Haly Abbas describes only the operation by the incision. He also states that if the sphincter ani be wounded, it will occasion irretention of the fæces. (Pr. ix, 60.) See also Rhases (Ad Mansor. ix, 80; Cont. xxviii); and Avicenna (iii, 18, 1, 18.) Avicenna prefers twisted hairs or bristles of a hog, as they will not putrefy.
Upon the whole no other of the ancient authorities has treated so efficiently of fistulæ in ano as Paulus.
See an excellent account of the operation in Sprengel’s ‘History of Medicine.’ John de Vigo trusted to septics, such as arsenic and the ægyptiacum. Ambrose Paré approved of the apolinose and incision. Severinus was an advocate for the cautery. Foubert and Camper likewise practised the apolinose—the one with a leaden thread, the other with a silk one. Guido de Cauliaco and Rogerius approve of the ligature. Brunus and Theodoricus prefer the actual cautery, but describe the others. The surgeons of this country have now generally rejected the methods with the ligature and the cautery.
The following account of the ancient specillum by the learned Harduin will serve to illustrate our author’s description of the operation. We overlooked it in the commentary on the fifteenth section. “Quid sit specillum Varro explicat (Lib. 5 de Lingua Lat.) Quo oculos inunguimus quibus specimus (hoc est, aspicimus), specillum est. Græcis μηλὴ dicitur. Aëtius Serm. 8, 14, cum specillo instrumento, quod melam Græci appellant. Instrumentum parvum ac teres, quo utuntur ad vulnerum aut fistularum viam aut profunditatem pernoscendam. Une sonde de chirurgien.” (Ad Plin. H. N. vii, 54.) If the κοπάριον, however, was the same as the μηλὴ or the specillum, it was evidently used for cutting with as well as for cutting upon.
The existence of hemorrhoids is rendered manifest to us by the discharge from them. Before proceeding to the operation we must use frequent clysters with the view of evacuating at the same time the contents of the intestine, and, by irritating the anus, of rendering it more disposed to eversion and protrusion of the gut. Having, therefore, laid the patient on his back in a clear light, if we are to use the ligature we pass a very thick thread round the lips and secure each of the hemorrhoids with this ligature, leaving one as an outlet to the superfluous blood (for so Hippocrates directs.) After the application of the ligature, using a compress that has been dipped in oil and the bandage adapted for the anus, we order the patient to remain quiet, and treat the bowels with tepid oil and honied water, and afterwards we use a cataplasm made of crumbs of bread and saffron; and after the falling off of the hemorrhoids the cicatrization is to be promoted by wine. Leonides has not recourse to the ligature, but having seized the hemorrhoids and held them for some time with the forceps used for operations on the uvula he cuts them off with a scalpel. After the operation we must use manna and starch with chalcitis, or the plaster of burnt sponge with pitch, and the trochisk called faustinum, in order to burn it completely. Others by filling the cavity of the instrument called staphylocaustes, with caustic medicines, have burnt hemorrhoids like a scirrhous uvula.
Commentary. Hippocrates directs us to pass a needle armed with a very thick thread through the hemorrhoids, and tie them with it. Septic applications are afterwards to be made to them. (De Victu Acut. 67.) The author of another of the Hippocratic treatises recommends us to cure them by burning with red-hot irons. (De Hæmorr.)
Celsus directs us when the base of a hemorrhoid is narrow to tie it with a thread where it joins the anus, and to apply over it a sponge squeezed out of hot water until it become livid, when it is to be scraped off with the nail or a scalpel. Sometimes, however, he says, the ligature occasions great pain and retention of urine. If the hemorrhoid be large and its base broad, he directs us to seize it with a hook, and dissect it out a little above its base: the part is to be secured with a thread. When there are many hemorrhoids he advises us not to operate upon them all at one time. When there is a discharge of blood it is to be stopped by the application of a sponge. The day after the operation he recommends us to use the tepid bath and catalapsms. (vii, 30.)
Aëtius approves of cutting off hemorrhoids, and describes the operation minutely. He directs us to seize the pile with a hook, grasp it firmly, and bind it with a thread, after which it is to be raised and cut off. To stop the bleeding a piece of sponge bound round with a thread is to be introduced into the anus. Suitable dressings and bandages are then to be applied, (xiv, 6.)
In the ‘Isagoge’ ascribed to Galen, the method of treating hemorrhoids by the ligature is particularly commended.
Albucasis prefers excision and burning, but if the patient will not submit to these methods of cure he approves of having recourse to the ligature. Excision is performed by seizing the hemorrhoid with a hook and cutting it at its base, after which some styptic application is to be made. The ligature is applied by transfixing the base of the hemorrhoid with a needle armed with a thread. (Chirurg. ii, 81.) He gives particular directions about the process of burning. (p. i, 37.)
When the hemorrhoid is internal Rhases directs us to evert the anus, and having laid hold of the tumour to cut it out. He also describes the process of tying them in the same terms as the other authorities. (Contin. xxiv.) The directions given by Avicenna are quite similar.
Haly Abbas recommends excision or the ligature. (Pract. ix, 61.)
Fabricius makes mention of all these methods of treatment, but speaks of the application of the cautery as being dangerous. Upon the whole he appears to have entertained great apprehensions from stopping the discharge of piles. (Œuv. Ch. ii, 94.)
Theodoricus and Brunus recommend excision, the cautery, and the ligature, according to circumstances. Theodoricus also makes mention of applications for consuming and drying them up.
Condyloma on the fundament differs in situation alone from that on the female parts of generation, being a wrinkled excrescence of the anus, either from a preceding inflammation or fissure. At first, then, it is called an excrescence, but when it becomes callous, condyloma. These also, like the former, are to be taken hold of with a forceps and cut out, and the cure completed with escharotics. Fissures are occasioned principally by hard fæces, and being slow of granulating owing to their callosity, must be converted into recent ulcers by paring them with the nails or a scalpel, when they may be made to granulate by proper applications.
Commentary. Celsus briefly directs us to seize the condyloma with a forceps and cut it out by the roots. Should any fungous flesh arise it is to be kept down with the squama æris. (vii, 30.)
Aëtius gives a fuller account of these affections than our author. The condyloma, he says, is a tubercle which forms in the soft wrinkled skin about the anus. When it becomes hard and callous he recommends us to take hold of it with a forceps and cut it out by the roots. Old fissures he directs us to treat by paring their edges and applying suitable dressings. (xiv, 3.)
The same treatment is recommended by the Arabians. See Haly Abbas (Chirurg. ix, 62); Albucasis (Chirurg. ii, 81, 82); Rhases (Contin. xxiv.)
In new-born children the anus is sometimes found imperforate, being blocked up by a membrane. If possible, then, the membrane is to be ruptured with the fingers, but if not, we must cut it with the point of a scalpel, and accomplish the cure with wine. And since often in adults, owing to an ulcer not properly cured, a stricture takes place at the anus, we must break it with a convenient instrument, and treat it properly with a pipe of lead, or some wedge-shaped tent introduced into the anus until the cure be completed, lest contraction should again take place. The wedge-shaped tent is to be anointed with some healing ointment.
Commentary. Soranus describes this operation in very distinct terms. (p. 164.)
Albucasis evidently copies our author’s account, recommending us to break or divide the membrane, and introduce a canula of lead into the opening to prevent adhesion. (Chirurg. ii, 79.)
Haly Abbas, in like manner, directs us to make an opening and introduce a leaden tube or a piece of sponge. (Pract. ix, 63.)
The varix is a dilatation of a vein occurring sometimes in the temples, sometimes in the hypogastric region below the navel, sometimes in the testicles, but more especially in the legs. For the most part it derives its origin from a melancholic humour. The operation for those of the testicle we have already described when treating of cirsocele, and those in the leg may be operated upon in a similar manner, making the attempt upon those in the inner parts of the thighs, where they generally arise; for below this, as they are divided into many ramifications, they are more difficult to succeed with. Wherefore, having washed the man, and applied a ligature round the upper part of the thigh, we are to direct him to walk about, and when the vein becomes distended we are to mark its situation with writing ink or collyrium, to the extent of three fingers’ breadth or a little more, and having placed the man in a reclining posture with his leg extended, we apply another ligature above the knee; and where the vein is distended we make an incision upon the mark with a scalpel, but not to a greater depth than the thickness of the skin, lest we divide the vein; and having separated the lips of the wound with hooks, and dissected away the membranes with crooked specilla, like those used in the operation for hydrocele, and laid bare the vein, and freed it all around, we loose the ligatures from the thigh, and having raised the vessel with a blind hook, and introduced under it a needle having a double thread we cut the double of it, and opening the vein in the middle with a lancet, evacuate as much blood as may be required. Then having tied the upper part of the vessel with one of the ligatures, and stretched the leg, we evacuate the blood in the limb by compression with the hands. Then having tied the lower part of the vein, we may either cut out the portion intermediate between the ligatures, or suffer it to remain until it drop out of its own accord with the ligatures; then we have to put a dry pledget into the wound, and apply over it an oblong compress soaked in wine and oil, and secure them with a bandage, and accomplish the cure by the treatment applicable in cases of suppuration. I am aware that some of the ancients do not use ligatures, but cut out the vessel immediately after it is laid bare, whilst others stretch it from below and tear it out by force. But the mode of operating now described is of all others the safest. Varices on the hypogastrium may be treated in like manner, and those on the temples as described in the operation of angiology.
Commentary. Hippocrates directs us to make small punctures in varices of the leg, but forbids to open them freely. (De Ulceribus, 16.) In the Hippocratic treatise entitled ‘Hippiatrica,’ it is recommended to burn varices in the legs of horses.
Celsus treats ingeniously of varices on the head (aneurism by anastamosis) on the belly (cirsocele?), and on the leg. With regard to the treatment, he says, in a word, that they are all either to be burnt or cut out. If the varix be straight, or if, although transverse, it consist of a single vein of moderate size, it will be better, he says, to burn it. If crooked and convoluted, and if it consist of a multitude of veins, it will be more useful to cut them out. He directs us, in burning them, to make an incision in the skin, and having laid bare the vein to touch it with a slender blunt piece of iron red-hot, taking care not to burn the edges of the wound which are to be drawn aside with hooks. This is to be done at intervals of about four fingers along the whole extent of the varix, and then the dressings for burns are to be applied. The varix is cut out in this way. The vein is to be exposed as above directed, and dissected with a scalpel from the surrounding parts (care being taken not to hurt it); a blunt hook is then to be introduced below it; and the same thing is to be done at the same interval as mentioned above. When this has been performed wherever there are varices, the vein is to be cut asunder at one of the hooks, and drawn towards the next hook, and then torn out. The leg being in this way cleared of the varices, the lips of the wound are to be united, and an agglutinative plaster applied above. (vii, 31.) It will be remarked that our author makes mention of this method of treatment but disapproves of it.
Aëtius describes the excision of varices in exactly the same terms as our author. He also makes mention of the treatment by the actual cautery. (xiv, 84.)
The operation of extracting varicose veins is briefly described in the ‘Isagoge’ of Galen. Albucasis describes accurately the different modes of operating upon varices. He says there are two methods of performing the operation with the knife, that is to say, by incision or by extraction. The former method is done by applying a piece of fillet round the upper part of the thigh, and at the inferior part near the knee, and then opening the vein in one, two, or three places, and evacuating the blood in it: the limb is then to be bound up. In performing extraction, the veins are first to be made to swell by putting the limb into hot water, applying fomentations, and taking strong exercise; and then a longitudinal incision is to be made in it, either at the knee or the ankle. The vein is afterwards to be dissected from the neighbouring parts and suspended with a blunt hook. The vein is to be laid bare in like manner at the distance of three fingers’ breadth, and in more places if required. At last, it is to be cut asunder at the ankle and drawn out. Afterwards wool dipped in wine and rose-oil is to be applied. When the varix consists of a congeries of tortuous vessels he recommends us to dissect it out entire. (Chirurg. ii, 92.)
Haly Abbas briefly inculcates the same treatment as Albucasis. (Pract. ix, 64.) Avenzoar considers the complaint nearly incurable.
Rhases directs us, in the first place, to bleed and purge, and then to expose the vessel or cut it out. He also approves of compression. (Cont. xxviii.)
It is related that the operation here described was performed upon the celebrated Caius Marius. See Cicero (Tusc. Disput. ii.) Pliny (H. N. xi, 104); and Plutarchus (in Mario.) It seems to have been a very painful operation, since it is mentioned as a proof of his fortitude that he submitted to it without being bound. It would appear that the learned and ingenious Aurelius Severinus used to perform it. (V. Mangeti Bib. Chir. xvi.)
The treatment of dracunculi being principally accomplished by medicines, we have given an account of it in the Fourth Book.
Commentary. We have treated fully of this subject at the end of the Fourth Book.
Sometimes the extremities, such as a hand or a foot, having mortified, so that the bones themselves are corrupted, either from having been fractured by some external means, or from having become putrid owing to some internal cause, it is necessary to saw them off; before doing which the parts surrounding the bones must be divided. But since, when this is done first, as a considerable time is required for the sawing, there is danger of a hemorrhage taking place, Leonides properly directs us not to divide all the parts at once unless they are completely mortified, but first to cut the part where not many nor very large veins or arteries are known to be situated, down to the bone quickly; then to saw the bone as expeditiously as possible, applying a linen rag to the parts which have been cut lest they be torn by the sawing and occasion pain, and then having cut through what remains, to apply red-hot irons to the vessels and stop the hemorrhage thereby with compresses of lint, and to apply proper bandages with the dressings suitable to suppurations.
Commentary. Hippocrates and Galen recommend amputation to be performed in general at a joint. (De Articulis, Galeni Comment. t. v, p. 650, ed. Basil.) Hippocrates says complete excision may be performed at the joints of the hand and foot, and at those of the wrist and ankle, and generally with safety, unless the patient be cut off by fainting, or continual fever supervene on the fourth day. When gangrene attacks a fractured limb, his rule of practice is to let the parts drop off, and he remarks, many persons thus recover, even when the fracture is seated in the femur. When gangrene comes on without being preceded by fracture, he directs the soft parts, as soon as they have lost all sensibility, to be removed at the nearest joint below, and the surgeon is to wait until the bone also separates. He says he had seen the bone of the thigh thus separate on the eightieth day; in that case the limb below had been removed at the knee on the twentieth day. In a similar case of gangrene of the leg, the bones separated on the sixtieth day. He pronounces gangrene of the extremities to be more formidable in appearance than in reality. He recommends a mild and anti-inflammatory treatment, and that the limb should be laid in an elevated position as long as there is any fear of hemorrhage. Violent attacks of dysentery are apt to come on, but do not generally prove obstinate. (De Artic. 69.) It would appear from Thucydides and Lucretius that it was not uncommon to amputate in cases of gangrene in the days of Hippocrates. (See their Descriptions of the Plague of Athens.)
In cases of gangrene Celsus directs us to make an incision of the flesh, between the sound and corrupted part, down to the bone, which is to be sawed across, and after the asperities have been removed from the end of the bone, the skin is to be brought over the stump. (vii, 33.) He gives us no particular description, however, of amputation of the extremities. We turn, therefore, to the celebrated fragments of the works of Archigenes and Heliodorus, preserved in the collection of Nicetas, published by Cocchius. (Chirurgici Græci, Florent. 1756.)
Archigenes begins by stating the circumstances which require recourse to be had to amputation. They are, the presence of some intractable disease, such as gangrene, necrosis, putrefaction, cancer, certain callous tumours, and sometimes wounds inflicted by weapons, and the like. Before attempting the operation he recommends us to consider well if the patient’s strength will enable him to endure it. The operator must then tie or sew the vessels which pass to the parts; in certain cases a ligature is to be applied round the whole limb, cold water is to be poured upon it, and some are to be bled. Amputation near the joints is not to be attempted. In such as are of a full habit of body, a circular band is to be put round the limb, to draw up the skin with, and to direct the incision. After cutting down to the bone, the tendons are to be retracted, and the bone scraped and sawn. When much blood is discharged, red-hot irons are to be applied, and a double compress laid on the part from which the blood proceeds. Having loosened the band, a cataplasm of leeks, bread, and salt is to be applied to the stump; and the parts about the jaw-bone are to be anointed with cerate of iris and old oil, doubtless in order to obviate the danger from tetanus.
Heliodorus states that a limb may require to be amputated owing to gangrene or any other cause that occasions the death of it. In the extremities, then, he remarks, amputation may be performed with less danger; but above the knee or elbow the danger of hemorrhage from the great vessels being wounded is very considerable. Some, he says, from too great anxiety for despatch, cut through all the bodies (the soft parts?) at one incision, and then saw the bones. But this method of removing the limb is not unattended with danger, as many vessels pour forth blood at the same time. “Wherefore,” he adds, “it appears to me better first to divide those parts of the limb where there is least flesh, as on the anterior part of the leg, and then to saw the bone; and I myself am in the practice of first applying a ligature above the part of the limb which is to be sawn across, and then of operating in the manner described. In sawing the bone the plate of the saw ought to be applied even, in order that the sawing of the bones may be even. When the bones are sawed the other parts which remain undivided are straightway to be cut through with a scalpel, and large pledgets applied along with suitable compresses. External to these, sponges with suitable bandages are to be put on. After the third or fourth day, when all fear of hemorrhage is over, suppuration is to be promoted by suitable dressings.”
In no other of the Greek medical works which have come down to us is there any description of amputation of the extremities.
Avicenna mentions the operation of sawing off the bones of the extremities, but in such general terms as gives us no information in what manner it was performed. (iv, 4, 4, 10, 11, 12.)
The description given by Haly Abbas is more complete. A limb, he says, is amputated thus. The operation is to commence with first cutting the skin, and then when the bone of a limb is to be sawn, you must not cut through the whole flesh at once, lest an immoderate discharge of blood take place from the veins and arteries so as to occasion the death of the patient and interrupt the process of sawing the bone; except the flesh of the limb be wasted or putrid. But you ought first to divide that part of the flesh where no great arteries and veins are situated, cutting them down to the bone, which is to be sawn across as quickly as possible, the fleshy parts in the mean time being retracted with a piece of linen, lest the saw should tear them and occasion bleeding and pain; when the bone is sawn across, whatever portion of the flesh remains undivided is to be cut, and then the veins and arteries are to be burned. When the bleeding is stopped a pledget with suitable bandages is to be applied. (Pract. ix, 65.)
Albucasis represents amputation as necessary in cases of mortification, as indicated by the smell and discoloration. When the disease is seated in the hand, he recommends us to amputate at the fore-arm; when in the forearm, at the elbow; and if the arm itself be affected, he pronounces the case to be hopeless. In like manner, with regard to the lower extremities, he pronounces all cases incurable in which the disease is seated above the knee. In performing the operation he directs us to apply two bandages around the limb, the one above and the other below the place at which it is to be cut off. These bandages are to be pulled, the former upwards and the latter downwards, by two assistants, so as to put the skin upon the stretch; the fleshy parts are then to be divided with a large scalpel down to the bone, which is afterwards to be cut out, or sawed across, and during this part of the process a piece of linen is to be applied around all the fleshy parts, to prevent them from being injured by the sawing. Should any hemorrhage occur during the operation, he directs us to apply the cautery, or a styptic powder; and after the operation he recommends us to bandage the limb in a suitable manner, until the stump is healed. He relates a case, from which the timidity of his own practice is rendered very apparent. A person who had a spreading mortification in the foot, cut it off at the ankle-joint himself, and was cured for the time. The disease next attacked the hand, upon which he applied to Albucasis, requesting that he would cut it off in the same manner, but this he refused to do, for fear that the man’s strength might not be able to endure the operation. He afterwards learned that the man had cut off his whole hand, and had recovered. (Chirurg. ii, 89.) The history of this case proves decidedly that the operative surgery of the Arabians, in the days of Albucasis, must have been very defective; this he himself frankly confesses, for he declares that all knowledge of this art had been lost, except what vestiges of it had been preserved in the works of the ancient authors, whose descriptions, he complains, had been mutilated and corrupted. (Prefatio.) We mention this, in order that the ignorance which prevailed in his time may not be imputed to all preceding ages, nor may be used as an argument against the genuineness of the extracts from the works of Heliodorus and Archigenes, given above.
Rhases makes some interesting remarks on the sawing of bones. He directs us to stretch the flesh upwards and downwards, with a piece of cloth, so that it may not come in the way of the teeth of the saw. When it is necessary to saw a rib or a bone, near any important membrane or organ, he recommends us to use a plate (tabella), to protect the soft parts from the saw. When the bone connected with a joint is diseased, he directs us to extract it at the joint. When the os brachii, or tibia, is diseased, he recommends us to extract it entire, but forbids to meddle with the head of the femur or the vertebræ. In another place he declares it as his opinion that when a joint is swelled, and the bone diseased, (in cases of white swelling?) it will be impossible to effect a cure unless the whole diseased portion of the bone be cut out. (Cont. xxix.) From these passages it is quite obvious that the ancients practised excision of the bones of joints. See also what our author says on this subject in the seventy-seventh section of this book. A Cooper or a Liston could not recommend a bolder plan of treatment in such cases.
Theodoricus, Guy of Cauliac, and the other surgical writers of that age, follow closely in the footsteps of the ancients, especially of the Arabians. When the mortified part is near to a joint, they recommend amputation at it. In other cases they direct us to make an incision between the sound and the dead parts, to saw the bone with a fine saw, and to stop the bleeding with a heated iron. Theodoricus recommends stupifying medicines, such as opium, hyoscyamus, mandragora, or cicuta, before the operation. Ambrose Paré has undoubtedly the merit of introducing the use of the ligature into modern practice in amputations, and, in fact, Archigenes seems to be the only ancient authority who mentions it in such cases. We have shown, however, in another place, that the ligature was freely used by the ancients for stopping bleeding from wounds.
The pterygium is a fleshy excrescence about the nails, covering part of the nail, and being commonly formed in the large fingers and toes. But those in the feet arise most commonly from an accident, whereas, those in the hands arise from whitlow, the inflammation being neglected and turning to pus. For, the pus being allowed to remain, corrodes and corrupts the root of the nail, and often destroys the whole of it, but generally the one half, while a portion of it uncorroded is left at the root of the nail, and sometimes the whole root is left uncorroded. Sometimes, too, it corrupts the bone, when a disagreeable smell arises from it, and the extremity of the finger becomes swelled and appears livid. They are to be treated, then, by cutting and removing all the remaining part of the nail with the point of a scalpel, and then burning both the ulcerated and cut part with cauteries. For, the pterygium is a spreading disease, and does not stop unless burnt, so that, if neglected, it affects the whole finger. If, while the nail and bone remain sound, the inner angle of the nail sink down and pierce the adjacent flesh, it occasions inflammation; and in this case the irritating portion is to be raised upon a thin probe, or some such thing put under it, and removed with the point of a scalpel, and the excrescence eaten down with an escharotic medicine. And most cases are cured by being treated in this way. But if larger, it is first to be cut out with a scalpel, and then the medicine is to be used.
Commentary. We have given an account of the ancient treatment of pterygia by medicines towards the end of the Third Book.
Celsus recommends excision with the knife and the application of cauteries or strong caustics afterwards. (vi, 19.)
Aëtius and Oribasius trust to septic and caustic applications without an operation. Antyllus (apud Rhasis Cont. xxxvi,) recommended excision and burning when the discharge from the ulcer is fetid.
Albucasis, like our author, recommends us to cut off the piece of nail that is attached, and then to apply a burning iron to the part. The burning, he adds, is of great consequence. When the bone is diseased he directs us to take it out, which generally may be done at the joint. (Chirurg. ii, 9.)
Haly Abbas likewise directs us to cut off the piece of nail and apply the cautery. He says, if this be neglected the bone is apt to become diseased. When pus is seated below the nail, he recommends us to introduce the head of a probe under it, and cut upon it with a knife; after which a caustic medicine is to be applied to the flesh. (Pract. ix, 66.)
Since, owing to nails having been bruised by accidents, pains supervene, which compel us to operate upon them, it will be sufficient to give you Galen’s account of the matter. He says, then: “When the nails are contused we have found the evacuation of the blood a palpable remedy for soothing the pain, when it and the throbbings are very violent. But we must make an oblique incision, not straight from above downwards, with a sharp scalpel, so that when the blood is evacuated the divided part of the nail may serve as a cover to the parts under it. But if you make a straight incision from above down to the fleshy excrescence, as it is called, another body is formed from the flesh below the nail shooting out through the division of the nail, whence pains again invade, as in the complaint we call paronychia, owing to the flesh under the nail being compressed by it. Wherefore, one may see the patients immediately relieved from pain by this section. On the following days we may gently raise the divided part of the nail, and press the sanies from under the nail, and then again, as I said, apply the nail as a cover to the flesh below. The rest of the treatment of the finger should be soothing and discutient.”
Commentary. Avicenna and Rhases approve of the plan of treatment here recommended, upon the authority of Galen. Rhases, in fact, gives the very words of Galen. (Cont. xxxvi.)
Albucasis directs us, in the case of a bruised nail, first to have recourse to venesection, and then to make a transverse (oblique?) incision through it. (Chirurg. ii, 91.)
See our remarks in the sixtieth section of this Book on the confusion of the terms transverse and oblique by the translators of the Arabians.
The same treatment is recommended by Haly Abbas. (Pract. ix, 67.)
The clavus is a round callus, white, resembling the head of a nail, and occurring in all parts of the body, but more especially on the soles of the feet and the toes, occasioning pain and lameness in walking. Wherefore, having scarified around the clavus or corn, and taken hold of it with a forceps, we cut it out by the roots with a sharp-pointed scalpel or lancet for bleeding. Some, in order that they may not grow again, use heated cauteries. The myrmecia is a prominence of the skin, small, callous, round, thick, spreading deep at the base, and, if rubbed, occasioning a sensation like the bites of ants, and being formed in all parts of the body, but more especially in the hands. Wherefore, some, among whom is Galen, advise us to scarify around the myrmecia with the stalk of a hard feather, such as those of old fowls, of geese, and of eagles, and to push it down so as to remove the myrmecia from the root. Others do the same thing with a copper or iron tube. The moderns are satisfied to scarify around it, and, having seized it with a forceps, to cut it out like corns with a scalpel. The acrochordon is a small rising of the surface, free of pain, callous, for the most part round, and having a narrow base so as to appear to hang. It is so called from its resemblance to the end of a cord. Having stretched out the protuberance then we may cut it out; or, otherwise, we may tie a thread or a hair round it. I have known many who consumed this and all the afore-mentioned protuberances with what is called the cold cautery.
Commentary. We have already treated fully of these diseases towards the end of the Third Book and in the Fourth, to which we refer the reader for further information on this head.
Celsus recommends us merely to shave the clavus or corn. The others he directs us to remove by caustics, such as the lees of wine (potass?), or a mixture of alum and sandarach. The acrochordon, he says, when cut out leaves no roots behind. (v, 28.)
Albucasis particularly recommends burning for the cure of clavus and myrmecia. This may be accomplished either with fire or hot water. If the former method is preferred, an iron proportionate to the size of the corn is to be heated red-hot and applied to it, and the burning carried to such an extent as to occasion suppuration. In the other method a funnel of copper or iron, or else the quill of a vulture is to be applied to the corn, and then filled with boiling water. By these means, he says, the corn may be eradicated. (Chirurg. i, 55.)
See also Haly Abbas (Pract. ix, 12) and Rhases (Cont. xxxvi.) Rhases does not state very distinctly the difference between the myrmecia and acrochordon. He speaks of scraping them out with a hard pen, and of tying them at the base; but upon the whole he approves most of taking hold of them with a forceps and dissecting them out.
Avicenna recommends us to cut out the clavus and then apply a caustic medicine to the part. (iv, 7, 4, 14.)
That the extraction of weapons is a most important department of surgery is declared by the Poet Homer, when he says:
We must first describe the different kinds of weapons. Warlike instruments, then, differ from one another in material, figure, size, number, mode, and power. In material, then, as the shafts are made of wood or of reeds; and the heads themselves are either made of iron, copper, tin, lead, horn, glass, bones, and of reeds, too, or of wood: and such differences are found especially among the Egyptians. In figure, inasmuch as some are round, some angled (as triangular), some pointed and lance-shaped, as some have three points; some are barbed and some are without barbs; and of the barbed, some have the barbs turned backwards, so that in attempting to extract them they may fasten in the parts; and some forwards, so that when pushed they may do the same thing: some have them diverging in opposite directions like the forked lightning, in order that whether pulled or pushed they may fasten in the parts. Some missiles have their barbs united by a hinge, which being expanded in the extraction, prevent the weapon from being drawn out. They differ in size, inasmuch as some are three fingers’ breadth in size, and some are as small as one finger, which are called micca in Egypt, and some are intermediate between them. In number, inasmuch as some are simple and some compounded. For certain small pieces of iron are inserted in them, which, in the extraction of the weapon, remain concealed in deep-seated parts. In mode, as some have the sharp extremity fixed to a tail and some to a shaft; and some have it carefully inserted in the shaft, and some carelessly, so that in the extraction they may separate and leave the head behind. In power, as some are not poisoned and some are poisoned. Such are the differences of weapons. We now proceed to treat of the extraction, both in cases of those who have been wounded in war and those not in war, whether voluntarily and involuntarily, under whatever circumstances, and of whatever materials they may be composed. There are two modes of extracting weapons from fleshy parts; either by pulling them backwards, or pushing them forwards. When the weapon is fixed superficially the extraction is made by pulling it back, and in like manner when it is lodged deep, but the opposite parts, if wounded, would occasion danger from hemorrhage or sympathy. It is to be pushed forwards when lodged deep, and the intervening substances between it and the opposite side are of small size, and neither nerve, bone, nor any such thing is an obstacle to the division. When a bone is wounded, the mode of extraction is by pulling; if, therefore, the head of the weapon be in sight, we make the extraction immediately; but, if it is hid, we must, says Hippocrates, get the wounded person to put himself in the same posture as when he received the wound, and thus make the examination; or, if this cannot be done, he is to be placed in the nearest possible to it, and thus it is to be examined with a sound. If the head of the weapon has fixed in the flesh, it is to be drawn out with the hands, or by laying hold of the appendage, which is called the shaft, if it has not fallen off. This part is mostly made of wood. When it has fallen off, we make the extraction by means of a tooth-extractor, or a root-extractor, or an instrument for extracting weapons, or any other convenient instrument. And sometimes we make an incision in the flesh around it in the first place, if the wound do not admit the instrument. And if the head of the weapon has passed to the opposite side, and it is found impossible to extract it by the way in which it entered, having divided the parts opposite we extract it through them, either drawing it out in the manner mentioned, or we make a hole with the weapon itself, pushing it either by the shaft, or, if it has come away, by an impellent instrument, taking care not to divide a nerve, vein, artery, or any important part, for it would be disgraceful if, in extracting the weapon, we should do more mischief than the weapon itself had done. If the weapon has a tail, which is ascertained by examination with the probe, having introduced the female part of the impellent instrument and fixing it, we push the weapon forwards, but if it has a shaft, the male part. And if the head when extracted appear to have notches, so that other small pieces of iron might be inserted in them, we make an examination again with the probe, if we find them we extract them in the same manner. And if the weapon has barbs in opposite directions, which do not yield to our pulling, we must make an incision in the adjacent parts, if no important vessel or the like lie there, and when the weapon is laid bare, we extract it without trouble. Some apply a tube about the barbs, so that when they draw out the weapon the flesh may not be torn by the barbs. If the wound does not become inflamed, we may use sutures, and heal it up like a bloody wound; but if it inflame we may remove the inflammation by embrocations, cataplasms, and the like. If the weapon be poisoned we must, if possible, cut off all the flesh which has imbibed the poison, which is known by its being altered from the sound flesh, for it appears pale, livid, and as it were dead. They say that the Dacians and Dalmatians touch the points of their weapons with elecampane, called also ninum, and that when it thus becomes mixed with the blood of the wounded animal it proves fatal, although it is eaten by them with impunity. If, again, the weapon fix in a bone, we make trial with the instrument, and, if flesh prevent the extraction, we cut it off, or separate it; but if it be lodged deep in the bone (which we know by its being so firm that it cannot be shaken with a considerable force) we first remove the remaining part of the bone with a cutting instrument, or bore it with trephines if it has considerable thickness, and thus disengage the weapon. If a weapon be lodged in any important part, such as the brain, heart, throat, lungs, liver, stomach, intestines, kidneys, womb, or bladder, and fatal symptoms have already shown themselves, as the extraction would occasion much laceration we must decline the attempt, lest while we do no good we expose ourselves to the reprobation of ignorant people. But if the result be dubious, we must make the attempt, having first given warning of the danger. For in many cases, when an abscess has formed in some vital part, recovery has unexpectedly taken place; and the lobe of the liver, part of the omentum and peritoneum, and the whole uterus are said to have been taken away, and yet death was not the consequence. And we often open the windpipe intentionally, in cases of angina, as we mentioned under the head of Laryngotomy. To leave the weapon then as it is, occasions certain death, and exhibits the art in an inhumane light, whereas by extracting it we might possibly save a life. It is not difficult to ascertain when an important part is wounded, this being discovered by the peculiarity of the symptoms, the discharges, and situation of the parts. When, therefore, the membranes of the brain are wounded, there is intense pain of the head, the eyes are fiery, the tongue red, and there is aberration of intellect; but if it is attended with a wound of the brain, there is prostration of strength, with loss of speech, distortion of the countenance, vomiting of bile, a discharge of blood from the nostrils, an evacuation of a white and pultaceous fluid by the auditory foramen, and of ichor, if it can find a passage by the wound. If the weapon has penetrated to the cavity of the chest, and sufficient room is left for it, the breath passes out. When the heart is wounded, the weapon appears at the left breast, and feels not as if in a cavity, but as fixed in another body, and sometimes there is a throbbing motion; there is a discharge of black blood if it can find vent, with coldness, sweats, and deliquium animi, and death follows in a short time. When the lungs are wounded, if the opening be sufficiently large, a frothy blood passes out at it; but if not, it is rather vomited up, the vessels of the neck are swelled, the tongue changes colour, and there is an urgent desire of cold things. When the diaphragm is wounded the weapon appears lodged about the false ribs, there are large inspirations with pain, sighs, and heavings of the parts about the shoulder-joints. If the viscera of the abdomen are wounded, the nature of the injury will be apparent from the discharge, if the wound be sufficiently large, or if the weapon be extracted, or if the shaft be broken internally; for chyle is evacuated from the stomach, and fæces from the intestines; sometimes the omentum or an intestine protrudes. When the bladder is wounded urine is discharged. When the membranes of the brain or the cerebrum itself is wounded, we extract the weapon by trepanning the skull, as will be described presently in fractures of the bones of the head. If the weapon is lodged in the chest, and does not come out readily, it is to be extracted by means of a moderate incision in the intercostal space, or by cutting out a rib with the assistance of the instrument called meningophylax. In like manner, when the stomach, bladder, and other deep-seated parts are wounded, if the weapon come out readily it is to be extracted without more ado; but if not, we must enlarge the wound, and afterwards use the dressings for fresh wounds. In wounds of the abdomen, gastroraphé as formerly described may be had recourse to, if necessary. But if the weapon has lodged in any of the larger vessels, such as the internal jugulars or carotids, and the large arteries in the armpits or groins, and if the extraction threaten a great hemorrhage, they are first to be secured with ligatures on both sides, and then the extraction is to be made. If parts have been fastened to one another, such as the arm to the chest, or the fore-arm to the other parts of the body, or the feet to one another, if the weapon (as a spear) do not penetrate through both parts, we are to take hold of the weapon externally and extract as if only one part were affected, but if it has passed through both, having sawed the wood through the middle, we extract each part singly, in the most convenient direction. But since often stones or the sharp points of rocks, or pieces of lead, or the like, are lodged in the body, either being impelled with force from a sling, or happening to be acuminated, they are to be known by the swelling being hard and irregular, and by the solution not being everywhere straight, but larger than common, and having the skin bruised and livid, and the pain being attended with a sense of weight. They are, therefore, to be dislodged by means of suitable instruments, or scraped out with the concave part of a specillum or of an ear-specillum adapted for wounds; or, if they can be applied, a tooth-extractor or a root-extractor may be used for pulling them out. In many instances weapons lodged in the body lie concealed, and a long time after, when the wounds are healed up, the part having suppurated bursts, and the weapon drops out.
Commentary. Hippocrates considered the extraction of weapons to be one of the most important departments of surgery. It is to be fully learned, he says, only by attaching oneself to a foreign army. (De Medico.) He makes some interesting remarks on the subject in his treatise ‘De Capitis Vulneribus.’
We must now attempt to give an abstract of Celsus’s very interesting chapter on the Extraction of Weapons. Every weapon is to be extracted either by the part at which it enters or by that to which it tends. If it is not deep-seated, or if it has not passed any great vessels or nerves, there is no better plan than to draw it out as it entered. But if there is a greater space through which it must return than there would be to push it out, and if it has already passed the vessels and nerves, it will be better to open what remains undivided, and extract it in this direction. If the weapon is to be drawn backwards, the opening is to be enlarged by a scalpel, which will occasion less inflammation and obstruction of the parts than if they are torn by the weapon itself. In whichever way it be extracted great care ought to be taken that no nerve, large vein, or artery be divided. If any of these parts be detected in the wound they are to be drawn aside with a blunt hook. These are his general directions. He then subjoins instructions for extracting particular kinds of weapons. An arrow being a slender body, and generally impelled with great force, is often lodged deep, and is to be extracted for the most part rather by the opposite side to which it entered, especially as it has barbs, which tear most if drawn backwards. The flesh about the weapon is to be separated by means of a suitable instrument, and then if the head (mucro) appear with the shaft (arundo) fixed to it, the weapon is to be propelled until it can be laid hold of at the opposite side and extracted; or if the shaft has fallen out and only the iron remain lodged within, the head is to be seized with the fingers or a forceps, and removed, and it is to be extracted by the opening at which it entered, upon the same principles; for the wound being enlarged, the weapon is to be drawn back by the shaft if it remain, or otherwise by the iron itself. If there appear to be barbs upon the arrow, and if short and small, they are to be broken off with a pair of pincers; or, if larger and stronger, they are to be covered with split writing-pens (fissis scriptoriis calamis) to prevent them from tearing the flesh during extraction. And here we may mention, that the common calamus scriptorius of the ancients was made from an Egyptian reed. See Montfauçon (Palæographia Græca, p. 3.) When the weapon which is lodged in the body is large it must not be extracted by the opposite side, as it would make the wound too large. He directs us to draw it back by means of an instrument invented by Diocles, of which he gives a description. Another class of weapons which must sometimes be extracted are leaden balls, stones, or any such thing which breaks the skin, and is buried within. In all such cases the wound, he says, must be enlarged and the body extracted with a forceps. A complication which increases the difficulty of extraction arises from the weapon being lodged in a bone, or between two bones at a joint. When lodged in a bone it is to be moved about until loosened, when it is to be grasped with a forceps and extracted in the same way that a tooth is pulled out. It rarely happens that the weapon cannot be removed in this way; but if it remain fixed in the bone, it is to be struck with some iron instrument until it be shaken from the place where it is lodged. When other means do not succeed, the bone is to be perforated with a trephine. When the body is lodged in a joint between two bones, the two members about the wound are to be wrapped round with strips of cloth, or leathern thongs, and thereby separated by pulling in opposite directions, by which means the space between them will be slackened, and then the weapon may be removed without difficulty. When the weapon had been poisoned, these things must be done with all possible despatch, and the remedies applied which are used when a poison has been swallowed, or a person has been stung by a serpent. The wound from which a weapon has been extracted requires no other treatment than what is applicable for ordinary injuries. (vii, 5.)
Albucasis borrows mostly from our author the account which he gives of the construction of weapons and the symptoms occasioned by the wounds which they inflict. He also relates some interesting cases of recovery from very severe wounds. An arrow entered at the root of a man’s nose and was extracted by Albucasis behind his ear; and the man recovered without having sustained any injury to the eye. He extracted another large arrow which had lodged deep below the eye of a Jew; and in this case also the sight was not impaired. He extracted a barbed arrow which had lodged in the throat of a Christian, by enlarging the wound, and the man recovered. An arrow had lodged in a man’s belly, so that, at first sight, Albucasis considered the case as hopeless; but, after thirty days, as no mortal symptoms had supervened, he enlarged the wound and extracted the weapon. He saw a man who had got an arrow lodged in his back; the wound healed, but after an interval of seven years the weapon came out below his buttocks. He knew a woman who had an arrow lodged in her belly, and the wound healed, and the weapon never afterwards occasioned her any inconvenience. He knew a man who had an arrow lodged in his face, and the wound healed up, and never gave him much trouble. He relates that he extracted an arrow which had been buried in the nose of a prince, after making various fruitless attempts for the space of four months. He then delivers general directions for the extraction of weapons, borrowing, as usual, very freely from our author. When a weapon cannot readily be got extracted at the time, he recommends us to let it alone until it become loosened by the putrefaction of the surrounding parts. When impacted in a bone, he directs us either to move it about until it is loosened, or to perforate the bone with a trephine. When lodged in the cranium, it is to be removed in like manner with a trephine, provided the dura mater is not injured, for if it is wounded the case must not be interfered with. When a weapon is lodged deep in any part of the body where there are no large nerves, veins, or bones, he directs us to enlarge the wound and extract the weapon; but if it has barbs, the fleshy parts about it must first be carefully separated to prevent them from being torn. When a weapon passes through a limb, or attaches one part of the body to another, he directs us to cut off the part which projects, and then extraction may easily be accomplished. If fastened in a bone, he advises us to turn it round so as to loosen it; and if that does not suffice, he recommends us to leave it for a few days, when it may be extracted without difficulty. If the shaft or wooden part of a weapon be broken off, he directs us to apply to the head an impellent instrument with a concave extremity, so as to adapt itself to the form of the body which is to be extracted. When the weapon is poisoned, he recommends us, if possible, to cut out the flesh around it. When a weapon lodges in the breast, belly, bladder, or side, and can be felt with a probe, he directs us to cut cautiously upon it, taking care not to wound a vein or nerve. He concludes with giving drawings of forcipes and impellents. (Chirurg. ii, 96.)
Rhases gives sensible directions for the management of these cases, but they are so similar to those of our author that we need not dwell upon them. If the size of the wound permit, he directs us to introduce a forceps to the iron head and draw it out. If the opening be too small, he recommends us to enlarge it. When the weapon has nearly passed through the limb, he advises us to push it out at the opposite side. Thorns and such like sharp things are to be removed by the application of extractive plasters. (Ad Mans. vii, 25.)
Avicenna gives a literal translation of the present chapter of Paulus, and supplies nothing additional of much interest. (iv, 4, 2, 10.)
The account given by Haly Abbas is full, but like that of Albucasis. He mentions that he had seen cases in which an arrow had been lodged in the intestines, and although fæces were discharged by the wound, the patient recovered. He adds that others relate cases in which recovery took place although the liver or omentum had been wounded. (Pract. ix, 15.)
The rules for the extraction of weapons laid down by Theodoricus and all the earlier authorities are mostly copied from the ancient authors. (i, 22.)
It would be naturally expected that we should give some account in this place of the surgery in the heroic ages, as far as it can be learned from the poems of Homer and the Commentary of Eustathius. The Commentator remarks that three methods of extracting weapons are mentioned by Homer: 1. By evulsion or pulling the weapon backwards, as in the case of Menelaus. (Iliad, iv, 214.) 2. By protrusion or pushing it forwards, as in the case of Diomedes. (Iliad, v, 112.) 3. By enlarging the wound and cutting out the weapon, as practised by Patroclus in the case of Eurypylus. (Iliad, xi, 218.) He further remarks that it appears to have been a common practice to suck a wound with the mouth; and, he adds, that this method was still in use among a barbarous people in his days. (Iliad, iv, 219.) The weapons used in the Trojan war were swords, spears or javelins, stones flung by the hand or by a sling, hatchets or axes, as used by the Trojans on certain occasions (Iliad, xii, 590), and arrows. Eustathius remarks, however, that there would appear to have been very few bowmen. In his Commentary on the Odyssey he states that poisoned arrows were never employed in war, but only for killing wild beasts. (Odyss. i, 260.) We believe that no weapons of iron were used in the war of Troy, and that they were all made of copper. (See Jameson’s Mineralogy, iii.) Little transpires from Homer with regard to the internal treatment. In one place (Iliad, xi, 638) mention is made of a mixture of wine and cheese having been given to a wounded warrior, which practice, Eustathius says, had given rise to a variety of conjectures. Some supposed that the wound in the case referred to was so slight as not to render the administration of stimulants improper; others rather believed that the loss of blood had been so great as to call for the use of wine to support the strength. But many, he adds, were of opinion that men in the heroic ages lived so temperately that their constitutions readily bore things on extraordinary occasions, which in after ages were reckoned to be of too inflammatory a nature. This explanation is advocated by Athenæus. (Deipnos, i.) In the Odyssey, mention is made of a hemorrhage being stopped by incantation, which shows, as Eustathius remarks, that amulets and incantations were as ancient as the heroic ages.
Having described the surgical operations on the fleshy parts, we have next to give an account of those which relate to the bones, I mean the treatment of fractures and dislocations; for these also fall under the department of surgery. And first, of fractures, beginning with fractures of the bones of the head, because they hold an intermediate place between the operations on the fleshy parts and the bones, and because the cranium overtops all the other parts. In general terms, then, a fracture is a division of a bone, or rupture, or excision of it, produced by external violence. The differences of fractures are many. A bone, then, is said to be fractured raphanatim, scandulatim, in unguem, polentatim, and per defractionem. A fracture raphanatim is a transverse one through the thickness of the bone, and is called also cucumeratim and caulatim, because cucumbers and cabbages break in this way. Scandulatim is a longitudinal fracture of a bone. In unguem is a fracture at one part straight, and at its extremity lunated, and it is also called arundatim. Polentatim is a fracture of a bone into small pieces; and it is also called nucatim by some: Defractio or præcisio is when part of a bone is taken away with tearing of the skin, so that part is removed and is wanting. These are the differences of fractures.
Commentary. The following is a list of the ancient authors who have treated of fractures and dislocations: Hippocrates (de Fracturis; de Articulis; de Vulner. Capit.; Officina Medici); Galen (Comment. in eosdem, Meth. Med. vi.); Celsus (viii); Oribasius (de Machinamentis, &c.); Nicetæ Collectio ex Chirurg. Græc.; Apollonius Citiensis (Scholia in Hippocrat. ed. Dietz); Avicenna (iv, 5, 23); Rhases (ad Mansor. vii, 26; Divis i, 140; Cont. xxix); Averrhoes (Collig. vii, 36); Avenzoar (ii, 6, 1); Haly Abbas (Pract. ix, ad finem.)
Hippocrates does not make use of the technical terms explained by our author in this section, and Galen hints that he thinks his Master did better in confining himself to words generally understood. Galen defines only a few of these terms. He calls that kind of fracture in which the end of a bone at an articulation is entirely taken away, âbruptio (ἄπαγμα.) A transverse fracture with a complete separation of the broken portions is called a fracture caulatim (καυληδὸν.) A longitudinal division not attended with an entire separation of the parts is called scandulatim (σχιδακηδὸν.) He thinks the later writers on the subject who had introduced the use of such terms as raphanatim (ῥαφανηδὸν) and polentatim (ἀλφιτηδὸν) had refined too much.
All the terms mentioned by our author occur in a fragment of Soranus, preserved in the collection of Nicetas. They are also treated of very elaborately in the fragments of Heliodorus, contained in the same collection.
Celsus, who was studious of perspicuity and elegance, avoids all technical terms as much as possible. He thus defines the varieties of fractures. A bone, he says, may be split longitudinally like a piece of wood, or it may be broken transversely or obliquely, and its ends may be blunt or sharp, which last variety is the worst of all, as they cannot be easily made to unite with the other parts, and are apt to wound the muscles and nerves. Sometimes the bone is broken into fragments, and in certain bones a fragment is occasionally separated entirely from the broken bone.
The Arabians, especially Avicenna, Haly Abbas, and Albucasis, adopt the terms used by our author. Albucasis remarks, that the fracture of a bone is recognised by the derangement of the broken pieces, by their projection, and the crepitus produced upon pressure. He says, however, that there may be a fissure without derangement or crepitus.
In particular, then, a fracture in the head is a division of the cranium, sometimes simple and sometimes complex, occasioned by some external violence. The differences of fractures of the head are these: a fissure, an incision, an expression, a depression, an arched fracture, and, in infants, a dent. A fissure, then, is a division of the skull, either superficial or deep, when the inward bone is not removed out of its place. An incision, or slash, (ἐγκοπὴ) is a division of the skull with refraction of the fractured bone (if the injured bone be broken off some call the affection deasciatio, i. e. as if done by a hatchet). An expression is a division of a bone into many parts, with a sinking down of the fractured pieces upon the membrane of the brain. A depression (ἐγγίσωμα) is a division of a bone with a sinking downwards of the fractured bone from its natural position towards the meninx. An arched fracture (καμάρωσις), as Galen says, is a division of the skull attended with elevation of the fractured pieces in the middle, and depression around the edges of the sound parts, like as in expression. Such is his opinion. Some enumerate also the capillary fracture, but it is a very narrow fissure which eludes the senses, and therefore, being often overlooked owing to the symptoms of it not being obvious, it occasions death. An indentation is not a division of a bone, and, therefore, such an injury is not properly called a fracture, but is, as it were, a protrusion and bending of the skull inwardly, forming a hollow without a solution of continuity, as when vessels made of copper, or the raw hide of an ox, are struck on the outside. There are two different kinds of indentation, for either the bone is depressed through its whole thickness, so that often a separation of the membrane of the brain takes place, or it is pressed upon by the skull throughout; or sometimes the indentation does not affect the skull through its whole thickness but only its outer plate down to the diploe. To these differences some also add that by repercussion, which happens, say they, when a fracture of the cranium takes place opposite to the part which received the blow. But they are in a mistake, for what happens to glass vessels does not, as they say, happen here; for, this happens to them from their being empty, but the skull is full and otherwise strong. But when many other parts of the head have been struck, as in a fall, and a fissure of the skull takes place without a solution of continuity of the skin, an abscess afterwards forms in it, and being opened, this fissure is discovered, which appears to them to have been occasioned by the blow on the opposite side; and this is to be cured like the fissure first mentioned. If a fracture, then, occur in the head, it is discovered by the sharpness, weight, hardness, or violent force of the body which struck it, and by the symptoms which supervene upon the person who has been struck, such as vertigo, loss of speech, and sudden prostration, more particularly if it be a fracture with depression, or contusion, or expression, or the internally-arched fracture, owing to the compression of the brain. It is also discovered by its appearances to the senses; for if there be a considerable division of the skin we ascertain the occurrence readily thereby; but if there be no division, or a very narrow one, and we suspect a fracture, we make an incision in the skin and ascertain it by the sight, or by probing it with an instrument. If then it be any of the other kinds of fracture it will readily be apparent, but if it is only a narrow capillary fissure which eludes the sense, having poured on the part some black liquid medicine, or the common writing ink, we scrape the bone, for the fissure appears black, and we must go on scraping until the symptoms of the fissure disappear; but if it extend to the membrane we must desist from the scraping, and endeavour to ascertain whether the membrane has separated from the bone or remains fixed. For if it remain, the inflammation of the wound continues moderate, the patient gets gradually freed from the fever, and the pus appears concocted. But if the membrane has separated, the pains increase and the fever in like manner, the bone changes colour, and then unconcocted pus is discharged; and if the person who has the charge of it neglect the case, and has not recourse to perforation, still more grievous symptoms will come on, vomiting of bile, convulsions, disorder of intellect, and acute fever, under which circumstances one must decline operating. But if these are not present, and the membrane has not separated, and if the fracture be a mere fissure, it may be cured by scraping alone, although it be of considerable depth. If it extend to the diploe only it is to be scraped down to it, or the broken bone removed, as will be described. If broken into small pieces, these also are to be extracted with a convenient instrument. And if the membrane separate, and you have treated the patient from the commencement, and if it be winter, endeavour by all means to effect the removal of the bone before the fourteenth day; but, if in summer, before the seventh, while the afore-mentioned symptoms have not come on you may operate in this way:
The Operation.—Having first shaved the head about the wound, we make two incisions intersecting one another at right angles like the Greek letter Χ, one of them being the wound already existing; then dissecting the four angles at the top, so that the bone about to be perforated may be wholly laid bare, if there be bleeding we apply pledgets moistened in oxycrate, but if not dry ones; and then applying a compress out of wine and oil, we use a proper bandage; and next day, if no new symptom supervene, we proceed to perforate the affected bone. Wherefore, having placed the patient on a seat, or in a reclining posture suitable to the wound, and stuffed his ears with wool in order to avoid the noise of the perforation, we loosen the bandage from the wound, and having removed all the dressings and sponged it, we direct two assistants with small twisted bands to retract the four angles of the parts lying over the fracture, and if the bone be weak, either naturally or from the fracture, we cut it out with counter-perforators, beginning first with the broader ones and changing to the narrower, and then using those which are of the form of a specillum, striking gently with the mallet to avoid shaking the head. But if the bone be strong it is to be first perforated with that kind of perforators called abaptistæ, which have certain eminences projecting a little above the point that prevent them from sinking down to the membrane, and then, by using the chisels, we remove the fractured bone not at once, but by pieces, if possible with the fingers, or otherwise with a tooth forceps, or bone forceps, or hair-nippers, or some such instrument. The space between the perforations should be as great as the breadth of the largest head of a specillum, and its depth should be until it is near the inner surface of the bone, taking care that the perforator (trepan?) do not touch the membrane. Therefore, in order to suit the thickness of the bone with the size of the perforator, several ought to be previously prepared for the purpose. But if the fracture extend only to the diploe the perforation should be carried no farther. After the removal of the bone, having cleared away any asperity that remained after the cutting of the bone with a carving instrument, or the extremity of a perforator, using the meningo-phylax as a protector, and bringing away carefully the small bones and spiculæ which remain, we proceed to the application of the dressings. This is the more common, and at the same time the easiest and least dangerous mode of operating; but the method of performing it with a sort of incisor called lenticular is greatly praised by Galen, being performed without perforation after the part has been scraped all round with hollow chisels (κυκλίσκοι). Wherefore he says thus: “If you have once laid bare the place, then applying the incisor, which has a projection at the extremity like a lenticular, blunt and smooth, but sharp longitudinally, when you apply the broad part of the lenticular to the meninx, divide the cranium by striking with the small hammer. For we have all that we require in such operations; for the membrane, even if the operator were half asleep, could not be wounded being in contact only with the broad part of the lenticular, and if anything adhere to the cranium, the round part of the lenticular removes its adhesion without trouble. And behind it follows the incisor, or knife itself, dividing the skull; so that is impossible to discover another mode of operating more free from danger or more expeditious.” But the mode of operating with saws and the instruments called chœnicides or modioli (trepans?) is condemned by the moderns as a bad one, and the operation may be done as we described for fissure. The same mode of removing bones will be applicable in the other fractures of the cranium. But regarding the amount of bones requiring extraction Galen informs us, writing thus plainly: “What parts of a fractured bone are to be removed I will now explain to you in order. When it is greatly bruised it is to be taken out entire, but if certain fissures extend from it farther, as sometimes they appear to do, we must not pursue them to their termination, well knowing that no harm will result from them if everything else be properly done.” After the operation, having dipped a simple linen rag of the size of the wound in oil of roses, we lay it over the membrane as a cover, and in like manner, having dipped a small ball of wool in oil of roses, we put it over the aforesaid rag, and then having moistened a doubled compress in wine and oil, or in the same oil of roses, we apply it to the whole wound, taking care that they be not too heavy for the meninx. We then have recourse to a broad bandage, which also must not be made tight, but so as merely to preserve the pledgets. And the regimen is to be what is called anti-inflammatory and such as is applicable for fevers, frequently bathing the membrane with oil of roses. After the third day loosing them and sponging the part we pursue the treatment applicable for recent wounds and the anti-inflammatory; sprinkling upon the meninx some of the powders called cephalics until it incarnate, and sometimes scraping the bone, if it require it, on account of certain projecting spiculæ, or for the sake of incarnation itself. And we may apply medicines of the ingredients recommended for wounds.
On inflammation of the membrane of the brain. Often after the operation the membrane is inflamed, so as not only to rise above the skull but likewise above the skin, and is attended with hardness, and obstructs the natural pulsatory motion of the brain, in which case convulsions and other severe symptoms, or death, for the most part supervene. It becomes inflamed either from the irritation of some sharp projecting piece of bone, or from the weight of the dressings, or from cold, or from eating too much, or from drinking wine, or some other cause not apparent. If then the cause be obvious it is to be speedily removed, or, if it is not, it will be proper to contend strenuously against it, either by having recourse to venesection, if nothing prohibit it, or to a diet suitable for inflammation. We must also use topical remedies, such as warm embrocations with hot rose-oil, and bathing the part with the decoction of marshmallows, or of fenugreek, of linseed, of camomile, and such like, and cataplasms of raw barley flour, or of linseed with the aforementioned decoction and the grease of a fowl; and irrigations with wool to be poured upon the head and occiput, and some anti-inflammatory oil is also to be poured into the meatus auditorius. The viscera also are not to be neglected, but suitable cataplasms are to be applied to them. And care is to be taken of the whole body, putting the patients into warm baths and anointing them. If the inflammation continues and nothing else prohibit, Hippocrates directs us to purge them with cholagogue medicines.