SECT. XIX.—ON STAPHYLOMA.
Staphyloma is an incurvation of the cornea, and of the tunica choroides, arising from debility, and being produced sometimes by a defluxion, and sometimes by ulceration. We operate upon it not in order to restore the eyesight, for that is impossible, but to moderate the patient’s deformity. Wherefore having passed a needle from below upwards through the base of the staphyloma, we are to push another needle, having a double thread, from the canthus next the hand to the other, through the base of the staphyloma; and the first needle remaining, we cut the double of the thread, and tie part of the staphyloma upwards and part downwards with the threads, and then removing the needle we apply wool dipped in eggs. After the removal of the dressings we soothe the eyes with emollient injections until the ligatures fall off along with the staphyloma.
Commentary. Celsus thus describes the disease: “In ipso autem oculo nonnunquam summa attolitur tunica, sive ruptis intus membranis aliquibus, sive laxatis: et similes figura acino fit: unde id σταφύλωμα Græci vocant.” He describes two methods of cure: the first of which is by ligatures, as recommended by our author; and the other consists in cutting from the apex a circular portion equal in size to a lentil.
Scarpa and Guthrie concur in recommending the latter operations, the merits of which, as they state, have not been generally appreciated properly.
Aëtius directs us to introduce the cross threads, as recommended by our author, and then to cut out the apex of the tumour. He is at great pains in directing us to introduce the threads obliquely, and not at right angles to one another. He also recommends general bleeding and emollient fomentations, (vii, 37.)
The operation with the ligatures is briefly described in the ‘Isagoge,’ generally ascribed to Galen.
Haly Abbas and Albucasis describe the operation with the cross threads in nearly the same terms as our author. The latter, however, makes mention of puncturing the apex of the tumour after the application of the ligatures. Jesu Hali gives nearly the same account of the operation.
Although Scarpa condemns in strong terms the use of the needle and ligatures, this method of treatment is sanctioned by the authority of Mr. Travers. This operation was approved of by William of Saliceto.
Scultet explains the descriptions given by Celsus and Paulus, but they are sufficiently plain of themselves. (Arsen. de Chirurg. tab. 32.)
It will be perceived that the ancients applied the name staphyloma to two distinct, or at least considerably different diseases, namely, to enlargement with protrusion of the cornea, and to prolapsus of the iris connected with ulceration of the cornea. Heister, Wenzel, and other continental writers, use it in the same sense as the ancients. Scarpa and our English oculists apply it only to protrusion of the cornea, without ulceration.
SECT. XX.—ON HYPOPYON OF THE EYE.
Regarding hypopyon of the eyes it will be sufficient to deliver Galen’s account, which is to this effect:—“A certain oculist of our time, named Justus, cured many cases of hypopyon by shaking the head. Placing them, therefore, erect upon a chair, and grasping their head on both sides obliquely, he shook them so that we could see clearly the pus descending downwards; and, owing to the weight of the substance, it remained below, although cataracts will not remain unless fixed carefully.” And again, he says below, “oftentimes we evacuate the pus freely by dividing the cornea a little above the place where all the coats of the eye unite. This place is called by some the iris, and by others the corona.” These are the words of Galen in his work, ‘On the Method of Cure.’ After the discharge of the pus, we clean the ulcer with injections of honied water, or of the juice of fenugreek with the addition of some honey, and then apply the other treatment conformably.
Commentary. Galen recommends three methods of treatment for the cure of hypopyon; namely, by discutients, shaking, and incision. (Meth. Méd. xiv.)
Aëtius, Albucasis, and Haly Abbas, like our author, are advocates for shaking and incision. Neither of these methods is now much in use, but both have had their advocates in modern times.
SECT. XXI.—ON CATARACTS.
The cataract is a collection of inert fluids upon the cornea at the pupil, obstructing vision, or preventing distinct vision. It arises most commonly from a congelation and weakness of the visual spirit, and on that account the disease rather attacks old persons, and those who are debilitated by protracted illness. It is occasioned also by violent vomiting, a blow, and many other causes. Those kinds of cataract which are but commencing, as not being proper objects of surgery, have been treated of in the Third Book. We shall now give the characters of those which are fairly formed and have acquired consistence. All those, therefore, who have cataract see the light more or less, and by this we distinguish cataract from amaurosis and glaucoma; for persons affected with these complaints do not perceive the light at all. Wherefore, again, Galen well instructs us as to the consistence and difference of cataracts and which kinds ought to be operated upon. Having shut the eye affected with the cataract, and with the large finger pressing the eyelid to the eye, and moving it with pressure to this side and that, then opening the eyelids and observing the cataract in the eye; if it has not yet acquired consistence, a certain flow takes place from the pressure of the finger, and at first it appears broader, but straightway resumes its former figure and magnitude. But in those which have acquired consistence no change takes place as to breadth or figure from the pressure. But since this appearance is common to those which are of moderate consistence, and those which are over-compacted, we distinguish these cases from one another by their colour. For those which are of an iron, cœrulean, or leaden colour, are of moderate consistence, and fit for couching; but those which resemble gypsum and hailstones are over-compacted. After ascertaining these circumstances, as directed by Galen, having placed the patient opposite the light, but not in the sun, we bind up carefully the sound eye, and having separated the lids of the other, at the distance from the part called the iris towards the small canthus, of about the size of the knob of the specillum, we then with the point of the perforator mark the place about to be perforated; and if it is the left eye we operate with the right hand, or if the right eye with the left; and turning round the point of the perforator, which is bent at its extremity, we push it strongly through the part which was marked out, until we come to an empty place. The depth of the perforation should be as great as the distance of the pupil from the iris. Wherefore, raising the perforator to the apex of the cataract, (for the copper of it is seen through the transparency of the cornea,) we push down the cataract to the parts below, and if it is immediately carried downwards, we rest for a little, but if it reascends we press it back again. After the depression of the cataract we turn round the perforator and extract it gently. After this, bathing with water and injecting into the eye a little Cappadocian salts, we apply externally some wool soaked in the white of an egg with rose-oil, and bind it up, and at the same time bind up the sound eye, that it may not move. Then lodging the patient in an apartment below ground, we order him to remain in a state of perfect rest, and upon a spare diet; and the bandages are to be kept on, if nothing prevent, until the seventh day, after which we loose them, and make trial of the sight by presenting him with some object: but this we disapprove of during the operation and immediately after it, lest by the intense exertion the cataract reascend. If the inflammation become urgent we loose the dressing before the seventh day, and must direct our attention to it.
Commentary. See Celsus (vii, 7); Galen (Ars Medica, 35; Isagoge); Aëtius (vii, 53); Albucasis (Chirurg. ii, 23), Canamusali (vi); Avenzoar (i, 8, 19); Mesue (de Ægr. Oculi; 15); Haly Abbas (Pract. ix, 28); Jesu Hali (Tract. de Oculis, 68); Avicenna (iii, 3, 4, 20); Rhases (ad Mansor. ix, 27, and Cont. ii); Vegetius (Mulom. ii, 17.)
This disease is called suffusio by the Latins, and aqua by the Arabians.
We have stated in our commentary on affections of the eye, in the Third Book, that the ancients were aware that the crystalline lens is the seat of one of the species of cataract. This opinion is clearly delivered by Galen, Aëtius, Oribasius, Haly Abbas, and some of the others. As a proof that this notion prevailed generally, we will give the words of Psellus literally translated: “Glaucoma is a grievous and incurable affection, being a certain change of the crystalline humour, and transmutation of its colour to a sea-green. The suffusion is a concretion of the fluid between the cornea and crystalline humour.” (Opus Medicum.) The other species then, as Psellus states, was held to be a concretion between the crystalline lens and the cornea. That such a disease, although of comparatively rare occurrence, is sometimes met with seems undeniable.
Celsus lays it down as a rule, that when the suffusion is small, immovable, and of the colour of sea-water, or of shining iron, and if a small degree of light can be perceived at the side, there is reason to hope well of the case. He forbids us to operate until the disease has attained a proper consistence. He directs us to place the patient opposite the operator, who is to sit on a higher seat, while the patient’s head is firmly held by an assistant. The sound eye is to be previously covered up with wool. If the left eye is affected the operator must use his right hand, and vice versa. A needle which is sharp and not too slender is to be passed direct through the two coats at a place intermediate between the temporal angle and the black of the eye, and towards the middle of the cataract. When the needle has perforated far enough, which is readily known by the absence of resistance, it is to be gently turned so as gradually to remove the cataract below the region of the pupil, and this object being attained it is to be strongly pressed to the lower part. If it remain there the operation is completed; but if it return it is to be cut and torn by the needle into many pieces, in which state they are easier depressed, and prove less troublesome. The needle is then to be drawn out direct, and soft wool smeared with the white of an egg, and other anti-inflammatory applications are to be used. Quiet, restricted diet, and soothing treatment will be proper.
Galen, in his ‘Ars Medica’ alludes to the operation, but does not describe it.
Paulus is the only Greek author who describes the operation. Sextus Platonicus, however, just mentions that the diseased part is sometimes to be depressed with a specillum. (De Medic. ex Animalibus.)
Mesue describes the operation of couching briefly, but nearly in the same terms as our author. He directs us to put the patient upon a spare diet, and to bleed him before the operation. He recommends us to be careful to depress the cataract (aqua) properly.
Albucasis describes the operation of Paulus very minutely, and gives drawings of the couching-needles, called by him almagda. The instrument is to be passed down into the eye to as great a space as the pupil of the eye is distant from the end of the black part called the corona. He says nothing of tearing the cataract into pieces when it proves difficult to depress. He mentions that he had heard of a certain oculist who, it was said, sucked out the cataract through a small tube. He adds, however, that he had never seen any person who performed this operation, nor had read anything about it in the works of the ancients.
Avenzoar briefly mentions that when a cataract cannot be got discussed it must be depressed. He gives directions to press it well down, but says nothing about tearing it into pieces. He recommends retirement, abstinence, and rest afterwards.
Avicenna’s description is evidently copied from our author. He also mentions that some surgeons open the lower part of the cornea, and extract by it. However, he does not approve much of this procedure.
Canamusali briefly mentions that cataract must sometimes be removed by a surgical operation. When convulsions come on after the operation he directs us to apply castor to the nose.
Rhases describes accurately the operations of couching, extracting, and sucking out the cataract. He is the only ancient author, except Celsus, who recommends the cataract to be torn in pieces when it cannot be got properly depressed. He mentions that the famous surgeon Antyllus practised extraction by opening the lower part of the cornea. He also speaks of a certain surgeon who sucked it out through a glass tube.
Haly Abbas describes distinctly the operation of couching, but evidently copies from Paulus. He makes no mention, however, of extraction, as far as we can discover, in any part of his works. The operation of couching the cataract is minutely described by Jesu Haly, but he makes no mention of extraction. He was the son of Haly Abbas.
Sprengel, in his ‘History of Medicine,’ refers to Haly Abbas as one of the ancient authorities who make mention of the operation of extracting the cataract; but if this be the case the edition from which they quote (Venetiis, 1492) must be considerably different from the one with which we are acquainted. (Lyon, 1523.) Haly forbids examinations of the eye after the operation, to ascertain whether or not the patient has recovered his sight.
We will give the description of Vegetius in his own language: “Jumentum igitur pridie temperabis a cibo vel potu maximè prohibebis, in loco molli elides caputque ejus et cervicem aptè collocabis: ita patentem oculum facies ut claudere non possit: deinde ab ipsâ fronte paracenterium inter tunicas oculares subjicito, ne pupillam tangas, aut aliquid lædas interius. sed ipsum album de superiori parte ubi hypochysis posita est, capitello paracenterii deorsum deprimis ad palpebram inferiorem subtiliter. Quod si depositum fuerit, non prius paracenterium eximas, nisi clausum oculum penicello calido diutissime vaporaveris. solet enim resilire. Quod si evenerit, reprimito, donec ita componatur ut resilire non possit. Cum itaque intellexeris claritatem pupillæ sine illo obstaculo hypochysis, tunc eximes ferrum, et invenies animal videre.”
Sprengel affirms, but not quite correctly, as will be perceived from the account of the ancient opinions given above, that it was towards the beginning of the 18th century that it was first discovered that the crystalline lens is the seat of the cataract. Otherwise he gives an admirable history of the operation, in which he does ample justice to the ingenuity and inventive genius of the ancients. (Hist. de la Méd. xviii. 2.)
Fabricius’s description is altogether borrowed from the ancient authors. (Œ. C. ii, 16.) Guy of Cauliac, and the other surgical writers of that age, describe the operation in the same terms as the ancients. Guy mentions the operation of sucking out the cataract through a cannula, but does not approve of it. (vi, 2.)
SECT. XXII.—ON ÆGILOPS, OR FISTULA LACHRYMALIS.
The ægilops is an apostematous swelling between the great canthus and the nose; and it is an affection difficult to cure, owing to the thinness of the bodies, and the fear of injuring the eye by sympathy. If, therefore, the abscess burst at the surface, we remove the whole protruberance as far as the bone; and if the fistulous sore incline towards the cheek, we must lay it all open, and if the bone be sound, we must scrape it; but if diseased, we must burn it with cauteries, applying to the eye a sponge soaked in cold water. Some, after the excision of the flesh, use a perforator, and make a passage for the fluid or matter to the nose; but we are contented with burning alone, using the cauteries for ægilops, and burning down until a lamina of bone drop off; and after the burning we have recourse to lentils and honey, or to the application consisting of pomegranate-rind with honey, and other such desiccative remedies. If the ægilops incline to the canthus, and do not tend at all towards the surface, then, with a lancet for the operation on ptrygium, or one for bleeding, we may dissect out the body between the canthus as far as the abscess, and remove the deep-seated flesh, and have recourse to moderately desiccative applications. Glass reduced to a fine powder is wonderfully desiccative, and aloes with manna, in like manner. The rest of the treatment of fistula lachrymalis we have delivered in the Third Book.
Commentary. Celsus remarks that the ægilops is sometimes of a carcinomatous nature, in which case he recommends us not to interfere with it. He refers here, no doubt, to lupus, which is of not uncommon occurrence near the inner angle of the eye. In recent cases which are not of this kind, he directs us to proceed in the following manner: the whole cavity of the abscess, as in fistulæ, is to be laid open down to the bone, which is to be burned with a red-hot iron, more especially if the bone be carious. Others, he says, instead of the cautery, use caustics, such as atramentum sutorium, chalcitis, or verdigris; but these things, he adds, are more slow in their operation, and less effectual. (vii, 7.)
When the bone is diseased the celebrated Archigenes recommends it to be pierced with a slender perforator, or a hole is to be burnt in it with a red-hot iron. He mentions that others burned it by means of a funnel and melted lead. (Apud Galen. sec. loc. v; and Rhases Contin. ii, 4.)
Aëtius gives a full and lengthy account of ægilops. He recommends us to attempt the cure first with medicines (see Book Third); and if these do not succeed, he directs us to open the abscess freely, and apply to the fungous flesh medicines possessed of strong stypticity, such as powdered glass, stone alum, and the like. A pledget of lint is to be placed over the medicines. When this method of practice does not succeed, he recommends burning, and for this purpose directs us to make a triangular incision in the flesh, and then to touch the bone with a heated iron, so as to produce exfoliation. Alum with turpentine is then to be applied to the bottom of the sore. (vii, 77.)
When the disease does not yield to medicines, Albucasis directs us to open the abscess freely, so as to make an outlet for the matter, and expose the bone. If it is found to be diseased, he recommends us to scrape it with an iron instrument, and then to apply styptic and desiccative medicines to it. When this treatment does not succeed, he directs us to perforate the bone with a triangular instrument of iron. When air issues from the nose by the opening we know, he says, that the operation is completed.
For the cure of ægilops, Mesue recommends the removal of all the diseased flesh by means of strong caustics, such as arsenic, sal ammoniac, chalcitis, alum, &c. When the bone is carious, he directs us to scrape off the carious part. Some, he adds, perforate the bone; but the operation had not succeeded well in his hands. He makes mention of the cautery in the same terms as the others. (De Ægr. Oculi, 12.)
Jesu Hali approves decidedly of perforating the bone with a specillum, or any suitable instrument. He also speaks favorably of the actual cautery. (De Oculis, ii, 32.)
Haly Abbas directs us to lay open the swelling, and apply the cautery. We have mentioned in another place that he was acquainted with the lachrymal duct. (Pract. ix, 29, and ix, 72.)
It will be unnecessary to give a particular account of the treatment recommended by Avicenna, as it does not differ from that of Albucasis. According to circumstances he approves of perforating the bone, and of applying the actual cautery to it. He also speaks of introducing a thread into the lachrymal passages and of using injections. (iii, 3, 2, 14.)
Avenzoar recommends compression and injections, but does not describe the operation. He speaks of the matter passing into the nose, from which it may be inferred that he also was acquainted with the lachrymal duct. (i, 8, 10.)
Rhases likewise makes mention of the lachrymal duct. He recommends us very particularly to make incisions down to the bone, to perforate it, or to apply the actual cautery to it. He makes mention also of escharotic applications containing arsenic, quicklime, and vitriol. He relates a case of apostema lachrymale in which he effected a cure by the ligature and friction. (Contin. ii, 2.)
The practice of perforating the bone as recommended by Albucasis, was approved of by Pott, and the use of the cautery for this purpose is also supported by the high authority of Scarpa. M. A. Severinus, Hildanus, and Garengoit, were likewise advocates for the actual cautery. Fabricius seems to have understood the disease very well, and treated it in the way recommended by the ancients. (Œuv. Chirurg. ii, 21.)
Guy of Cauliac, Theodoricus, and Lanfrancus describe and appear to have performed the ancient operations for the cure of fistula lachrymalis.
SECT. XXIII.—ON IMPERFORATE MEATUS AUDITORIUS.
This affection is sometimes congenital, being occasioned by a membrane which blocks up the entrance into the ear; and it is sometimes superficial and sometimes deep-seated. And it is formed in after life by a preceding ulceration in the meatus; for a growth of fungous flesh taking place blocks up the passage. If, therefore, the membrane which obstructs the opening be deep-seated, the attempt at cure is hazardous; and yet we may try with some slender instrument to divide it, but if it is superficial we divide it with a sharp knife, and if necessary cut it out. If there be a fleshy excrescence it may be dissected out with the scalpel used for the operation in pterygium, or that used for polypus; then making a twisted tent of the size of the meatus from a linen rag, we soak it in water, and sprinkling it with levigated chalcitis, or some such powder, we introduce it into the meatus to prevent the flesh from growing again. Should inflammation come on we must soon take it out. If there be a discharge of blood from the meatus we may soak a sponge in cold water, and apply it along with other appropriate remedies.
Commentary. Celsus describes this case with his usual terseness: “Solet tamen evenire vel a primo natali die protinus, vel postea factâ exulceratione, deinde per cicatricem aure repletâ ut foramen in eo nullum sit, ideoque audiendi sensu careat.” He directs us to make an examination with a sound (specillum) in order to ascertain whether the membrane be superficial or deep-seated, and in the latter case recommends us not to interfere with it, but in the former, directs us to make an opening by means of caustics, burning iron, or scalpel. (vii, 8.)
Albucasis describes the nature of the case and the operation in nearly the same terms as Celsus and our author. If the obstruction is occasioned by a superficial membrane he directs us to perforate it with a slender instrument. If a fleshy excrescence obstruct the passage he approves of seizing it with a hook, and dissecting it out. If the obstruction be more deeply seated he directs the membrane to be opened by means of a heated iron, taking care not to hurt the nerves. It is to be kept open with a tent. (Chirurg. ii, 7.)
Avicenna mostly borrows his account of the case from Paulus. When the obstruction is occasioned by a fleshy excrescence he directs it to be burnt down with arsenic or some other escharotic. He also approves of perforating the membrane. (iii, 4, 1, 17.)
The account given by Haly Abbas accords very well with our author’s. (Pract. ix, 30.)
Fabricius ab Aquapendente describes correctly the treatment recommended by the ancients. He admits that he had never attempted to perforate the membrane when deep-seated. (Œuv. Chirurg. ii, 41.)
SECT. XXIV.—ON SUBSTANCES THAT HAVE FALLEN INTO THE MEATUS AUDITORIUS.
Not only do stones fall into the meatus, but also glass, beans, and the stones of carob nuts. Of these the stones and glass retain their original magnitude, but the beans and stones of carobs being swelled with the natural moisture of the body, occasion very severe pains. They must therefore be extracted by an earpick, a hook, or tweezers, or by using powerful shaking of the head, while the ear is placed upon some circular board. In like manner we extract bodies frequently by sucking them through a reed; and do the like with water when it falls into the ear, covering up the outside of the reed with wax when it is applied to the ear in order that there may be no outlet to the breath. Stones and such like bodies we extract by wrapping wool around an earpick, and smearing it with turpentine-rosin, or some glutinous substance and introducing it gently into the meatus auditorius. If it does not yield we introduce a sternutatory into the nose and close the mouth and nostrils. If it yield to none of these, before inflammation, convulsions, and dangerous symptoms supervene, we must bring it away by a surgical operation. Wherefore, having placed the patient in a proper position with his ear turned upwards, at the base of the ear, behind what is called the lobe, we make a small lunated incision, and with the circular part of an earpick we extract the body which is lodged there. After the extraction the wound is to be sewed up, and the cure completed by the treatment applicable in cases of recent wounds.
Commentary. See Celsus (vi, 7); Aëtius (vi, 87); Alexander Trallianus (iii, 6); Oribasius (Loc. Affect. iv, 36, 39); Galen (de Med. sec. loc. iii); Avicenna (iii, 5, 1, 23); Mesue (ii, 7, 8); Serapion (ii, 12); Rhases (ad Mansor. ix, 36; Contin. iii); Haly Abbas (Pract. ix, 31.)
Celsus gives nearly the same directions as our author, recommending us to use wool wrapped round a specillum, and smeared with turpentine-rosin, or a hook slightly bent, or an ear-syringe, or sternutatories, or shaking the patient’s head. The last-mentioned operation he directs us to execute in the following manner: “Tabula quoque collocatur, media adhærens, capitibus utrinque pendentibus, superque eam homo deligatur in id latus versus, cujus auris eo modo laborat, sic, ut extra tabulam non emineat: tum malleo caput tabulæ, quod a pedibus est, feritur: atque ita concussa aure, id quod inest excidet.”
The treatment recommended by Aëtius is exactly the same as our author’s. Alexander and Oribasius also deliver similar directions. However, Aëtius, Oribasius, Alexander, and our author, copy from Galen, who in his turn acknowledges his obligations to Archigenes and Appollonius. (De Comp. Med. sec. loc. iii.)
Albucasis’s directions are so judicious that we regret our limits do not allow of our giving them fully. For the extraction of a piece of stone he recommends us among other means to use a slender forceps, of which he gives a drawing. It resembles the modern dissecting forceps. He also gives a drawing of a hook slightly bent, which he commends; and also of a brazen tube to be used for sucking out bodies. When other means do not succeed, he directs us to make an incision at the under part of the ear, having previously let blood in order to avert inflammation and convulsions. Animals are to be sucked out with a tube narrow below and wider externally, or they are to be extracted with a forceps or hook. When these means do not succeed, an oil, to which some substance destructive of these animals has been added, is to be injected with an instrument, of which he gives a drawing.
The reader may likewise consult Mesue with advantage. Serapion also recommends the same remedies as the Greeks. Avicenna supplies no new views. Haly recommends incision when other means have failed.
Rhases directs us to pour tepid oil into the ear, and to put the patient into a warm bath in order to lubricate and produce relaxation. His translator, however, remarks that if the substance lodged in the ear be a bean or a pea there may be danger of the water occasioning a swelling of it.
SECT. XXV.—ON POLYPUS.
The polypus is a preternatural tumour forming in the nose; so called from its resemblance to a sea polypus, because it resembles its flesh, and because, as the animal with its fibrils resists those who would seize on it by catching at their hands, so does this affection, in like manner, block up the nostrils, occasioning inconvenience both in breathing and speaking. Wherefore those kinds of polypi which are hard, unyielding, somewhat livid and malignant, inasmuch as they partake of a carcinomatous nature, are not to be meddled with; but such as are more friable, spongy, insensible, and not malignant, are to be subjected to a surgical operation. Having placed the person on a seat exposed to the rays of the sun, and opened the nostrils with the left hand, and holding in the right hand a polypus scalpel, having its extremity shaped like a myrtle-leaf, we cut around the polypus or sarcomatous tumour, applying the extremity of the instrument to the parts where it adheres to the nose. Afterwards, turning round the instrument, we bring out the separated fleshy body with its concave part. And if we see that the nasal passage is perfectly cleared, we proceed to the cure; but if any part of the polypus be left behind, we take another instrument for eradicating polypi, and, with the extremity thereof, we bring away what remains by stretching, twisting, and scraping it strongly. Malignant polypi we burn with cauteries, knob-shaped; and, after the burning, we have recourse to the treatment for burnt parts. After the operation, having sponged the parts carefully, we inject oxycrate or wine into the nose, and, if the fluid descend by the roof of the mouth to the pharynx, the operation will have been rightly done; but if it does not descend, it is clear that about the ethmoid bones, or the upper parts of the nose, there are fleshy bodies which have not been reached with the polypus instruments. Taking, then, a thread moderately thick, like a cord, and having tied knots upon it at the distance of two or three fingers’ breadths, we introduce it into the opening of a double-headed specillum, and we push the other extremity of the specillum upwards to the ethmoid openings, passing it by the palate and mouth, and then drawing it with both hands, we saw away, as it were, with the knots the fleshy bodies. After the operation, we keep the opening separate by means of a tent resembling the wick of a lamp; and after the third day we consume whatever is left behind by the trochisk of Musa or the like, and at the same time use desiccative applications to the part. Afterwards, we have recourse to epulotic trochisks, and, if necessary, during the whole treatment we keep leaden tubes in the nose.
Commentary. For an account of the treatment by medicines we refer to section xxiv of the Third Book.
The author of one of the Hippocratic treatises, according to circumstances, recommends sawing it out, consuming it with septics, tying it with a ligature, and burning it with a red-hot iron. (De Morbis, ii.)
In the ‘Isagoge’ of Galen, it is merely recommended to cut out the tumour, and to scrape its roots.
Celsus, like our author, recommends excision with a sharp instrument of iron, and directs us to apply afterwards to the part a tent smeared with some styptic. A proper dressing is then to be applied for cleansing the sore. (vii, 10.)
Oribasius briefly mentions excision as a proper remedy when medicines fail.
Albucasis describes minutely the operations of excision and sawing out the tumour. Like our author, he directs us to seize the tumour with a hook, to pull it down, and cut it out. If any part remain, he recommends us to scrape it out with a slender instrument, and then to apply styptics, such as vinegar, water, or snow. The operation of sawing it out with a thick knotted thread is minutely described by him. He also speaks of cauterizing the part from which the tumour has been removed.
Mesue describes the process of sawing out the tumour, with some slight differences. He recommends us to use three horse-hairs, which, being tied together with knots, are to be introduced into the nose with a leaden needle, and one end conveyed out by the openings of the palate; and then, by pulling at both ends, the tumour is to be sawed out.
Avicenna, Haly Abbas, and Rhases make mention of excision and the process of sawing out the tumour. Rhases relates the history of a case of polypus, unusually large, which he had seen extracted in an hospital. He and Albucasis recommend the part to be dressed with green ointment.
The veterinary surgeons appear to have depended principally upon the actual cautery. See Vegetius (Mulom. ii, 38.)
The method of curing polypi of the nose, by sawing them out, seems to have now fallen completely into disuse, whether deservedly or not we cannot, from our own experience, venture to decide. Fabricius ab Aquapendente disapproved of it; but he was evidently much prejudiced in favour of the operation with a new forceps of his own invention. (Œuv. Chir. ii, 24.) Sprengel informs us that this method was practised by the surgeons of the middle ages. It is described by Brunus (Chir. Mag. ii.)
Sprengel thus explains the other operation described by our author: “Il se servait d’un instrument particulier auquel il donnait le nom de σπάθιον πολυπικὸν et qui était garni à l’une de ses extrémités d’un ciseau, κυκλίσκος” (Hist. de la Méd. viii, 4.) Why does he substitute κυκλίσκος for κυαθίσκος? That the instrument had a chisel (ciseau) at its extremity is altogether improbable, and this supposition is unwarranted by the context. Κυαθίσκος means the cup-like or concave end of the instrument.
SECT. XXVI.—ON MAIMED PARTS.
When the ears or the lips have been mutilated, we restore them by first dissecting the skin below, and afterwards bringing together the lips of the wounds; then removing the callous parts, and afterwards sewing and glueing them together.
Commentary. This section is taken from Galen. (Meth. Med. xiv.) See, also, the ‘Isagoge.’
Celsus’s observations are too minute and lengthy for our limits. Suffice it to say, that he directs the edges to be pared, and then united with sutures. (vii, 9.)
Rhases’ directions for the treatment of mutilated ears and noses are to the same effect as our author’s. (Cont. xiv.) Similar ones are given by Albucasis. He directs us to make the suture either with needles, as in gastroraphe, or with a thread. (Chirurg. ii, 26.)
Celsus has been supposed, but, as we think, incorrectly, to touch on the operation for the hare-lip. (vii, 10, 6.) See Sprengel (Hist. de la Méd.)
SECT. XXVII.—ON EPULIS AND PARULIS.
Epulis is a fleshy excrescence which forms upon the gums beside one of the teeth; but parulis is an abscess which forms near the gums. The epulis, then, we raise with a flesh forceps or a hook, and cut out; but the parulis we divide circularly and fill the incision with tents. I am aware that often when opened only with the common lancet used for venesection and the matter evacuated, the disease has ceased. After the operation we give orders to gargle with wine, then with honied water, and afterwards apply to the wound the Flowery powder, until the cure is completed. But if mortification attack the gums, and do not yield to the suitable applications, we must burn the part with knob-shaped cauteries.
Commentary. Parulis is the gum-boil. Epulis is a soft fleshy tumour which forms on the gums. Aëtius treats fully of them. To the former he directs us to apply at first such things as promote suppuration, after which it may either be allowed to break of itself or may be opened with a lancet. Styptic applications will then be proper. For the epulis he recommends us at first to apply alum, verdigris, &c., and if these have not the desired effect he directs us to cut it off with a scalpel. (viii, 24, 25.)
Celsus treats of both at considerable length by the name of parulides. For that species which corresponds to the gum-boil, among other remedies, he recommends us to hold in the mouth a decoction of figs, and directs to open it before it is ripe, lest the matter should hurt the bone. Larger tumours are to be cut out entire. (vi, 13.)
Haly Abbas recommends excision for the epulis, and to open the parulis in due time with a lancet. (Pract. ix, 33.)
It appears to us that of all the ancient authorities Albucasis lays down the best rules for treating the epulis. He directs us to cut it out with a forceps and scalpel, and then to apply styptic powders to the part, or if the tumour grow again, the actual cautery. For our own part, we have generally found that no permanent cure could be effected without the cautery. See Chirurg. (ii, 28, and i, 22.)
It is unnecessary to detail the treatment recommended by the other authorities.
SECT. XXVIII.—ON THE EXTRACTION OF TEETH.
Having scarified around the tooth down to the socket, we must by degrees shake the teeth with a tooth-extractor, and draw it out. But if it is carious we must first plug up the hole with a small tent, that it may not break when compressed by the instrument. After the extraction we may consume the flesh that is left by sprinkling it with finely levigated salts, and afterwards gargles of wine or oxycrate may be used until the completion of the cure. And since sometimes supernumerary teeth are formed, those that are fixed in the socket we must scrape down with a graving-tool, but those that are not so fixed we must extract with a tooth-extractor. If any tooth grow to an unnatural size, or is broken, we may scrape away the projecting or redundant part of it with a file. The laminæ which unite to them we may remove as may appear proper, with the concave part of a specillum, a raspatory, or a file.
Commentary. Cælius Aurelianus disapproves of extracting teeth, except in cases of extreme necessity. Herophilus and Heraclides Ponticus, he says, have related cases in which the operation had proved fatal; and in modern times we hear sometimes of such occurrences. (Pass. Tard. ii, 4.)
Celsus directs us, when the pains of toothache cannot be got otherwise alleviated, to separate the gums from the tooth by free scarifications, and then to shake it until it is loosened, and forbids us to proceed rashly to perform extraction, for fear of occasioning dislocation of the jaw-bone, or, if the tooth belong to the upper jaw, of hurting the temples or eyes. If loose, it is to be taken out with the hand, but otherwise with a forceps, and, if eaten, the hole is to be filled with a tent, or with lead, to prevent it from breaking during extraction. The instrument is to be pulled direct, lest the spongy bone to which the tooth is fixed should be broken. Of this accident occurring there is, he adds, considerable danger; and not unfrequently when the tooth is short and its roots long, the instrument takes hold of a piece of bone and breaks it; in which case he directs us to extract the broken piece with a pincers. When the teeth are carious he directs us to scrape them, and apply to them a mixture of the flowers of roses, galls, and myrrh, and to hold undiluted wine in the mouth. When the teeth are slackened by any accident, he directs us to fasten them to the surrounding ones with a golden thread, and then to hold some stringent decoction in the mouth. When in young persons a second tooth appears before the first has fallen out, he recommends us to scarify around the latter and pull it out, and to endeavour to force the other gradually into its proper place. Stumps of teeth are to be taken out with a stump-extractor. (vii, 12.)
Scribonius Largus makes some ingenious observations on the extraction of teeth, but disapproves of the operation, except in extreme cases. (De Comp. Med. i, 10.)
Galen, and the medical authorities subsequent to him, direct us to file down teeth when they are diseased and project, but disapprove in general of extraction.
Albucasis is particularly full in treating of the operations on the teeth. Like our author, he recommends us to perform extraction by first making free scarifications, and then pulling the tooth direct with a forceps, the patient’s head being held between the knees of the operator. When the tooth is hollow he directs us to stuff it beforehand with a tent of cloth. When a piece of the alveolar process has been broken, he properly recommends that it be taken out. He gives suitable directions for filing down the teeth, and for fastening them with gold threads. He gives drawings of instruments for extracting roots. (Chir. ii, 30.)
The other Arabians describe the operation, but less precisely than Albucasis. Haly’s directions are judicious. He recommends the operator to use a forceps, and to stuff the tooth when it is hollow. (Pract. ix, 31.)
SECT. XXIX.—ON CONSTRICTION OF THE TONGUE, OR TONGUE-TIED PERSONS.
The affection called ancyloglossus is sometimes congenital, the membrane which fastens the tongue being originally harder and more constricted than ordinary; but sometimes is acquired from some hard cicatrix formed under it by ulceration. Those therefore who have this affection naturally are distinguished by being slow in beginning to speak, and by having the frænum linguæ larger than its moderate size, and that without any previous ulceration. When the complaint is occasioned by a cicatrix it is easily recognised. Wherefore the patient is to be placed on a proper seat, the tongue raised to the roof of the mouth, and the membranous frænum cut transversely. But if the curvature is occasioned by a cicatrix, we transfix the callus with a hook and draw it upwards, and making a cross incision free the bent part, taking care not to make deep incisions of the parts; for hemorrhages which have been found difficult to stop have thereby been occasioned. After the operation the part is to be washed with cold water or oxycrate; and after all these things the cure is to be completed with relaxing and incarnative applications.
Commentary. Celsus thus describes the treatment in congenital affections: “Horum extrema lingua vulsellâ prehendenda est, sub eâque membrana incidenda, magnâ curâ habitâ, ne venæ quæ juxta sunt, violentur et profusione sanguinis noceant.” (vii, 12, 4.)
Aëtius’s plan of treatment is quite similar to our author’s. (viii, 38.)
Albucasis gives a similar account of the operation. He cautions against opening the artery below the tongue, for fear of hemorrhage. Should this accident occur he directs the surgeon to use the actual cautery. (Chirurg. ii, 34.)
Rhases recommends when the frænum extends to the tip of the tongue that it be divided, so as to allow freedom of motion. However, one of the authorities quoted by him directs us to pass through the frænum a needle armed with a thread, which is to be tightened so as to divide the intermediate space. He recommends this method in order to obviate the fear of hemorrhage from the incision. Rhases himself states that a dangerous hemorrhage will result from opening the green veins below the tongue. (Cont. vii, 1.)
Avicenna also recommends the operation with the ligature. (iii, vi, 11.)
Haly Abbas describes very distinctly the operation of dividing the frænum. (Pract. ix, 35.)
Alsaharavius mentions that the operation is sometimes necessary. (Pract. ix, 35.)
SECT. XXX.—ON ANTIADES, OR INDURATED TONSILS.
As indurated glands are called strumæ, so the almonds of the ears when inflamed, swelled, and as it were, dried, occasioning difficulty of deglutition and of breathing, are called antiades, from their being placed opposite one another. When therefore they are inflamed we must not meddle with them; but when the inflammation is considerably abated, we may operate, more especially upon such as are white, contracted, and have a narrow base. But those which are spongy, red, and have a broad base, are apt to bleed. Wherefore, seating the person in the light of the sun, and directing him to open his mouth, while one assistant holds his head, and another presses down the tongue to the lower jaw with a tongue spatula, we take a hook (tenaculum) and perforate the tonsil with it, and drag it outwards as much as we can without drawing its membranes along with it; and then we cut it out by the root with the scalpel suited to that hand, called ancylotomus, for there are two such instruments, having opposite curvatures. After the incision of one we may operate upon the other inversely in the same manner. After the operation the patient must gargle with cold water or oxycrate; and if any hemorrhage come on he may use a tepid decoction of brambles, roses, and myrtle-leaves; or if the blood flows copiously we must give for a gargle the juice of plantain and comfrey, and the trochisk from amber and the Lemnian earth, dissolved in oxycrate. When the hemorrhage stops, the parts on the next day may be anointed with the flower of roses, saffron, and starch with milk, or with water, the white of an egg, or hydrorosatum. When sordes collect about the ulcers, we may use injections and linctuses made from honey.
Commentary. Celsus directs us when the tonsils are indurated to scrape the membrane with the finger, and tear it out; or, if this does not succeed, to seize the tumour with a hook or tenaculum, and cut it out; then the wound is to be washed with vinegar, and a styptic medicine applied to it. (vii, 12.)
Aëtius directs us to seize the tonsil with a hook and cut it out at the middle. When cut out at the base, he remarks there is danger of hemorrhage. (viii, 57.)
Albucasis directs us to make the patient sit with his head on the operator’s bosom, and, while an assistant presses down his tongue, the operator is to seize the indurated tonsil with a hook, and drawing it out, to cut it off with a sharp instrument resembling a forceps, or, in other words, with a pair of scissors. He likewise gives a drawing of another instrument which consists of a lunated piece of iron fixed to a handle. He relates an interesting case in which he performed the operation. (ii, 36.)
Rhases, upon the authority of a surgeon called Ancilisius, in the barbarous translation of his works, which probably is a corruption of Antyllus, briefly describes this operation. He directs us to open the mouth and take hold of the tonsils, the fourth part of which may be cut off. He recommends us to make the patient gargle with vinegar. He forbids the operation when the tonsils are enlarged and red. (Contin. vii, 2.)
Haly Abbas (Pract. ix, 36,) and Mesue (de Ægr. Gutturis, 4,) describe the operation, but not so minutely as Albucasis.
Guido de Cauliaco copies the descriptions of Albucasis and Haly Abbas. (c. vi, 2.)
SECT. XXXI.—ON THE UVA.
The uvula being, as it were, the quill or plectrum of the organ of speech is often the seat of defluxion from the head, and becoming preternaturally enlarged, of a lengthened form and slender shape, it is called columella; but when thick below and round it is named uva, from its resemblance to a grape, as the other is so called from its resemblance to a column. If, therefore, it cannot be made to yield to general treatment,—I mean evacuations by bleeding and purging,—nor to topical, such as astringents, repellents, and discutients,—we must proceed to the operation, lest, by its constant irritation, it bring on coughs, sleeplessness, and even suffocation. Such, therefore, as are contracted, round, not of a lengthened shape, bloody, or somewhat black, we must decline operating upon; but those that are slender, long, small at the extremity, loose, not very bloody, but whitish, we must operate upon; for the inflammation of them soon subsides. We must only take away as much of the uva as exceeded its natural size; for the complete extirpation of it proves greatly injurious to the parts about the chest, and occasions the loss of voice. Wherefore, having placed the patient on a seat in the rays of the sun, and directed him to gape wide, we seize with the forceps adapted for this purpose, or a common tenaculum, upon the redundant part and drag it downward, and cut it out with the instrument called staphylotomus, or the scalpel used in the operation for the suture of the upper eyelid. After the operation the same things are to be done as are recommended for angiology. But since often, from the timidity of the patient, or the fear of the hemorrhage, or the success attending the treatment by medicines, he declines the operation by instruments, we may rather consume it by means of a caustic medicine. Wherefore, taking the caustic used for burning the eyelids, or some such, we are to fill with it the hollows of the instrument called staphylocaustos, and directing the patient to gape wide, and getting the tongue pressed down with a tongue spatula, we open the instrument sufficiently and grasp with it as much of the uva as we cut off in the other operation. The medicine must neither be of too liquid a consistence, lest it run down from the uva improperly, and burn the adjoining parts (and, therefore, we direct the patient not to swallow during the whole operation of burning), nor very hard, that it may soon act upon the uva. And if from one application the extremity of the uva become black, this will be sufficient, but if not we must use it again. During the whole time of its action the patient must sit with his head bent forwards, in order that the saliva which is melted down with the portions of the medicine may flow from the mouth. The part becomes dead in one hour, and falls off about the third or fourth day. After the burning, having wrapped the index-finger round with soft wool or tow, we wipe the parts about the uvula, or direct the patient to gargle with water. But after this operation, and also that on the tonsils, soothing fomentations from the oil of camomile are to be applied around the neck, and in like manner we may use gargles and liniments.
Commentary. It appears from the Hippocratic treatises that excision of the uvula was sometimes performed in early times. (Prognost. de Morbis, ii; De affect.)
Celsus recommends us not to meddle with the operation when the uvula is red and enlarged, for fear of hemorrhage; but when it is slender, sharp, and white, or when it is pale and thick below, but slender above, it may be extirpated without danger. For this purpose he merely directs us to seize upon it with a forceps and cut it out. (vii, 12.)
Galen describes fully the operation by medicines, but says nothing of excision. (De Med. sec. loc. vi.) Aëtius describes the operation in nearly the same terms as our author. He directs us to grasp the enlarged uvula with a forceps and cut it off, using afterwards some astringent gargle. (viii, 44.) Oribasius briefly mentions the operation, which he directs to be performed with extreme circumspection. (Med. Collect. xxiv, 10.)
Albucasis describes the operation similarly to the Greeks. He directs the operator to get the patient’s tongue pressed down by an assistant; when the operator is to seize upon the uvula and cut off as much as is proper of it. He gives a drawing of an instrument for the operation with caustic medicines. (Chirurg. ii, 37.)
Avicenna’s description is to the same effect, but not so circumstantial. (iii, 9, 15.) Mesue directs us to perform the operation with a heated scalpel of gold. (De Ægr. Gutturis, 3.)
Rhases states that when the uvula is enlarged, but is not red, the operation may be performed without danger. He mentions that some preferred the actual or potential cautery, but that he preferred excision. He describes, but not distinctly, an instrument for applying the caustic medicines. He states that loss of the entire uvula impairs the voice and exposes the lungs to danger from cold. (Contin. vii; and Divis. i, 49.)
SECT. XXXII.—ON THORNY SUBSTANCES FIXED IN THE PHARYNX.
Thorns, or the bones of fishes, or other substances, are often swallowed in eating, and fix in different places. Wherefore, such as can be seen we are to extract with the forceps for that purpose; but those which are lower down in the gullet we must manage differently. Some are of opinion that the patient ought to be made to swallow large morsels, such as the stalk of lettuces, or pieces of bread; but others direct us to bind a thread about a small piece of clean soft sponge and give it to the patient to swallow, and then taking hold of the thread to draw it up, and to do this frequently in order that the thorn may get fixed in the sponge and be brought up. Leonidas orders suppurative cataplasms to be applied, such as those from raw barley-flour, in order that the part may be converted into pus and the thorn fall out of its own accord. If we see the patient at the time of swallowing, before digestion has taken place in the stomach, and cannot perceive the substance which is fixed, we may order him to vomit by pushing the fingers or feathers down the throat, for sometimes the thing which is fixed will be brought up with the matters that are vomited.
Commentary. Our author’s directions are mostly taken from Aëtius. (viii, 50.)
Albucasis repeats our author’s directions, and further recommends us, when they fail, to introduce an instrument made of lead, which he gives a drawing of, and either to extract the substance or push it downwards. (Chirurg. ii, 38.) A similar plan of treatment is recommended by Mesue (de Ægr. Gutturis); by Avicenna (iii, 9, 43); and by Alsaharavius (Pract. xii.) When a morsel of food sticks to the œsophagus, Alsaharavius directs that the person should be struck on the back, which will facilitate the descent of it. (6.)
SECT. XXXIII.—ON LARYNGOTOMY.
The most famous surgeons have also described this operation. Antyllus, therefore, says, “In cases of cynanche (as we will explain under the head of Dietetics) we entirely disapprove of this operation, because the incision is utterly unavailing when all the arteries (the whole of the trachea?) and the lungs are affected; but in inflammations about the mouth and palate, and in cases of indurated tonsils which obstruct the mouth of the windpipe as the trachea is unaffected, it will be proper to have recourse to pharyngotomy, in order to avoid the risk of suffocation. When, therefore, we engage in the operation we slit open a part of the arteria aspera (for it is dangerous to divide the whole) below the top of the windpipe, about the third or fourth ring. For this is a convenient situation, as being free of flesh, and because the vessels are placed at a distance from the part which is divided. Wherefore, bending the patient’s head backwards, so as to bring the windpipe better into view, we are to make a transverse incision between two of the rings, so as that it may not be the cartilage which is divided, but the membrane connecting the cartilages. If one be more timid in operating, one may first stretch the skin with a hook and divide it, and then, removing the vessels aside, if they come in the way, make the incision.” These are the words of Antyllus. We judge that the windpipe has been opened from the air rushing through it with a whizzing noise, and from the voice being lost. After the urgency of the suffocation has passed over, we pare the lips of the incision so as to make them raw surfaces again, and then have recourse to sutures, but sew the skin only, without the cartilage. Then we use the applications proper for bloody or fresh wounds, but if it does not unite we must treat it with incarnants. We must follow the same plan of treatment if we should meet with the case of a person who had cut his own throat from a wish to commit suicide.
Commentary. Aretæus makes mention of this operation in such terms as proves that it must have been practised occasionally in his time. He, however, does not approve of it, at least in cases of angina. (De Curat. Morb. Acut. i, 7.)
Cælius Aurelianus says that Asclepiades performed the operation in cases of cynanche; but he himself disapproves of it. (De Morb. Acut. i, 7.) We may mention further in this place that Avicenna, Avenzoar, Haly Abbas, Mesue, and Rhases express themselves rather favorably of the operation in urgent cases of cynanche. From the circumstance mentioned by Pollux of cynanche, that it mostly attacks children, we are inclined to think that the ancients meant the croup by it.
None of the Greek authorities, except our author, have left a description of the operation. Psellus, however, mentions it in such a manner as would lead us to infer that the operation had not been lost sight of in his time, i. e. “Laryngotomy is a certain surgical operation.”
Avicenna and Albucasis merely copy our author’s description, and appear to have never seen the operation performed. To show, however, that the windpipe may be opened without occasioning death, Albucasis relates the case of a female who cut her trachea while attempting to commit suicide; in which case, by sewing up the wound, he effected a cure without difficulty. (Chirurg. ii, 13.)
Rhases mentions that, in cases of cynanche which threaten instant death, a certain physician, Ancilisius (Antyllus?) recommends the surgeon to open the windpipe. His description of the operation is as follows: The patient’s head being kept back the skin is to be divided, and the sides of it separated by means of threads, so as to expose the windpipe, which is to be opened by making an incision in the membrane which connects two of the rings together. After the abcess bursts the wound is to be sewed up. (Cont. vii, 2.)
Haly Abbas likewise describes the operation accurately. He directs us to make an incision in the skin, and to separate the edges with hooks so as to expose the windpipe, which is to be opened between two cartilages. (Pract. ix, 38.)
The modern history of the operation is given in Van Sweiten’s Comment. (814); Mémoires de l’Acad. Royale (ii); and Cooper’s Surgical Dictionary. See a complete history of the operation by Sprengel. (Hist. de la Méd. 18, 6.) He says, that Anthony Benivieni, a surgeon of Florence, is the first after Antyllus who is known for certain to have performed the operation.
SECT. XXXIV.—ON ABSCESS.
That the abscess is a corruption and transmutation of the flesh or fleshy parts, and what are its modes of formation, and how many kinds of abcesses there are, we have sufficiently explained in the Fourth Book. Now we have only to treat of the operation upon it. If it be completely changed to pus, which we ascertain from the pains, fever (if any was formerly present), redness, pulsation, and the other symptoms of inflammation being diminished, from the swelling assuming a sharp point, and from pus being felt under the fingers upon pressure, more especially if the abscess be superficial, in that case we may proceed to the operation. But if it is not felt to the touch, nor is elevated to a point, owing to its being deep-seated, we must attend to the other symptoms before operating. It is to be understood, however, that before the conversion to pus is completed, we sometimes open abscesses when they are unripe, on account of their being near joints or vital parts, lest, by their continued putrefaction, a ligament or some necessary part should be corrupted by it. And Hippocrates directs us to open abscesses about the anus before they are completely ripened, for fear of their perforating the intestine. In opening them we must not, in all cases, make the incisions in the same manner, but observe the natural lines—as on the face; and the growth of the hairs—as on the head, and taking as much care as possible not to occasion deformity. Straight incisions are to be made in the legs, as in the muscles and tendons; and nerves, arteries, and vital parts are to be avoided, taking care of their safety by sometimes making a straight incision and sometimes a transverse one into the abscess, according to the circumstances of each case. When the abscesses are small we make one incision, but when they are larger we make more, always dividing the thinner parts, and those which are most convenient for the escape of the matter. When the swelling is much raised up to a point, unconcocted, thin, and devoid of vitality, we must cut out a piece either like a triangle, or like a myrtle leaf, or of some other angular figure, because the circular is unfavorable to cicatrization. Those which are not pointed we open by a simple incision, and when we find a sinus, if the part is fleshy and the skin proper for uniting, we only make such incisions into the part as will allow the matter to be discharged; but if it be thin and very devoid of flesh we make a simple incision along its whole length; and after this simple incision, if the parts on each side appear thin and not fleshy we must pare them off. After the operation, having first sponged the part, if the abscess be small, and if only one incision has been made, we may use a simple pledget, but if it be large, and there be many incisions, we draw through them a fillet which can be easily extracted; and when the part has been cut out we fill it in like manner with lint. If a hemorrhage take place we must use cold water or oxycrate, and if the bleeding continue we may sprinkle upon the part finely powdered chalcitis, which we may also have recourse to often when the part is gangrenous and flaccid. In winter, and when the parts are nervous, we may soak oblong pledgets in wine and oil and apply them; and in summer, when the parts are fleshy, we may soak these applications in water and oil, or in the same cold wine and oil, and binding them, on the following day we may bathe with the same fluids; but on the third day, having loosed the dressings and sponged the parts, we may use the application called tetrapharmacon on a pledget, and if there be no inflammation present we may apply the same wash for the preservation of the pledget; but if there be inflammation, we must apply a digestive cataplasm, having first poured water on the parts. When the inflammation abates we may effect the cure by promoting suppuration and incarnation. Sinuses are to be cured by agglutinative remedies, as has been said, in the Fourth Book, on sinuses.
Commentary. All the authors quoted under this head in the Fourth Book may be consulted.
Celsus is more than usually prolix in laying down the rules for the surgical treatment of abcesses. Before the abscess harden, he directs us to make incisions in the skin, and apply a cupping instrument, in order to remove any symptoms of inflammation which may have been present, or, in other words, to procure resolution. Sometimes, however, as he explains, the matter is collected in a cyst (tunica), in which case it is not to be supposed that the contents of the abscess can be removed by a cupping instrument. When the pus ripens it is seldom proper to let it out if seated in the armpits, or groins; nor when the collection is superficial, or in the flesh; and it is better, as he prudently directs, to apply cataplasms until the pus make an opening for itself. When it is judged necessary to open an abscess, he recommends us, if not seated in a nervous part, to perform the operation with a red-hot iron, because a small opening made in this manner will remain longer open. Abscesses in nervous parts are to be opened with a scalpel. In making an incision, the form and size of it are to be considered. In general the openings are to be made as small as possible; but large sinuses require larger incisions, and sometimes two or three are necessary: when the skin is livid or diseased it sometimes must be cut off to further the cure. In this case an opening is to be made of the shape of a myrtle-leaf. When the pus is evacuated, if in the armpit or groins, no pledget is to be used, but a sponge out of wine is to be applied. In other places, a little honey is first to be used; then agglutinative medicines; and above these likewise, if necessary, a sponge squeezed out of wine. (vii, 2.)
The treatment of abscesses is fully explained by Galen. (Therap. ad Glauc. ii.) He directs us, when an abscess is slow of ripening, to make superficial scarifications in it, and afterwards to apply a cataplasm of barley-meal.
Aëtius’s directions are, upon the whole, similar to our author’s, but not quite so minute and precise. Like our author, he directs us to make the incision long and narrow, like a myrtle-leaf. The ancients were well aware that circular sores are slow of healing; and the causes of this fact are fully explained by Cassius and Alexander Aphrodisiensis.
Little additional information is to be obtained from the other authorities. Albucasis directs us, when the abscess is large, not to evacuate all its contents at once, lest it produce dangerous prostration, especially if the patient be weak; for, he remarks, the animal spirits will escape along with the pus. Like our author, he forbids us to open abscesses until they are ripe, unless seated near the anus, or some vital part. (Chirurg. ii, 40.)
Haly Abbas justly remarks that if an abscess be opened prematurely, the lips of it remain in an indurated state, and prevent the sore from healing. But when seated near nerves or ligaments, he advises not to wait until it is ripe. His treatment upon the whole does not differ from our author’s. (Pract. ix, 8.)
The method of opening abscesses, by means of caustic applications, is described in the Fourth Book, 18.