BOOK VI. (continued 4)

Avicenna and Rhases treat of the pneumatocele, and recommend carminative applications to it; but they do not describe the surgical operation.

Haly Abbas borrows the description of Paulus. (Pract. ix, 49.)

SECT. LXV.—ON ENTEROCELE, OR INTESTINAL HERNIA.

Enterocele is a descent of the intestine into the scrotum, and is occasioned either from rupture of the peritoneum which takes place in the groin, or from stretching of the peritoneum. Both these, I mean rupture and stretching, are occasioned by previous violence, such as a blow, a leap, or loud crying, but that from stretching in particular is connected with relaxation and other weaknesses of the body. The common symptoms of both are a marked swelling in the scrotum, which is increased by exercise, heat, retention of the breath, and other exertions; and its symptoms are, that it goes up slowly upon pressure, and quickly falls down again, and that while the person affected with it lies in a recumbent posture it remains in its proper place until he stands again erect. The retention of fæces in the region of the scrotum often brings on dangerous symptoms; for it is attended with pain, and sometimes with rumbling of wind upon pressure. The peculiar symptoms of hernia from distension are, that it does not occur suddenly, but gradually; that it falls down occasionally from any ordinary causes; that the swelling appears equable and deep-seated, the protruded intestine being surrounded by the peritoneum. In those from rupture the descent at first is sudden, and happens only from violence; the swelling is very large, and appears seated superficially immediately under the skin, owing to the intestines having burst through the peritoneum. If the omentum alone falls down to the scrotum in rupture of the peritoneum the affection is called epiplocele, but if intestine descend along with it, it is named epiploenterocele; and if water be contained in the tunica vaginalis it receives an appellation compounded from all the three. But neither these nor the intestinal hernia from rupture of the peritoneum are proper subjects for surgery, but we operate upon enterocele alone from distension, in the following manner: after placing the patient in a recumbent posture, and getting the skin in the groin stretched by an assistant, we make a transverse incision, cutting as in the operation of angiology (but some make the incision not transverse but longitudinal), then having transfixed it with hooks we stretch out the incision to such a degree as to afford room for the testicle to pass through; then passing through the inner skin a number of hooks proportionate to the size of the wound, and dissecting the membranes and fat with a blind hook or scalpel we cut them across. When the peritoneum is everywhere laid bare, introducing the index-finger at the back part of the scrotum between the darti and peritoneum, we free the posterior process (epididymis?); and then with the right hand doubling its extremity to the inside of the scrotum, and at the same time stretching the peritoneum in the left hand, we bring the testicle with the vaginalis tunica to the incision, and give directions to one assistant to stretch the testicle, whilst we, having completely cleared the posterior process, ascertain by the fingers whether a fold of intestine be comprehended in the tunica vaginalis, and if so we must press it down to the belly; then we take a large-sized needle containing a doubled thread of ten pieces, and we pass it through the middle at the extremity of the peritoneum close to the incision; and cutting the double we make four pieces of them, and laying them over one another in the form of the Greek letter Χ, we bind the peritoneum securely, and again twisting round the pieces we secure it so that none of the nutrient vessels may have a free passage to it lest any inflammation be occasioned, and we apply another ligature farther out, less than two fingers’ breadth distant from the former. After making these ligatures we leave about the size of a finger of the peritoneum, and cut off the whole all round, removing at the same time the testicle, then making an incision at the lower part of the scrotum to favour the discharge, we introduce an oblong pledget, and apply embrocations of oil and bandages as for hydrocele. We must also make the other applications as there laid down. I have known some not unskilful surgeons who after the incision into the tunica vaginalis burnt the extremity of it with heated cauteries for fear of hemorrhage, as would appear. These after the operation straightway bathed their patients in a long wooden trough containing hot water, until the seventh day, repeating this as often as five times during the period of a day and a night, more especially with children; and it succeeded wonderfully, for they remained free from inflammation, and the ligatures fell out speedily along with the parts. In the intervals between the bathings the afore-mentioned embrocations were applied. Another surgeon, in addition to the means already mentioned, rubbed into their back at the time pepper triturated with oil.

Commentary. Celsus recommends us, if the patient be a child, to make an attempt, in the first place, to effect a cure with bandages. In more advanced ages, if a large portion of intestine has fallen down, and if attended with pain and vomiting, which symptoms generally arise from retention of the fæces, it is clear, he says, that the knife is not applicable, and that the case is to be remedied by other means. He recommends venesection in the arm, the tepid bath, warm cataplasms, and spare diet; but he disapproves of purgatives. This is his treatment of strangulated hernia. When an operation with the scalpel is resolved upon, an incision having been made in the groin down to the middle tunic (tunica vaginalis?), the lips of it are to be separated with the assistance of hooks, while the surgeon frees the tunic from all the small membranes (external fascia?). When this tunic is removed, an incision is to be made from the groin down to the testicle, which is to be carefully cut out. This process, however, is only applicable when the patient is of a tender age, and the mischief is moderate. When the patient is a strong man and the disease greater, the testicle is not to be removed, but is to be allowed to remain in its place. It is accomplished in this manner: the groin being opened with a scalpel, in the same manner, down to the middle tunic, it is to be seized with two hooks, so that an assistant may prevent the testicle from falling out at the wound; then that tunic is to be cut downwards with a scalpel, and under it the index-finger of the left hand is to be pushed down to the bottom of the testicle so as to force it up to the wound: then the thumb and index-finger of the right hand separate the vein, artery, nerve, and their tunic, from the upper tunic. But if any small membranes (fasciæ?) come in the way, they are to be cut out with a scalpel, until the whole tunic be exposed. Having cut out what is proper, and replaced the testicle, a somewhat broader thong of skin is to be removed from the lips of the wound in the groin, in order to enlarge the wound, and thereby occasion a greater formation of new flesh. The object of this operation, it will be remarked, is to produce a firm cicatrix at the external abdominal ring. In cases of epiplocele, he recommends us either to replace the omentum, or to cause the death of it by septic medicines, cauteries, or the ligature; or to cut it out with a pair of scissors, but of this proceeding he does not much approve, as it may occasion dangerous hemorrhage. (vii, 20, 21.)

Galen briefly states that intestinal and omental herniæ are to be cured by pressing up the intestine or omentum, removing as much as possible of the spermatic vessels; or otherwise drawing out the peritoneum, fomenting it, and then cutting it off. (Isagoge.) He mentions that it was customary to bleed the patient before the operation when he was plethoric. (De Opt. sec.)

Aëtius speaks of the operation as being highly dangerous. He forbids attempts at reduction while the prolapsed parts are affected with inflammation, tormina, and flatus. (xiv, 23.)

Albucasis’s account of the treatment is quite similar to our author’s. He states that the disease is occasioned by the descent of a portion of intestine to the testicle, owing to rupture or distension of the peritoneum. Sometimes, he says, fæces get into the prolapsed bowels, and being retained give rise to violent and sometimes fatal symptoms. When going to operate he directs us, in the first place, to make the patient reduce the intestine if reducible. Then an incision is to be made along the whole skin of the testicle, and hooks are to be fixed in the lips of the wound so as to enlarge it, and allow a passage for the testicle. The membranes, then, below the skin, are to be dissected, so as to expose completely the tunica vaginalis (sifac album.) The index-finger is then to be introduced between the tunica vaginalis and the second coat (tunica albuginea?) so as to free the adhesions at the back part of the testicle. The operator is afterwards to separate the testicle from all its adhesions and raise it up to the external wound. He must now examine whether any portion of intestine remain protruded, and if so, it must be replaced. The operator is then to take a large needle armed with a cord of ten threads, and having introduced it behind the tunic under the skin of the testicle (tunica vaginalis?) its extremities are to be cut, and the threads arranged into four pieces. With them the peritoneum is to be tightly bound in a crucial form, so as that the nutrient vessels may not be able to reach it, which will obviate inflammation. Another ligature is to be applied afterwards at the distance of less than two fingers’ breadth from the former. After applying these two ligatures, about a finger’s breadth of the peritoneum is to be left, and the rest is then to be cut all around, and the testicle removed along with it. An incision is then to be made at the lower part so as to allow an outlet for the blood and matter. Wool dipped in oil is to be applied afterwards, and bound as formerly described. Sometimes, he adds, the cautery is applied to the tunica vaginalis after the incision for fear of hemorrhage. (Chirurg. ii, 65.) He describes minutely the treatment by burning in another place. (i, 47.)

Avicenna recommends the cautery, but does not describe the other operation. Haly’s description is evidently taken from our author. (Pract. ix, 50.)

Rhases states correctly that hernia generally arises from dilatation of the passage which leads from the cavity of the abdomen to the testicle. In ordinary cases, he says, there is no rupture of the peritoneum. He states that the contents of the hernial tumour are either intestines or omentum. The omentum, he adds, is the intestine most commonly found in ruptures. He says the peritoneum (sifac) lines the whole intestines and surrounds the testicles. Antyllus, from whom he gives a subsequent extract, states in like manner that the peritoneum descends to the testicles and forms the tunica elytroides, i. e. vaginalis. Antyllus also affirms that hernia arises from relaxation of the passage between the cavity of the abdomen and the testicles. This opinion regarding ruptures is maintained by several of the authorities quoted by Rhases. (Contin. xxiv.)

Sprengel says of Rhases: “Sa théorie des hernies proprement dites est infiniment préférable à celle des Grecs.” (Hist. de la Méd.) The account which Rhases gives of ruptures is, no doubt, very correct; but there is every reason to suppose that it was entirely taken from the works of the Greek surgeons.

The operations practised by the ancients for the radical cure of hernia cannot but appear to us extremely cruel and hazardous; and yet the danger attending them must have been less than is generally supposed, otherwise they could not have been so frequently performed as they were about two centuries ago. Fabricius ab Aquapendente mentions that a celebrated rupture doctor of his time informed him that he used to operate upon 200 patients at an average every year. Fabricius, however, prudently recommends us not to perform the operation except in extreme cases, and to be content in general with supporting the parts by means of a truss.

The ancients never operated to relieve strangulated hernia.

SECT. LXVI.—ON BUBONOCELE, OR INGUINAL HERNIA.

Enterocele arising from distension commences as bubonocele; for at first the peritoneum being stretched the relaxed intestine is protruded as far as the groin, and forms this disease, which the ancients operated upon in this manner. After making the incision to the extent of three fingers’ breadth transversely across the tumour in the groin, and removing the membranes and fat, and the peritoneum being exposed in the middle where it is raised up to a point, let the knob of a probe be applied, by which the intestines will be pressed deep down. The prominences, then, of the peritoneum formed on each side of the knob of the probe are to be united to one another by sutures, and then we extract the probe, neither cutting the peritoneum nor removing the testicle, nor anything else, but curing it with the applications for fresh wounds. But since burning in cases of bubonocele is preferred by most of the moderns it will be right for us to give an account of this operation. After the man has undergone moderate exercise, let him cough violently and strain to keep in his breath; and when the swelling appears at the groin we mark with black ink or collyrium the place that is to be burned in a triangular figure, making its transverse line above in the situation of the groin, and we also make a mark in the middle of the triangle. Having laid the patient in a recumbent posture we first apply to the mark in the middle nail-shaped cauteries heated in the fire, afterwards burn the sides of the triangle with gamma-shaped (Γ) cauteries, and afterward level the triangle with cauteries shaped like tiles or lentils, an assistant during the whole process of burning wiping away the ichorous discharges with a rag; and in those who are of a moderate habit of body the burning should be carried to such a depth as to touch the fat. But in those who are lean we must not attend to this mark lest by mistake we should burn the peritoneum; nor again in those who are grosser and fatter, for in them the fat appears before a sufficient burning has taken place. We must, therefore, be rather guided as to its extent by a skilful conjecture. After the burning, having triturated salts with leeks we apply them to the eschar, and use the inguinal bandage shaped like the Greek letter Χ. On the following days we complete the cure with the dressings fitting for eschars, such as lentils with honey, and the like.

Commentary. Celsus directs us, when the inguinal tumour is moderate in size, to make one incision; but if larger, he recommends two lines to be made, so that the middle may be cut out; then, without extracting the testicle, as advised in certain cases of prolapsed intestines, the veins are to be bound together and tied where they adhere to the tunics, and afterwards cut below the knots. (vii, 24.)

Avicenna speaks of astringent applications and the actual cautery, but disapproves of the incision and suture. (iii, 22, 1.)

The operations of the suture and burning are described by Albucasis (Chirurg. ii, 67, and i, 47); by Rhases (Cont. xxiv); and by Haly Abbas (Pract. ix, 52, and ix, 80.) They all evidently copy from our author.

Garengoit affirms that Paulus has made mention of crural hernia, but we agree with Heister that this is a mistake.

SECT. LXVII.—ON RHACOSIS, OR RELAXATION OF THE SCROTUM.

When the skin about the scrotum is relaxed without the bodies within being affected, rhacosis is formed, being a most unseemly complaint. Wherefore Leonides, having placed the man in a recumbent posture, cut off the redundant skin with a scalpel direct upon some board or some hard skin, and united the lips of the wound with sutures. But Antyllus, having first transfixed the redundant skin with three or four ligatures, cut off what was external to them with a sharp-pointed pair of scissors or scalpel, and having secured the parts with sutures, effected the cure by the treatment for recent wounds.

Commentary. Our author’s description of the two modes of performing the operation is copied by Albucasis. (Chirurg. ii, 68); and by Haly Abbas (Pract. ix, 53.)

SECT. LXVIII.—ON CASTRATION.

The object of our art being to restore those parts which are in a preternatural state to their natural, the operation of castration professes just the reverse. But since we are sometimes compelled against our will by persons of high rank to perform the operation, we shall briefly describe the mode of doing it. There are two ways of performing it, the one by compression, and the other by excision. That by compression is thus performed: children, still of a tender age, are placed in a vessel of hot water, and then when the parts are softened in the bath, the testicles are to be squeezed with the fingers until they disappear, and, being dissolved, can no longer be felt. The method by excision is as follows: let the person to be castrated be placed upon a bench, and the scrotum with the testicles grasped by the fingers of the left hand, and stretched; two straight incisions are then to be made with a scalpel, one in each testicle; and when the testicles start up they are to be dissected around and cut out, having merely left the very thin bond of connexion between the vessels in their natural state. This method is preferred to that by compression; for those who have had them squeezed sometimes have venereal desires, a certain part, as it would appear, of the testicles having escaped the compression.

Commentary. We have given Celsus’s description of the operation in the 64th section of this Book. Albucasis describes the operations by compression and by excision. In the former the testicle is squeezed by the operator while the patient is seated in hot water. In the other the spermatic cord is to be first secured with a ligature and then the testicle cut out. (Chirurg. ii, 69.)

They are likewise described in nearly the same terms by Haly Abbas. (Pract. ix, 54.) The castration of the inferior animals is mentioned by Aristotle (Hist. Animal. ix, 50); by Varro (De Re Rustica, iii, 9); by Columella (De R. R. vi, 26); and by Palladius (De R. R. vi, 7.) Varro informs us that it was customary to make capons by burning the testicles of cocks with a red-hot iron. It appears from Juvenal that the surgeons in his time were often called upon to perform castration. (Sat. vi, l. 370.) Abulpharagius likewise mentions that the performance of this operation constituted at one time an important part of the surgical practice in Bagdad. (Dynast. ix.) But the Emperor Justinian condemned the operation as being dangerous and often fatal.

Sprengel gives an interesting history of castration. One of the most important points in this operation is the mode of tying the cord. Some modern authorities affirm that no bad effects result from putting a ligature round the whole cord, but others condemn this practice as bringing on convulsions and tetanus. All admit the difficulty of securing the artery separately.

SECT. LXIX.—ON HERMAPHRODITES.

This affection derives its name from a combination of the names Hermes and Aphrodite (Mercury and Venus,) and occasions great deformity to both sexes. There being four varieties of it, according to Leonides; three of them occur in men and one in women. In men, sometimes about the perineum and sometimes about the middle of the scrotum, there is the appearance of a female pudendum with hair; and in addition to these there is a third variety, in which the discharge of urine takes place at the scrotum as from a female pudendum. In women there is often found above the pudendum and in the situation of the pubes the appearance of a man’s privy parts, there being three bodies projecting there, one like a penis, and two like testicles. The third of the male varieties in which the urine is voided through the scrotum is incurable; but the other three may be cured by removing the supernumerary bodies and treating the part like sores.

Commentary. This section of our author is copied by Albucasis (Chirurg. ii, 70); and by Haly Abbas (Pract. ix, 55.) Avicenna briefly mentions this monstrosity. (iii, 20, 2, 43.)

Guy of Cauliac and Brunus describe it in the same terms as the Arabians.

SECT. LXX.—ON EXTIRPATION OF THE NYMPHA AND CAUDA PUDENDI.

In certain women the nympha (clitoris?) is excessively large and presents a shameful deformity, insomuch that, as has been related, some women have had erections of this part like men, and also venereal desires of a like kind. Wherefore, having placed the woman in a supine posture, and seizing the redundant portion of the nympha in a forceps we cut it out with a scalpel, taking care not to cut too deep lest we occasion the complaint called rhœas. The cauda is a fleshy excrescence arising from the mouth of the womb, and filling the female pudendum, sometimes even projecting externally like a tail; and it may be removed in the same manner as the nympha.

Commentary. That the nympha and clitoris were used anciently as synonymous terms is evident from Ruffus Ephesius (De Partibus Hominis); Soranus (c. 6); and Pollux (Onomasticon, ii.) Martial, in more than one place, makes allusion to unnatural practices connected with an enlarged clitoris. Aëtius says that it is a small muscular substance situated at the commissure of the alæ pudendi above the meatus urinarius. He adds, that when preternaturally enlarged it is to be amputated. Like our author, he directs us to take hold of the tumour with a forceps and cut off the protuberance, taking care not to carry the excision too far. He recommends us to apply a sponge squeezed out of an astringent wine or cold water, with suitable dressings. He gives the same account of the cauda as our author. (xvi, 103 and 104.) It was a tumour arising from the uterus itself. Albucasis merely transcribes our author’s account of these operations. (Chirurg. ii, 71.) Avicenna briefly recommends us to remove the enlarged nympha by medicines or the knife. (iii, 22; i, 24.) It would appear that this operation, like circumcision, is still often practised in the East.

The chapters of Soranus, in which these operations were treated of, are unfortunately wanting.

On extirpation of the enlarged clitoris see Heister’s Surgery (ii, 5, 147). The cauda pudendi was probably the cauliflower excrescence of the os uteri described by late authorities on midwifery.

SECT. LXXI.—ON THYMI, CONDYLOMATA, AND HEMORRHOIDS ABOUT THE FEMALE PARTS OF GENERATION.

The thymus is an excrescence sometimes red, but sometimes white, for the most part without pain, and resembling the clusters of thyme. The condylomata are rugose protuberances; and the hemorrhoids resemble those about the anus, and, like them, sometimes pour forth blood. Such excrescences in women, when brought into view and exposed, are to be seized with a forceps and cut out with the point of a half-spatula. And we are then to use pounded galls, or fissile alum. For the more distinguished surgeons do not approve of ligatures in these cases.

Commentary. Aëtius gives a fuller account of these tubercles. He recommends us to seize them with a forceps and cut them out by the roots. He directs us not to interfere with such hemorrhoids of the womb as are varicose and malignant. Those which are hard and do not bleed are to be cut out at once, but such as are disposed to bleed are to be seized with a forceps and a ligature put round them before they are cut. Moschion, however, condemns this practice as being highly dangerous.

Albucasis evidently copies from our author. (Chirurg. ii, 73.)

Haly Abbas briefly directs us to seize these tubercles with a forceps and cut them out with a pair of scissors. (Pract. ix, 65.)

Rhases, treating of diseases of the uterus, says, “if there be a red piece of flesh in the mouth of the womb, if situated at its anterior part, and if it be round, or long, and not attended with pain, some surgeons cut it off, but I prefer tying it.” (Cont. xxii.) This description seems to apply to polypus of the womb.

See a full account of the condylomata and hemorrhoids of the womb, by Lodovicus Mercatus (in the Gynæcia, p. 962.) He remarks that Celsus and Aëtius call any tubercle arising from inflammation by the name of condyloma, whereas Paulus applies the term only to callous tubercles of the uterus. He approves of seizing them with a forceps and cutting them out.

SECT. LXXII.—ON IMPERFORATE PUDENDUM AND PHIMUS.

Some women have the genital parts imperforate, sometimes naturally, and sometimes owing to some previous disease. And sometimes it is deep-seated, sometimes in the alæ pudendi, or in the intermediate places, and is sometimes occasioned by an adhesion of the parts, and sometimes by obstruction. The obstructing substance is either flesh or membrane. The disease occasions great impediment sometimes in coition, sometimes in conception, or in parturition, and occasionally during the menstrual purgation, provided the membrane or flesh occasion a complete obstruction; for in certain cases there is a perforation in the middle. Having ascertained the cause, either from its being obvious to the sight, or by introducing the speculum, if it be a simple adhesion only, it may be separated by a straight incision, made with a scalpel, for operating upon fistulæ. But if it is an obstruction, having transfixed the connecting body, whether it be membrane or flesh, with hooks, we stretch it and divide with a scalpel for fistulæ; and having stopped the hemorrhage with such applications as are desiccative without being stimulant, we have then recourse to such medicines as promote cicatrization, applying a priapus-shaped tent covered with some epulotic medicine, in those cases especially in which the operation is performed upon a part not very deep-seated, in order that the parts may not unite again. And the phimus which is formed at the mouth of the uterus is operated upon in the same manner.

Commentary. Aristotle makes mention of imperforate vagina. (De Generat. Animal. iv, 4.) Aëtius treats of these diseases at considerably greater length than our author, but his practice is nearly the same. Upon the whole the amount of his directions respecting the treatment is, that when the obstruction is occasioned by a membrane, it is to be divided and the lips of the incision prevented from adhering by the introduction of suitable tents; or, if it is a fleshy body, it is to be dissected out, and the parts separated by a piece of sponge or tents. (xvi, 96.) The same operation is described by Soranus. (219.)

The same method of treatment, however, had been previously recommended by Celsus. Thus, when the obstruction is occasioned by a simple membrane, he recommends us to divide it by two transverse incisions like the letter Χ, taking great care not to wound the urinary passage, and then the membrane is to be cut out. When the obstruction is produced by a fleshy tumour, he directs us to expose it by making a straight incision; then, having seized it with a forceps or hook, to dissect it out, and introduce an oblong tent (λημνίσκος) soaked in vinegar, and apply externally wool moistened with vinegar. The dressings are to be removed on the third day, and the sore treated upon general principles. When the wound is healing, he advises us to introduce a leaden tube smeared with some suitable ointment to prevent adhesion. (vii, 28.)

Albucasis makes mention of a singular substitute for the leaden tube recommended by Celsus: “Coeat mulier omni die ut non consolidetur locus vice alia!!” The same advice is gravely given by Rhases (Cont. xxii), and by Alsaharavius, who, as we have formerly stated, was probably the same person as Albucasis. (Pract. xxv, 2, 19.) But when the obstruction arises from a fleshy tumour, Albucasis recommends us to make use of the leaden tube. (Chirurg. ii, 72.) Alsaharavius directs us to remove the obstruction by corrosive medicines or with the knife.

Rhases briefly describes the phimus, and directs us to perforate it with an instrument of iron, and then to introduce a tent moistened in some styptic wine.

Haly Abbas states that obstruction of the uterus may arise either from a natural, that is to say, a congenital impediment, or from the effects of ulceration. He recommends us to make the midwife clear away the obstruction with a scalpel or any other convenient instrument. The Arabians were very delicate in allowing male practitioners to perform surgical operations about the genital organs of women. (Pract. ix, 66.)

SECT. LXXIII.—ON ABSCESS OF THE WOMB.

When the abscess is situated at the mouth of the womb, so as that it can be operated upon, we must not be in haste in having recourse to incision, nor until the disease be ripened, and the inflammation has increased to its utmost, and the vascular bodies which surround it have become attenuated, owing to the importance of the uterus in the system. In operating, the woman should be placed on a seat in a supine posture, having her legs drawn up to the belly, and her thighs separated from one another. Let her arms likewise be brought down to her legs and secured by proper ligatures about the neck. The operator, sitting on her right side, is to make an examination with a speculum proportionate to her age. The person using the speculum should measure with a probe the depth of the woman’s vagina, lest the stalk (fistula) of the speculum being too long it should happen that the uterus should be pressed upon. If it be ascertained that the stalk is larger than the vagina, folded compresses are to be laid upon the alæ pudendi, in order that the speculum may be placed upon them. The stalk (fistula) is to be introduced, having a screw at the upper part, and the speculum is to be held by the operator, but the screw is to be turned by the assistant, so that the laminæ of the stalk being separated the vagina may be distended. When the abscess is exposed, if it be soft and thin (which may be ascertained by touching it with the finger), it is to be divided at the top by a scalpel or needle, and after the discharge of the pus, a soft oblong tent well smeared with rose-oil is to be introduced into the incision, or rather external to the opening into the woman’s vagina, so as not to produce compression. And externally to the alæ pudendi and the region of the pubes and loins unwashed wool, or clean wool dipped in oil, is to be applied. On the third day she is to be placed in a hip-bath of warm oil or water, or of a decoction of mallows; and having wiped the parts, we introduce the tent gently into the opening, spread with the ointment tetrapharmacon, either alone or with clarified honey; its strength, however, ought to be reduced with butter or oil of roses. The external parts are to be covered with cataplasms until the inflammation subside and the sore become clean. If it is got cleansed with difficulty, an injection of the decoction of iris, of birthwort, or of honey, may be thrown up with an ear-syringe. The healing process may be promoted by the calamine ointment diluted with wine and applied upon a pledget. But if the abscess be within the mouth of the uterus, we must decline operating.

Commentary. A similar description of the method of opening abscesses in the vagina is given by Aëtius. (xvi, 85.) The only difficulty in comprehending his description or our author’s arises from our unacquaintance with the construction of the ancient dioptræ or specula. Drawings of several sorts of them are given in the surgery of Albucasis and by Scultet. (Arsenal de Chirurg. tab. 18.) One of the simplest of them consists of two laminæ or plates so united that by turning a vice or screw they separated to the proper distance. Albucasis evidently copies our author’s description. (Chirurg. ii, 71.) The account given by Haly Abbas is quite similar. (Pract. ix, 57.)

SECT. LXXIV.—ON EMBRYULCIA AND EMBRYOTOMY.

We have described the treatment of difficult labours in the Third Book. If the process of parturition be not rectified by the means there laid down, we must proceed to the surgical operation, after having formed a probable conjecture whether the woman will survive or not; and if she may be saved, then we are to operate; but if not, we must decline attempting the operation. Those in a dying state are affected with coma, lethargy, and loss of muscular motion; they are difficult to rouse, or if roused by loud cries, they return a feeble answer, and again sink into a comatose state. Some have convulsive contractions, or subsultus tendinum, or insensibility to food. The pulse is found to be greatly inflated, but obscure and feeble. Those who are to recover have none of these symptoms. Having placed the woman in a supine posture, with her head rather depressed, her thighs are to be kept elevated by women on each side, or by certain assistants; or if they are not at hand, her chest is to be first fastened to the bed by ligatures, so that when the fœtus is pulled the woman’s body may not follow, and diminish the force of the pulling. Then the alæ pudendi being separated by an assistant, we must introduce the left hand lubricated with some unctuous substance, the fingers being contracted, to the mouth of the uterus, and dilate it, and having got it relaxed by lubricating it with oil, we seek for the most convenient place for fastening the hook (embryulcus). The most convenient places in presentations of the head are—the eyes, the occiput, the roof of the mouth, the chin, the clavicles, and the parts about the sides and hypochondrium; and in feet presentations, the bones of the pubes, the middle of the ribs, or, again, the clavicles. The hook is to be held in the right hand, and its curvature grasped with the fingers, and it is to be gently introduced with the left hand, and fixed on some of the afore-mentioned places, being pushed to the cavity of the uterus. And another is to be applied opposite to it in order that the pulling may be straight down and not to one side. Then we are to pull gently, not only straight-forward but also from side to side, as in the extraction of teeth; and there ought to be no relaxation of the pulling in the intervals. Then introducing the index-finger or more fingers besmeared with fat between the mouth of the womb and the impacted body, we must lubricate it all around. When the hook comes down properly it must be changed to a part above, and so on until the fœtus is completely extracted. When a hand presents, and is so impacted that it cannot be returned, we must wrap a cloth round it so that it may not slip, and pull it so far, and when it is properly fallen down it should be cut off at the shoulder. The same thing is to be done when two hands fall down into the vagina; and in like manner, when the feet come down, and the rest of the body does not come along, we must amputate at the groins, and then endeavour to turn the rest of the body. If the impaction take place owing to the head being larger than natural, if it be a hydrocephalous fœtus, we must open its skull with a polypus-scalpel, or a needle, or a sharp-pointed knife concealed between the fingers, in order that it may collapse when evacuated; but if it be a naturally large head, we must open the skull in like manner, and break down its bones with a tooth-forceps or a bone-forceps, and if the bones project they ought to be extracted. If, after the head has been delivered, an impediment should take place at the chest, the parts about the clavicles should be divided down to the cavity of the thorax with the same instrument, so that the thorax may collapse when its fluid contents are discharged; but if it do not collapse we may divide the clavicles and extract them, when the thorax will collapse. If the belly be inflated, owing to the death of the child, or its being dropsical, we must evacuate its contents with the intestines in the same way. In presentations by the feet the wrong direction may be easily rectified at the mouth of the womb. But if the fœtus stick at the chest or belly, we must wrap a cloth about it and draw it down, and making a division in the same manner, evacuate its contents. If, after the other parts are cut off, the head retreat backwards and is retained, we must introduce the left hand, and if the mouth of the womb be open, push up the hand to the cavity of the womb, and having found the head, bring it down with the fingers fixed in the mouth, and extract by one or two hooks fixed in it; but when there is inflammation at the mouth of the womb we must use no violence, but lubricate the parts with unctuous and fatty applications, and have recourse to hip-baths, embrocations, and cataplasms, in order that when the mouth is dilated extraction may be accomplished in the manner described above. Cross presentations, if they can be rectified, may be treated according to the afore-mentioned methods; but if not, the whole fœtus must be cut asunder within, and extracted in pieces, taking care that none of the parts of it be left behind. After the operation we must have recourse to the treatment for inflammations of the uterus. If hemorrhage come on, you have already had the management of it described.

Commentary. There is a curious treatise commonly published along with the works of Hippocrates on the extraction of the fœtus; but, as it is not mentioned by Erotian and Galen, it is now generally admitted not to be genuine. The author of it directs us, when the arm presents, to pull it down and amputate at the shoulder-joint; after which the head is to be brought to the proper position and delivery accomplished accordingly. This is not now the general rule of practice, and yet we were once compelled by necessity to deliver in this way, after we and an intelligent assistant had been foiled in all our attempts to turn the child. We have known of similar cases happening in the practice of other surgeons; and, in fact, this method of procedure was advocated lately by a sensible writer in the ‘Edinburgh Medical and Surgical Journal.’ The author of the ancient treatise in question recommends us to bring down the head in its natural state, if possible, but if this be found impracticable, to break it down. He directs us to give for drink a white, sweet, undiluted wine.

Celsus gives an interesting account of this subject, and his practice is deserving of much consideration. He recommends us, when the position is unnatural, to turn the child either to the head or the feet; adding, afterwards, that delivery may generally be accomplished easily enough by the feet. In arm presentations, he approves of turning to the head, that is to say, in cases when it is ascertained that the fœtus is dead. If the head is at hand, a smooth hook with a small point is to be fastened at the eye, the ear, the mouth, or the forehead, and its body is to be thus dragged down. This, however, must not be attempted when the mouth of the womb is not properly dilated. The right hand is to be employed in dragging down the fœtus, and the left in directing the instrument and the fœtus. When the body of the fœtus is distended with a fluid, it is to be let out, and the body brought down with a hook. If the child lie across and the position cannot be got rectified, the hook is to be inserted at the armpit, and extraction gradually performed. In extreme cases he recommends us to cut the neck asunder, and extract the parts separately, beginning with the head, for fear of its being left in the uterus. Should such an accident occur, however, he directs us to get the belly compressed so as to force the head down to the os uteri; after which it may be extracted with a hook in the manner described above. (Smellie relates histories of such cases.) When one foot presents, and the breech sticks at the os uteri, he recommends us, when the other foot cannot be found, to separate the one which protrudes; after which the body of the child may be pushed up, and the other leg found and brought down. It is to be recollected that this practice is only recommended when the child is dead. He adds, that other difficulties may give rise to the necessity of performing embryotomy. (vii, 29.)

Aëtius has an interesting chapter on the Extraction of the Dead Fœtus, copied from the works of Philumenus. His description of embryotomy is similar to our author’s. He directs us to apply two hooks to certain parts of the head, such as the eye, mouth, and chin, and thus to drag down the body. If the head is large or hydrocephalic, he advises us to open it and evacuate its contents; and if even then it is found to be too large for the passage, he recommends us to break down the bones of the skull and remove them with a forceps, after which the instrument is to be fixed and the fœtus dragged down. If obstruction to the delivery take place at the chest or the belly, he directs us to evacuate their contents in like manner. When an arm or both present, he recommends us to amputate at the shoulder-joint. If the child come down doubled, and the position cannot be got rectified, he advises us, if the head can be reached, to break down its bones, and then extract the other parts accordingly; but if the legs are got at most easily and cannot be brought down, they are to be amputated at the hip-joint, and then the head will be got delivered. When the body is so impacted in a doubled state that it cannot be moved, he directs us to separate the vertebra at the neck, and then to drag down the lower part of the body; after which the head is to be sought for by the hand introduced into the uterus, and brought along with two hooks. (xvi, 23.)

No ancient author has described the operation of embryotomy so accurately as Soranus; but as his account of the process is lengthy and does not differ essentially from that of Aëtius, (indeed the latter evidently copies from Soranus,) we need not seek to give any outline of it. (Op. 51, 52, 53.)

Avicenna takes his chapter on the extraction of the dead fœtus from our author. (iii, 21, 2, 24.) We have mentioned in the Third Book that he was acquainted with the forceps.

Albucasis, in like manner, takes his account of embryotomy from Paulus. He relates a singular case that came under his own knowledge of an extra-uterine conception; the most remarkable circumstance about which was, that the bones of the fœtus after a time were discharged at the umbilicus. The work of Albucasis contains drawings of the instruments used in his time for obstetrical operations. There are several forcipes among them, but as they all have teeth, it is to be presumed that they were used only for delivering the fœtus when dead. It is to be regretted that he has entirely omitted the forceps mentioned by Avicenna. (See Chirurg. ii, 76 and 77.)

Rhases directs us when the child’s head is large and cannot be brought down with fillets, to open it and deliver with hooks. When it is ascertained that the child is dead, he recommends us to break down the bones of the head and evacuate the brain. In preternatural presentations he recommends us to deliver, if possible, by the head or feet, but if this cannot be got accomplished, he directs us to cut off the protruding part. Upon the whole his rules of practice are much the same as our author’s. (Cont. xxii.)

Haly Abbas gives ample directions for the management of these cases. When the head presents (the child being dead and delivery found otherwise impracticable), he directs us to fix hooks in the hollows of the eyes, neck, or jaw-bone; or if the feet present, at the tops of the thighs. The body of the child is then to be dragged along. When a hand presents, he recommends us to pull down the arm and amputate at the shoulder; and in like manner he directs us to amputate at the hip-joint when in footling presentations the delivery cannot be otherwise accomplished. When the head is preternaturally large, he directs us to open it and evacuate its contents; and to do so in like manner with the chest when any obstruction takes place at it. He makes no mention of any instrument resembling the modern forceps. (Pract. ix, 57.)

SECT. LXXV.—ON RETENTION OF THE SECUNDINES.

Often, after the removal of the fœtus, the placenta (which is also called the secundines) is retained in the uterus. When the mouth of the uterus is dilated and the placenta separated, and rolled into a ball in some part of the uterus, the extraction is most easy. The left hand warmed and anointed is to be introduced into its cavity, and the secundines extracted as they present. But if they adhere to the fundus uteri we must introduce the hand in like manner, and grasp them and pull them along, not straight down for fear of prolapsus, nor with great violence, but they are to be moved gently, at first from this side to that, and afterwards somewhat more strongly, for thus they will yield and be freed from their adhesion. If the mouth of the uterus be found shut we must have recourse to the same treatment. If the strength is not sunk, sternutatories and fumigations with aromatics in a pot may be used; and if the mouth of the womb dilate, the hand is to be introduced and an attempt made to extract the placenta, as aforesaid. If even in this way it cannot be extracted, one need not be alarmed, for after a few days it will putrefy, dissolve into sanies and drop off. But since the fetid smell affects the head and disorders the stomach, we must use suitable fumigations, among which cardamom and dried figs are much approved.

Commentary. We have mentioned in another place that Hippocrates’ practice in retention of the placenta consisted in suspending weights from the end of the umbilical cord.

Celsus directs us, when the placenta is not cast off soon after the delivery of the child, to draw down the umbilical cord gently with the left hand, taking care not to break it. The right hand is then to follow it up to the secundines, and their veins and membranes being separated from the womb, the whole are to be extracted along with whatever coagulated blood may be in the uterus. (vii, 29.)

Our author merely abridges a fuller account of the subject given by Aëtius from the works of Philumenus. (xvi, 24.)

Moschion reprobates the ancient practice of using sternutatories, pessaries, and fumigations, and of suspending scales or weights from the cord, because these means sometimes occasion hemorrhage. He recommends the midwife, if the mouth of the womb be still open, to introduce her left hand, and to take hold of whatever part of the placenta presents: then, if it does not adhere to the fundus uteri it is to be extracted; but if it is not separated it is to be moved gently hither and thither without violence. When the mouth of the uterus is contracted, he advises her to use those liquors and injections which are applicable for inflammations of the womb. (Section liv.) His method of securing the umbilical cord after delivery is nearly the same as that now adopted. After the child has been allowed to lie on the ground for a few minutes, two ligatures are to be applied round the cord, the nearest being four fingers from the belly; it is then to be cut with a scalpel or any sharp knife. He disapproves of using instruments of wood, glass, or reeds, and hard crusts of bread, as practised by the ancients. (lxv.) He directs lacerations of the perineum to be treated by applying ointments composed of wax, oil of roses, litharge, ceruse, and alum, with suitable bandages. (lvii.)

The practice of Soranus in these cases is most judicious, and such as can scarcely be improved upon at the present day. He disapproves of all violent attempts at extraction, but when the placenta cannot be got otherwise removed from the womb, he approves of introducing the hand well lubricated to extract the secundines gently. He directs us when the mouth of the womb is shut to open it if possible with the fingers in a gentle manner. This is the case now incorrectly called the hour-glass contraction.

Avicenna repeats the directions given by Paulus and Aëtius, but seems to have considered the introduction of the hand into the uterus as a painful, and, in general, an unnecessary operation. (iii, 21, 2, 16.)

Albucasis follows our author’s practice. (Chirurg. ii, 78.)

Haly Abbas directs us to introduce the hand well lubricated with oil of violets, or the like, into the uterus, and extract the placenta if it be separated; but if it still adhere it is to be moved from side to side, and not pulled straight downwards. He adds, that when not extracted, it becomes putrid. (Pract. ix, 59.)

Rhases directs us when the secundines do not come away after delivery to make the woman sneeze, and if they are still retained, to pare the nails, and having introduced the hand into the uterus to pull cautiously so as not to give pain. When they cannot be removed in this way, he recommends us to throw injections into the womb so as to promote putrefaction of the placenta. In another place he mentions, that when long retained, the placenta putrefies and comes off in pieces. (Cont. xxii.)

SECT. LXXVI.—ON BURNING THE HIPS.

As in the case of the shoulder, so also the hip-joint getting dislocated from a collection of humours requires burning. Wherefore Hippocrates says: “When dislocation at the hip-joint takes place from long-continued ischiatic disease, the leg wastes, and the patients are lame unless burnt.” Burning, therefore, is to be performed more particularly at the place where the joint is dislocated, for thus the redundant humour will be dried up, and the part being condensed by the cicatrix will no longer be able to receive the bone, wherefore the burning should be carried to a considerable depth. The moderns form three eschars by burning; one behind in the hollow of the buttocks, another a little above the knee on the outside, and a third on the outside of the ankle in the fleshy part.

Commentary. Hippocrates recommends us to burn the parts over the hip-joint with crude flax. (De Affectionibus.) The author of another of the Hippocratic treatises directs us to burn the bony parts with fungi and the flesh with a red-hot iron. (De Affect. Int.)

Aëtius, upon the authority of Archigenes, recommends burning in this case with irons, the roots of fuller’s herb and birthwort, or with goat’s dung. (xii, 3.)

Cælius Aurelianus, in cases of ischiatic disease, speaks of forming issues over the hip-joint by the actual and potential cauteries. His potential cauteries, with which he mentions that eschars were burnt, appear to have been the ashes of herbs, that is to say, impure preparations of the caustic alkali, to which quicklime was sometimes added. They must, therefore, have been nearly the same as the calx cum kali of modern use. He states, that some burned the part with the root of fuller’s herb; others with pieces of iron shaped like the letter Γ; that some raised the skin in a fold and transfixed it with heated irons; that some burned it with fungi, and others with a piece of linen cloth folded and laid on the part. (Pass. Tard. v, 1.)

But the fullest account which we have of the ancient modes of burning the hips for diseases of the joint is that which is given in the book ‘Euporistôn,’ ascribed to Dioscorides. Mention is there made of the methods of burning with goat’s dung, and with wool smeared with oil. Some, it is said, form a ball of clay, and, having laid it on the place, apply to it a burning staff as long as it can be borne. Others, having stretched the skin over the affected joint, transfix it with a heated style or writing pen. The Libyans performed the operation with shavings of the lote tree, sulphur, and elaterium. The Marmaridæ are said to have done it with green pieces of the wood of olive trees. The Parthians used a leaden tube, the extremity of which they smeared with dough, in order to prevent the oil in the inside from escaping; then hot cauteries, to the number of forty or fifty, were introduced, and the burning continued as long as it could be well endured. Care in the meantime was taken to cool the face with cold water; and it was attended to, that the tube was not over-filled with oil, lest it should run over. (Euporist. i, 242.)

Albucasis describes minutely the process of burning with red-hot irons. (Chirurg. i, 43.) Haly Abbas in like manner directs us to burn an eschar over the joint, and to keep it open for a considerable time. (Pract. ix, 81.)

Asclepiades (apud Nicetæ Collect.) mentions that he had seen two cases in which dislocation had taken place at the hip-joint without any accident. The editor of this work, Anthony Cocchi, states that he had met with only one such case in the whole course of his practice. We need scarcely remark that such cases, however, are by no means of rare occurrence.

SECT. LXXVII.—ON FISTULÆ AND FAVI.

The present occasion requiring us to treat of fistula in ano, it will not be improper to give an account in the first place of fistulæ in general. A fistula then is a callous sinus, attended with little or no pain, and forming in most parts of the body. It generally originates in abscesses not properly healed. The callus is compact and white, the flesh dry, and therefore insensible, neither vein nor nerve passing to it. Sometimes the sinus is dry and sometimes filled with a discharge. The discharge is sometimes constant, and sometimes at intervals, the mouth of it being at one time shut up, and at another time open. Sometimes the fistula terminates on a bone, sometimes on a nerve, or some other important part; and it is either straight or crooked; has either one orifice or many. Those therefore that terminate upon large arteries, or nerves, or tendons of considerable size, or the pleura, or any important part, are either not to be meddled with at all, or with great and skilful caution; but the others may be operated upon in this manner. We first examine them if they be straight with a sound (specillum), or if crooked with a double-headed specillum of a very flexible nature, such as those made of tin, and the smallest of those made of copper. When there are two or more orifices, we must not trust to the examination with a specillum, but injecting the sinus by one of its openings we ascertain from the manner in which the injection comes out whether it be one fistula with many orifices, or if there be several fistulæ. After the examination, if the sinus be superficial and narrow, it is to be distended by the introduction of a specillum, and the callus is to be cut off with a properly-shaped scalpel, or pared with the nails or the point of a scalpel. If it is also broad the redundant parts are to be dissected away. If it is not superficial, but deep and straight, we must cut off the callus all around as far as we can make incisions, and if any part remain, destroy it with a caustic medicine; or if the callus be large, and do not yield to medicine, we must form a slough by burning it with hot irons. If the fistula terminate with a bone, and if it is not diseased, we need only scrape it, but if it is carious, or otherwise corrupted, the whole diseased portion is to be cut out with counter perforators, and if necessary we may bore a hole with a wimble (trephine?) whether the bone be diseased only to the diploe or as far as the marrow. If a bone project, as after a transverse fracture, we must saw it off. Taking, therefore, two bandages, we apply the middle of the one to the projecting bone itself, and get it kept stretched by an assistant; the other being thicker, or formed of wool, we are to take in like manner, and apply the middle of it to the flesh under the bone, and taking its ends below, we give directions that the flesh below be retracted by this band lest it be torn by the teeth of the saw, and in this manner we accomplish the sawing. When any vital part is situated below, such as the pleura, spinal marrow, or the like, in cutting or sawing the bone, we must use the instrument called meningophylax for protecting them. If the bone is not diseased, but is denuded of flesh all around, it is to be sawn in the same manner, for bones which are disengaged from the other parts all around cannot possibly incarnate. In like manner, the extremity of a bone near a joint, if diseased, is to be sawn off; and often, if the whole of a bone, such as the ulna, radius, tibia, or the like, be diseased, it is to be taken out entire. But if the head of the thigh-bone, or pelvis, or a vertebra of the spine be diseased, we must not attempt to operate upon them for fear of the adjoining arteries. We must proceed in this manner in every particular case, attention being paid to the situation, proximity, and connexions of the affected parts, the extent of the disease, the strength and powers of the patient. The favus being a fistulous sinus with a milky discharge must be subjected to the same operation and treatment as fistula.

Commentary. For an account of the practice of Hippocrates we refer to our notes on the 49th section of the Fourth Book.

Celsus states that if fistulæ spread deep, are crooked, or are numerous, they are to be cured by an operation rather than by medicines. Wherefore, if it spread transversely, he recommends us to introduce a specillum, or sound, and cut down upon it. But if it is crooked, its bendings are to be followed out and cut open in the same manner. When the operator has reached the end of the fistula, all the callus is to be cut out, and the lips of the wound secured by clasps and agglutinative applications. When the fistula terminates with a rib he directs us to saw out a piece of it lest it affect the adjoining parts. Fistulous sores about the abdomen he pronounces to be highly dangerous. He recommends us, however, to attempt a cure by making an incision, and uniting the edges of the wound by sutures. (vii, 4.)

Aëtius lays down nearly the same rules for the treatment of fistulæ as our author. When the sinus runs transversely along the skin, he directs us to lay it open. When it penetrates downwards he advises us to cut off the callus; and when the ulcer terminates with a bone to remove the diseased lamina of it. (xiv, 55.)

Albucasis delivers the surgical treatment of fistulæ at great length. He is very particular in inculcating the necessity of making free incisions, and of removing any pieces of diseased bone which may happen to be found at the bottom of the sore. He relates a case of fistulous ulcer in the thigh, to cure which he removed large pieces of bone, sawing it down as far as the marrow. Some of his saws are very ingeniously constructed, and one of them is not unlike the saw introduced into the practice of surgery by the late Mr. Hey, of Leeds. He enumerates nine causes which prevent sores from healing; and as they appear to be of some practical utility we shall briefly mention what they are: 1, a deficiency of blood in the body; 2, cachexy, or bad condition thereof; 3, fungous flesh, which prevents the union of the edges of the sore; 4, much sordes in the ulcer; 5, putridity, or any other bad quality of the fluids; 6, improper applications; 7 and 8, the pestilential state of the atmosphere and the insalubrity of the place where the patient resides; 9, a diseased bone. When none of these causes are present, the restorative principle of nature will of itself effect the cure of any solution of continuity. (Chirurg. ii, 88.)

Rhases gives extracts from Antyllus, and many other authors, on this subject, but as their principles of treatment are much the same as those delivered by Paulus, we need not occupy much room with an abstract of them. Antyllus forbids us to use the knife when the fistula is situated in the groin or fundament. When it is not judged expedient to have recourse to an operation, one of his Arabian authorities, Aaron, recommends a powder composed of equal parts of quicklime, cantharides, arsenic, sandarach, sal ammoniac, and ginger. (Cont. xxviii.)

SECT. LXXVIII.—ON FISTULÆ IN ANO.

Fistulæ in ano are discovered, if they are blind, from their being attended with pain, although no orifice appears; from there being a purulent moisture about the anus, and in most cases from their being preceded by symptoms of abscess; or, if they are open, by the introduction of a sound or swine’s bristle; for the instrument will pass down into a cavity and meet the index-finger introduced into the anus if the fistula has penetrated to the inside; but if it has not penetrated, the instrument does not come in contact with the finger but the intermediate substance between them remains imperforated. The fistula is known to be crooked and winding from the instrument’s passing down but a short way, while a great quantity of pus is discharged in proportion. Those near the intestines are known by an abdominal worm or fæces sometimes passing through the mouth of them. In almost all cases some callus appears about the orifice of the fistula. A fistula is incurable that perforates the neck of the bladder, or extends to the joint of the thigh, or to the rectum. A fistula is difficult to cure when it has no orifice, is blind, ends with a bone, and has many windings. All the rest are, in general, easily cured. We proceed with them thus: having placed the patient in a supine posture, with the legs elevated, so that the thighs may be bent upon the belly, as when an injection of the bowels is administered, if the fistula terminate superficially, having introduced a sound or ear-specillum through the orifice of it, we cut the skin which covers it at one incision. But if the fistula terminate deeply in the anus, having introduced a specillum into the mouth of it, and if we find that it has perforated the gut, by introducing the finger into the anus opposite the affected buttock, we take hold of the head of the specillum, and bending it, bring it to the outside, and with one simple division cut asunder the parts which lie over the sound. If the fistula is found not to have as yet perforated the gut, and to have terminated only deeply in the fundament, and if upon examination we find that a scaly or membranous substance intervenes between the index-finger and the extremity of the sound, we must perforate it violently with the head of the sound, and forcing the sound through the rectum, we must again, as formerly described, cut asunder the intervening parts with a scalpel; or, having perforated the bottom of the fistula in ano with the sharp part of a falciform instrument for operating upon fistulæ, we bring the instrument out at the anus, and so divide all the intermediate space with the edge of the instrument; and after the incision, having taken hold of the surrounding parts, which mostly consist of callus, with a common forceps, or one called staphylagra, we cut them out all around, avoiding the sphincter muscle; for some cutting deep in an unskilful manner, have wounded it, from which the patient has had an involuntary discharge of fæces. Those who from timidity, avoid a surgical operation may be treated with the ligature, as recommended by Hippocrates. For Hippocrates directs us to pass a raw thread, consisting of five pieces, through the fistula by means of a probe having a perforation, or a double-headed specillum, and to tie the ends of the thread and tighten it every day until the whole intermediate substance between the orifice be divided and the ligature fall out. If it remain long, the thread may be sprinkled with the detergent powder called psarum, or some such powder, and drawn in. Some insert a thread into the opening of the falciform instrument for operations on fistulæ, and pass it through in the manner described, which I think ought not to be done. For by avoiding an operation, in addition they incur the inconvenience of a slow recovery. With regard to blind fistulæ, Leonides says: “When the fistula is deep, and penetrates the sphincter, whether beginning in the fundament, or arising from a distance and terminating in the sphincter, after the examination which has been described, we dilate the anus as we do the female vagina, with the instrument for that purpose, or the small specillum. When the orifice of the fistula is discovered, the end of an ear-specillum is to be passed through it, and pushed deep into it, and cutting down upon it where it presents, the whole fistula is to be divided with a semispathula or a spathula for operating upon fistulæ.” We having met with this state of the disease, have found it impossible to practise this mode of operating, because we could not discover the cavity of the fistula. For it was situated between the anus and sphincter towards the right side, and the dilator rather obscured the operation. But having dilated the wrinkles about the anus a certain fissure appeared among them, being as it were the defluxion of the fistula, for the pus passed out by it we saw to pass the head of the specillum into the fistula by it, which served as a director; and having passed the index-finger of the right hand to the sphincter, and having found a certain thin substance intervening between the finger and the sound, by pressing the sound violently to the finger, we perforated the bottom of the fistula, which was turned upwards; and passing with the finger the head of the instrument outwards, the whole of the substance between the mouths of the fistula, (I mean the one so situated as to favour the defluxion, and that now made by us,) we divided with a scalpel and cut out the sound.

Commentary. Hippocrates describes minutely the apolinose, or the cure with the ligature, in his work ‘De Fistulis.’ We must mention, however, that Kühn and Sprengel do not admit this among the genuine treatises of Hippocrates, although they allow that it is ancient. Littré also, though with some hesitation, has rejected it from his list of the genuine works of Hippocrates. And yet, considering that it was received as such by Galen and Erotian, it seems bold in any modern critic to refuse its claims.

Celsus likewise describes distinctly the method of applying the ligature. The process, he says, is slow but free from pain. It may be expedited by smearing the thread with some escharotic ointment. The same thing, he adds, may be accomplished by means of a scalpel guided upon a specillum (sound). When many sinuses open by one mouth, he directs us to cut open a straight fistula with a scalpel, and then the others being thereby exposed are to be tied with a thread. The diet is to be of a diluent nature, with a liberal allowance of water for drink. (vii, 4.)

Aëtius gives, from Leonides, a full account of fistulæ in ano, as we have explained in another place. He recommends us to introduce a specillum, and having cut open the fistula upon it, to pare away the callous parts of it. (xiv, 11.)

Actuarius approves of the same practice as the others. He cautions against making large incisions lest the sphincter ani be wounded. (Meth. Med. iv, 6.)

Albucasis delivers nearly the same rules of treatment as our author. According to circumstances he approves of the knife, the cautery, or the apolinose. (Chir. ii, 80.)

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.

SECT. LXXIX.—ON HEMORRHOIDS OR PILES.

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.

SECT. LXXX.—ON CONDYLOMATA OR EXCRESCENCES, AND FISSURES.

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.)

SECT. LXXXI.—ON IMPERFORATE ANUS.

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.)

SECT. LXXXII.—ON THE EXCISION OF VARICES.

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.)

SECT. LXXXIII.—ON THE DRACUNCULI OR GUINEA-WORMS.

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.

SECT. LXXXIV.—ON AMPUTATION OF THE EXTREMITIES.

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.