyelid diseases.
The epilation of hair in the eye (“trichiasis”), however, remains the only ocular operation
mentioned in the document.
3,4
Nothing is known about ophthalmic plastic surgery operations of the Babylonians and
Assyrians and very little is known about their medicine in general. In contrast, Indians
bequeathed abundant historical records by way of a Sanskrit text entitled Sushruta Samhita.
This encyclopedic volume (samhita is Sanskrit for encyclopedia) was written by a renowned
Indian surgeon named Sushruta, who lived during the 6th century B.C. In his book, he
described over 120 surgical instruments and 300 surgical procedures and classified human
surgery into 8 eight categories.
5
Among all achievements of Indian medicine, the art and
science of restoring facial injuries, in particular total nasal reconstruction, and the cataract
operation (all of which were described by Sushruta) constitute important chapters in the
history of plastic surgery
5-85–8
and ophthalmology.
4,7,8
About 20 diseases of the lids are
mentioned in the treatise. Lid abscesses were first approached with warm compresses and
then opened and expressed.
4
Entropion was restored by excising a strip of skin that should be
3 lines wide and should involve the lower third of the upper lid (Sushruta underlined
brilliantly how an excision involving the upper part of the lid would likely fail). Hair sutures
were used to close the wound. If this operation was not successful, the hair follicles had to be
destroyed by heat or by cauterisation.
4,7,8
Pterygium removal was another well-described
operation. Many stages of pterygia were described as distinct diseases.
7,8
Surgical removal of
the inflamed pterygium was the choice of treatment once eye-drops and salves had failed.
With the eyelids held wide apart by the surgeon, the pterygium was grasped with a hook and
held with a threaded needle and then excised at its base while the patient was obliged to
rotate his affected eye medially toward his internal canthus. The root of the pterygium was
pushed asunder from the black outline (cornea) of the eye to the medial canthus and then
removed.
7,8
The eye was then protected for three 3 days with
eye patches and dressed with
various salts. Adequate excision of the pterygium prevented any recurrence.
7,8
Hippocratic surgery never went beyond what we now call minor surgery; however,
Hippocratic teachings remain extremely relevant in the surgical context
10
outlining brilliant
measures to treat and restore facial injuries.
11
Twenty different eye diseases or symptoms are
described by Hippocrates, including lid diseases; notwithstanding, operations on the eye are
not mentioned in the authentic books by Hippocrates. This, of course, does not mean that they

- 10 -
were completely unknown. Even in the unauthenticated Hippocratic books, few ocular
operations are mentioned.
4
Of interest among these we found the treatment of trichiasis
performed by extraction with needle and thread.
4
The School of Alexandria (third century B.C.) should get credit for the following minor
eyelid operations:
4
incision of a sty; excision of chalazia, pterygia, tumor of the caruncle,
pustules and dermoids; and excision of a fistulae of the lacrimal sac with burning of the bone.
The separation of adherent lids and of lids adherent to the eyeball was described.
4
Alexandrian surgeons further adopted several approaches for the treatment of pathologic
lashes: a red hot iron was used to cauterise lashes as an alternative to the removal of
pathologic lashes with a thread. Other interesting procedures elegantly proposed by
Alexandrian surgeons to treat trichiasis included the transplantation of lashes with the
excision of skin and suturing and incision into the palpebral conjunctiva close to the lid
margin.
4
the The approach used to treat lagophtalmus involved a semilunar incision (the
same operation was used against ectropion). Recurrent ectropion was treated with a hot iron
(also used to burn the everted mucosa of the lid).
4
We have to wait three centuries and reach Imperial Rome to meet one of the greatest sources
of ancient surgery, the Roman medical writer Aulus Cornelius Celsus (25 B.C.– - 50 A.D.)
(Fig. ure 1). With his pioneering work, De medicina, known also as De Re Medica (Fig. ure
2), Celsus earned a reputation as one of the most important contributors to medicine and
scientific thought during the Roman Empire, and the most important source of present-day
knowledge on Alexandrian medicine (Celsus did not change the Greek and Alexandrian
anatomical terminology used in writing about the eye). Although the practice was quite
advanced by that time, the first century A.D., Celsus is the first among the Greco-Roman
authors to deal systematically with ophthalmology and eyelid surgery, with related
manuscripts preserved to the present day. The preceding Hippocratic writings are silent on
the subject, and therefore the Alexandrian school mainly influenced by the knowledge
inherited by Indians must have developed the teachings to the advanced level recorded by
Celsus.
Having analysed analyzed the contribution of Celsus’work in the development of several
branches of surgery, we focused our attention on his real contribution: ophthalmic plastic
surgery. The question we tried to answer was whether he was an innovator, a brilliant
physician or just a methodic compiler.

- 10 -
CELSUS’S DESCRIPTION OF EYELID SURGERY
Because eyelid surgery is extremely risky for the practitioner and potentially perilous for the
patient, it was avoided wherever possible.
4,12–14
Thus the recourse to surgery was necessary
only when all the non-surgical procedures performed by the eye doctors had failed.
Indications for surgery were in this way acute, and chronic infections or dysfunction was
often caused by improper or failed medical treatment. Celsus’ chapter on eye surgery was
organised organized accordingly: diseases of the periocular tissues were followed by those
involving the eyelids and, lastly, the eyeball. Concerning eyelid surgery Celsus began with
minor afflictions, small tumour or cysts. A transverse incision in the eyelid was described as
the best approach with which to remove intact encysted tumours and enlarged sebaceous
glands as well as chalazia and dermoid cysts. Mature Meibomian cysts in which fomentations
had failed to disperse pus were incised and squeezed. The practice of surgical removal of the
pterygium was well known. Ancyloblepharus, a frequent consequence of inadequate
treatment of an ulcer resulting in adhesion between the eyelids or the eyelids and the eyeball,
was approached with the reverse end of a probe followed by the insertion of a pledgelets[AU:
Please check and confirm whether the term is pledgelets or pledgets.] of wool and vigilant
after-care to avoid re-adhesion.
With respect to diseases of the lashes, trichiasis which involves “a second row of lashes
growing beneath the first one” and eyeball irritation by eyelashes caused by entropion (“the
lashes turn against the eyeball because the
skin of the upper lid becomes loose, relaxes and
droops down”) were common conditions.
12
Celsus did not distinguish these two conditions
as we do in modern medicine. Three different operations were described according to the
precise manifestation and severity of the condition. The first was cauterisation of the hair
follicles with a red hot needle; the second involved the extraction of the hair with needle and
thread; and the third was the cutting and suturing of a relaxed eyelid. Although Celsus did not
despise the first method, he undoubtedly preferred the last method and certainly disapproved
of the second, especially when many eyelashes were to be removed, as the repeated
perforation of an already affected eyelid could dramatically exacerbate pain and cause
potentially troublesome inflammation. The third method involved re-shaping of the eyelid by
removing excess skin (the term blepharoplasty was coined in 1818 by Karl Ferdinand Von
Graefe
15
to describe a technique for repairing deformities caused by resection of cancer in the
eyelids) from the upper and/or lower eyelid that was causing entropion-related eyelash
Formatted: query, English (U.S.)

- 10 -
irritation. Upper and lower eyelid skin is grasped with the fingers and then lifted upward to
estimate how much of the skin has to be excised so that the normal lid position will be
regained. Celsus described how to plan the operation as follows: ’‘…to seize a fold of skin
between a finger and thumb…then consider how much must be removed so that the lid will be
in a natural position for the future.’ He brilliantly advised the creation of deliberate incisions
with ink taking care ‘…that between the margin holding the eyelashes, and the marked line
adjacent, there remains skin enough for a needle afterwards to take up.’ The Roman author
further indicated which direction to take and how deep the incision should be, emphasizing
the placement of sutures (no more than three) at intervals. Perceptively, the Roman author
suggested an additional linear incision under the row of eyelashes itself of the upper eyelid in
order to draw them seperiorlysuperiorly. He further indicated the need for proper distance of
the suture from the wound edge (thus preventing tension and tissue strangulation) and
described when the suture should be removed (after four 4 days, similar to modern concepts).
The position and the size of the excised strip were critical to a successful result, though
adjustment was possible at the suturing stage. With his modern approach to surgery, he
underlined that complications should be considered in advance, that common iatrogenic
mistakes should be avoided and how mistakes should be managed if they do occur. Celsus
specifically stated that conditions such as ptosis, eyelid retraction, entropion and ectropion
occurred sometimes as a consequence of an imperfect operation performed to treat trichiasis
and gave an accurate report about the technical details for preventing such complications; he
also described detailed procedures for treatment. For lagophthalmus Celsus advised incision
of the skin of the upper lid just below the eyebrow in the figure of a crescent with the horns
pointing downwards and allowing the wound to heal by second intention inserting a lint in
the gap “…both to prevent the separated edges from reuniting, and to help the growth of the
flesh between, so that the eyeball comes to be properly covered when the gap has filled up.”
When ectropion occurred after defective lower lid surgery, it was managed in the same way,
but the horns of the incision were directed ‘towards the jaws not towards the eyeball’, and the
wound was closed with fine cautery.
Finally, the entire everted mucosa of ectropion caused by old age was to burned with a thin,
hot iron.
DISCUSSION

- 10 -
According to Ebers,
3
the Egyptians knew conditions such as blepharitis, chalazion, ectropion,
entropion, trichiasis, granulations, chemosis, pinguecula, pterygium, leucoma, staphyloma,
iritis, cataract, hyphaema, inflammation, ophthalmoplegia and dacryocystitis. No trace or
evidence of marked advances in surgery made by Egyptians exists. The only procedure that
could be considered “a form of surgery” is epilation of hair, mentioned in the Eber papyrus.
3
The numerous epilation forceps found among the relics suggest how widespread this method
was.
Some centuries later, the brilliant Indian surgeon Sushruta recognised recognized and named
76 different diseases affecting the eye, dedicating 18 chapters of his work Sushruta Samhita
to them.
7
It becomes immediately obvious that surgery in the wider sense played an
important role in the ophthalmology and ophthalmic plastic surgery of ancient India. It was
more important in India than among the Arabs and certainly played a greater role in India
than in ancient Greece.
4
Cataract, pterygia and trichiasis were commonly treated diseases.
7
The widespread incidence of trachoma in India may explain the high incidence of trichiasis as
a secondary consequence of it. The description of this procedure is one of the highest merits
reached by Indian surgery and has influenced all oculoplastic surgeons up to modern times. A
barleycorn-sized incision was made horizontally and parallel to the eyelashes in the distal
third of the lid and then sutured with horse’s hair. A piece of linen was tied around the
forehead, and the horse’s hair used to sew up operated parts, was attached thereto. Once the
adhesion of the two margins was obtained, the sutures were removed. When this approach
failed, salvage procedures included cauterisation of the upper lid or complete epilation.
7,8
Nothing produced by Greek and Hippocratic medicine in the field of surgery could be
comparable with the brilliant innovations and ideas developed by Sushruta.
16
Nevertheless, it
has been shown that Hippocrates borrowed much of his medical material from the Indians. It
is likely to the Indians that we owe the first system of medicine; thus, the literature suggests
that Greek medicine adopted Indian medicaments and methods.
17
To date, it is not still
confirmed whether the secrets of plastic surgery practiced by Indian surgeons diffused rapidly
to the western world or remained hidden for centuries until later connections were established
between the Indians and the ancient world. Although likely, there is no documentation about
the transfer of reconstructive procedures prior to the 7th century B.C., whereas it is
historically proven that a substantial medical knowledge was shared by the two civilisations
even before the expedition of Greeks to India guided by Alexander the Great (4th century
B.C.). The answer to this intriguing question may explain how many Greek and Roman

- 10 -
authors provided the care and surgical restoration of various facial defects with methods and
approaches so similar to those of their Indian counterparts.
Despite the claims of some historians, it does not appear that Celsus performed nose
reconstructions using skin flaps. However, the detailed descriptions in De Medicina leave no
doubt that he successfully repaired lips and ears after trauma by surgical means adopting
techniques extremely similar to Indian methods.
13
The advancement flap described so clearly
by Celsus did not differ greatly from Sushruta’s procedure, even though Celsus introduced
one important improvement to the procedure, in recommending that the surgeon modify the
defect whenever possible, imposing a geometric (preferably quadrangular or triangular)
outline so that it could be more easily covered by a matching flap. Concerning eyelid surgery,
the techniques reported by Celsus in his seven books resemble those described by Sushruta
(mainly pterygium removal and re-shaping of the relaxed eyelid) in the sixth century A.D.
7
The similarities between these techniques reported by Sushruta and Celsus indicate that the
Roman author probably had a source that described Indian surgical practices. This source
might have been the text of an ancient Greek physician of the Alexandria School, both
because it is known that Celsus also used many Alexandrian sources to write his works and
because ancient Greeks were silent on the subject.
18
Interestingly, pterygium removal as described by Celsus is similar to that described by
Sushruta. Regarding the treatment of trichiasis by eyelid tightening, one of the innovations
introduced by the Roman writer that should be considered vital is the preoperative marking of
the quantity of lid skin that has to be removed. However, in correcting entropion, Sushruta
recommends excising the third of the skin closer to the lid margin, emphasizing how an
excision involving the upper part of the lid would remain unsuccessful. Celsus also advises
the use of this excision without, however, specifically making a record of it.
4
In discussing
the restoration of the lagophthalmus, Celsus does not provide any approach when extreme
lagophthalmus occurs due to excessive skin removal.
4
Celsus, therefore, did not know much
about oculoplastic surgery; the knowledge of Indian physicians was superior to that of the
Greeks and other Europeans until the1800s.
4
The Roman author provided a detailed account
about the surgical treatment of minor afflictions of the eyelid, small tumour or cysts, whereas
Sushruta advocated scarification in the treatment of chalazia and styes.
Works from the Alexandrian school may have been the source through which Celsus and all
who have been later influenced by the Roman’s book inherited the secrets and techniques of
ophthalmologic surgery, including eyelid surgery.

- 10 -
CONCLUSION
There is no doubt that Celsus is one of the most important contributors to surgery and
medicine. The description of ophthalmology and ophthalmic plastic surgery is the oldest one
available. This contribution by Celsus merits our closest scrutiny, though we should not
overlook certain defects and some real errors because of blind admiration for antiquity.
However, it is indeed necessary to read his work with a critical eye so as to relate it to a
historical context and better understand his contribution as a physician and innovator, to be
distinguished from his contributions as an encyclopedist and compiler.
De Medicina, the form and proportion of which seems to be almost perfect, comes in all
probability from the hand not of a physician but of a layman. However, these books are far
more than just simple translations of Greek writings. Celsus clearly formulated his own
opinion from the collected knowledge till his time and wrote down his independent theories,
involving one that ultimately became-- – and remains – --the basic principle in medicine:
“accurate diagnosis must precede treatment.” Celsus was extremely methodical in
approaching every aspect of all the eyelid surgery procedures known up to his time. He
innovated slightly eyelid surgery, but mainly helped to publicise approaches and techniques
inherited from Indian and Alexandrian surgeons to the West. Perhaps due to the loss of so
much early medical literature, he became one of the most influential sources of ancient
medicine.
The form in which the material is presented, particularly in oculoplastic surgery chapter,
deserves the highest praise for being extremely adaptable for use in teachings and instruction.
ACKNOWLEDGEMENTS
We wish to express our gratitude to the Aboca Museum (www.abocamuseum.it) in
Sansepolcro, Arezzo, Italy for permitting reproduction of the figures from Celsus’ book. In
particular, we feel indebted to Miss Anna Zita Di Carlo (director of the museum) and Mister
Michelangelo Rossi of the Aboca Museum for their help.
Conflicts Declaration of interest:
The authors have report no conflicts of interest to
declare.
REFERENCES
Formatted: Font: Not Bold

- 10 -
1. Breasted JH. Edwin smith surgical papyrus. In: Facsimile and Hieroglyphic
Transliteration with Translation and Commentary, . Chicago, : University of Chicago
Press, ; 1930[AU: Please provide editors name for Ref. 1, if available.]
2. Majno G. The Healing Hand, Man and Wound in the Ancient World. Cambridge,
MA, : Harvard University Press,; 1975
3. Corleto LM. [Pharmacopoeia in ancient Egypt]. Med Secoli 1993;5:1–18.
4. Hirschberg J. The History of Ophthalmology, Vol. 1: antiquity. (Blodi FC, transl),
Bonn, Germany, Verlag JP Wayenborgh, ; 1982, . pp 7, 12, 33, 43, 44, 47, 122, 130,
215–256.
5. Rana RE, Arora BS. History of plastic surgery in India. J Postgrad Med 2002;48:76–
78.
6. Nichter LS, Morgan RF, Nichter MA. The impact of Indian methods for total nasal
reconstruction. Clin Plast Surg 1983;10:635–647.
7. Raju VK. Susruta of ancient India. Indian J Ophthalmol 2003;51:119–122.
8. Kansupada KB, Sassani JW. Sushruta: the father of Indian surgery and
ophthalmology. Doc Ophthalmol 1997;93:159–167.
9. Garrison FH. History of Medicine, . Philadelphia: W.B. Saunders Company,
Philadelphia, ; 1966, . pp 92–93[AU: Please provide in-text citation for Ref. 9 or
delete reference.].
10. . Major RH. Classic Descriptions of Disease., 3rd Edition. Springfield, Illinois: Charles
C Thomas Pub Ltd, third edition, Springfield, Illinois, ; 1945.
11. Adams F. The Genuine Works of Hippocrates, Vol. 2, 1st Edition. New York, :
William Wood & CompanyWilliam Wood & Company,; 1886.
12. Spencer WG. De Medicina By Celsus. Edited by: (trans.). Cambridge: Massachusetts
Harvard University Press, Massachusetts Harvard University Press,; 1935, Book VII.
13. Santoni-Rugiu P, Sykes PJ. A History of Plastic Surgery. Germany: Springer-Verlag
Berlin and Heidelberg GmbH & Co. KG, ; 2007, . pp 9, 49, 63, 65, 67, 75, 173, 189,
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16. Thorwald J. Science and Secrets of Early Medicine. (Translated by Winston R,
Winston C). New York: Harcourt, Brace & World, Inc. ; 1963. p 194.
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FIGURE LEGEND
FIGURE 1 .
The famous Roman medical writer Aulus Cormelius Celsus (25 B.C.– - 50 A.D.). ((Courtesy
of Biblioteca Antiqua, Aboca Museum, Sansepolcro (AR), Italy).
FIGURE 2 .
Frontispiece of Celsus “De Re Medica libri octo” from Lugduni, apud Sebastianum Gryphum
edition, published in 1542. (Courtesy of Biblioteca Antiqua, Aboca Museum, Sansepolcro
(AR), Italy).
FIGURE 3 .
“De Pilis palpebrarum oculum iritantibus”. From Celsus’ “De Re Medica libri octo”,
Lugduni, apud Sebastianum Gryphum edition, 1542, page 334. The method involved re-
shaping of the eyelid by removing excess skin from the upper and/or lower eyelids to treat
trichiasis. (Courtesy of Biblioteca Antiqua, Aboca Museum, Sansepolcro (AR), Italy)[AU:
Please provide in-text citation for Figure 3.].
Formatted: query, English (U.S.)
Formatted: query, English (U.S.)