BOOK VI. (continued 2)

The reader may likewise consult Mesue with advantage. Serapion also recommends the same remedies as the Greeks. Avicenna supplies no new views. Haly recommends incision when other means have failed.

Rhases directs us to pour tepid oil into the ear, and to put the patient into a warm bath in order to lubricate and produce relaxation. His translator, however, remarks that if the substance lodged in the ear be a bean or a pea there may be danger of the water occasioning a swelling of it.

SECT. XXV.—ON POLYPUS.

The polypus is a preternatural tumour forming in the nose; so called from its resemblance to a sea polypus, because it resembles its flesh, and because, as the animal with its fibrils resists those who would seize on it by catching at their hands, so does this affection, in like manner, block up the nostrils, occasioning inconvenience both in breathing and speaking. Wherefore those kinds of polypi which are hard, unyielding, somewhat livid and malignant, inasmuch as they partake of a carcinomatous nature, are not to be meddled with; but such as are more friable, spongy, insensible, and not malignant, are to be subjected to a surgical operation. Having placed the person on a seat exposed to the rays of the sun, and opened the nostrils with the left hand, and holding in the right hand a polypus scalpel, having its extremity shaped like a myrtle-leaf, we cut around the polypus or sarcomatous tumour, applying the extremity of the instrument to the parts where it adheres to the nose. Afterwards, turning round the instrument, we bring out the separated fleshy body with its concave part. And if we see that the nasal passage is perfectly cleared, we proceed to the cure; but if any part of the polypus be left behind, we take another instrument for eradicating polypi, and, with the extremity thereof, we bring away what remains by stretching, twisting, and scraping it strongly. Malignant polypi we burn with cauteries, knob-shaped; and, after the burning, we have recourse to the treatment for burnt parts. After the operation, having sponged the parts carefully, we inject oxycrate or wine into the nose, and, if the fluid descend by the roof of the mouth to the pharynx, the operation will have been rightly done; but if it does not descend, it is clear that about the ethmoid bones, or the upper parts of the nose, there are fleshy bodies which have not been reached with the polypus instruments. Taking, then, a thread moderately thick, like a cord, and having tied knots upon it at the distance of two or three fingers’ breadths, we introduce it into the opening of a double-headed specillum, and we push the other extremity of the specillum upwards to the ethmoid openings, passing it by the palate and mouth, and then drawing it with both hands, we saw away, as it were, with the knots the fleshy bodies. After the operation, we keep the opening separate by means of a tent resembling the wick of a lamp; and after the third day we consume whatever is left behind by the trochisk of Musa or the like, and at the same time use desiccative applications to the part. Afterwards, we have recourse to epulotic trochisks, and, if necessary, during the whole treatment we keep leaden tubes in the nose.

Commentary. For an account of the treatment by medicines we refer to section xxiv of the Third Book.

The author of one of the Hippocratic treatises, according to circumstances, recommends sawing it out, consuming it with septics, tying it with a ligature, and burning it with a red-hot iron. (De Morbis, ii.)

In the ‘Isagoge’ of Galen, it is merely recommended to cut out the tumour, and to scrape its roots.

Celsus, like our author, recommends excision with a sharp instrument of iron, and directs us to apply afterwards to the part a tent smeared with some styptic. A proper dressing is then to be applied for cleansing the sore. (vii, 10.)

Oribasius briefly mentions excision as a proper remedy when medicines fail.

Albucasis describes minutely the operations of excision and sawing out the tumour. Like our author, he directs us to seize the tumour with a hook, to pull it down, and cut it out. If any part remain, he recommends us to scrape it out with a slender instrument, and then to apply styptics, such as vinegar, water, or snow. The operation of sawing it out with a thick knotted thread is minutely described by him. He also speaks of cauterizing the part from which the tumour has been removed.

Mesue describes the process of sawing out the tumour, with some slight differences. He recommends us to use three horse-hairs, which, being tied together with knots, are to be introduced into the nose with a leaden needle, and one end conveyed out by the openings of the palate; and then, by pulling at both ends, the tumour is to be sawed out.

Avicenna, Haly Abbas, and Rhases make mention of excision and the process of sawing out the tumour. Rhases relates the history of a case of polypus, unusually large, which he had seen extracted in an hospital. He and Albucasis recommend the part to be dressed with green ointment.

The veterinary surgeons appear to have depended principally upon the actual cautery. See Vegetius (Mulom. ii, 38.)

The method of curing polypi of the nose, by sawing them out, seems to have now fallen completely into disuse, whether deservedly or not we cannot, from our own experience, venture to decide. Fabricius ab Aquapendente disapproved of it; but he was evidently much prejudiced in favour of the operation with a new forceps of his own invention. (Œuv. Chir. ii, 24.) Sprengel informs us that this method was practised by the surgeons of the middle ages. It is described by Brunus (Chir. Mag. ii.)

Sprengel thus explains the other operation described by our author: “Il se servait d’un instrument particulier auquel il donnait le nom de σπάθιον πολυπικὸν et qui était garni à l’une de ses extrémités d’un ciseau, κυκλίσκος” (Hist. de la Méd. viii, 4.) Why does he substitute κυκλίσκος for κυαθίσκος? That the instrument had a chisel (ciseau) at its extremity is altogether improbable, and this supposition is unwarranted by the context. Κυαθίσκος means the cup-like or concave end of the instrument.

SECT. XXVI.—ON MAIMED PARTS.

When the ears or the lips have been mutilated, we restore them by first dissecting the skin below, and afterwards bringing together the lips of the wounds; then removing the callous parts, and afterwards sewing and glueing them together.

Commentary. This section is taken from Galen. (Meth. Med. xiv.) See, also, the ‘Isagoge.’

Celsus’s observations are too minute and lengthy for our limits. Suffice it to say, that he directs the edges to be pared, and then united with sutures. (vii, 9.)

Rhases’ directions for the treatment of mutilated ears and noses are to the same effect as our author’s. (Cont. xiv.) Similar ones are given by Albucasis. He directs us to make the suture either with needles, as in gastroraphe, or with a thread. (Chirurg. ii, 26.)

Celsus has been supposed, but, as we think, incorrectly, to touch on the operation for the hare-lip. (vii, 10, 6.) See Sprengel (Hist. de la Méd.)

SECT. XXVII.—ON EPULIS AND PARULIS.

Epulis is a fleshy excrescence which forms upon the gums beside one of the teeth; but parulis is an abscess which forms near the gums. The epulis, then, we raise with a flesh forceps or a hook, and cut out; but the parulis we divide circularly and fill the incision with tents. I am aware that often when opened only with the common lancet used for venesection and the matter evacuated, the disease has ceased. After the operation we give orders to gargle with wine, then with honied water, and afterwards apply to the wound the Flowery powder, until the cure is completed. But if mortification attack the gums, and do not yield to the suitable applications, we must burn the part with knob-shaped cauteries.

Commentary. Parulis is the gum-boil. Epulis is a soft fleshy tumour which forms on the gums. Aëtius treats fully of them. To the former he directs us to apply at first such things as promote suppuration, after which it may either be allowed to break of itself or may be opened with a lancet. Styptic applications will then be proper. For the epulis he recommends us at first to apply alum, verdigris, &c., and if these have not the desired effect he directs us to cut it off with a scalpel. (viii, 24, 25.)

Celsus treats of both at considerable length by the name of parulides. For that species which corresponds to the gum-boil, among other remedies, he recommends us to hold in the mouth a decoction of figs, and directs to open it before it is ripe, lest the matter should hurt the bone. Larger tumours are to be cut out entire. (vi, 13.)

Haly Abbas recommends excision for the epulis, and to open the parulis in due time with a lancet. (Pract. ix, 33.)

It appears to us that of all the ancient authorities Albucasis lays down the best rules for treating the epulis. He directs us to cut it out with a forceps and scalpel, and then to apply styptic powders to the part, or if the tumour grow again, the actual cautery. For our own part, we have generally found that no permanent cure could be effected without the cautery. See Chirurg. (ii, 28, and i, 22.)

It is unnecessary to detail the treatment recommended by the other authorities.

SECT. XXVIII.—ON THE EXTRACTION OF TEETH.

Having scarified around the tooth down to the socket, we must by degrees shake the teeth with a tooth-extractor, and draw it out. But if it is carious we must first plug up the hole with a small tent, that it may not break when compressed by the instrument. After the extraction we may consume the flesh that is left by sprinkling it with finely levigated salts, and afterwards gargles of wine or oxycrate may be used until the completion of the cure. And since sometimes supernumerary teeth are formed, those that are fixed in the socket we must scrape down with a graving-tool, but those that are not so fixed we must extract with a tooth-extractor. If any tooth grow to an unnatural size, or is broken, we may scrape away the projecting or redundant part of it with a file. The laminæ which unite to them we may remove as may appear proper, with the concave part of a specillum, a raspatory, or a file.

Commentary. Cælius Aurelianus disapproves of extracting teeth, except in cases of extreme necessity. Herophilus and Heraclides Ponticus, he says, have related cases in which the operation had proved fatal; and in modern times we hear sometimes of such occurrences. (Pass. Tard. ii, 4.)

Celsus directs us, when the pains of toothache cannot be got otherwise alleviated, to separate the gums from the tooth by free scarifications, and then to shake it until it is loosened, and forbids us to proceed rashly to perform extraction, for fear of occasioning dislocation of the jaw-bone, or, if the tooth belong to the upper jaw, of hurting the temples or eyes. If loose, it is to be taken out with the hand, but otherwise with a forceps, and, if eaten, the hole is to be filled with a tent, or with lead, to prevent it from breaking during extraction. The instrument is to be pulled direct, lest the spongy bone to which the tooth is fixed should be broken. Of this accident occurring there is, he adds, considerable danger; and not unfrequently when the tooth is short and its roots long, the instrument takes hold of a piece of bone and breaks it; in which case he directs us to extract the broken piece with a pincers. When the teeth are carious he directs us to scrape them, and apply to them a mixture of the flowers of roses, galls, and myrrh, and to hold undiluted wine in the mouth. When the teeth are slackened by any accident, he directs us to fasten them to the surrounding ones with a golden thread, and then to hold some stringent decoction in the mouth. When in young persons a second tooth appears before the first has fallen out, he recommends us to scarify around the latter and pull it out, and to endeavour to force the other gradually into its proper place. Stumps of teeth are to be taken out with a stump-extractor. (vii, 12.)

Scribonius Largus makes some ingenious observations on the extraction of teeth, but disapproves of the operation, except in extreme cases. (De Comp. Med. i, 10.)

Galen, and the medical authorities subsequent to him, direct us to file down teeth when they are diseased and project, but disapprove in general of extraction.

Albucasis is particularly full in treating of the operations on the teeth. Like our author, he recommends us to perform extraction by first making free scarifications, and then pulling the tooth direct with a forceps, the patient’s head being held between the knees of the operator. When the tooth is hollow he directs us to stuff it beforehand with a tent of cloth. When a piece of the alveolar process has been broken, he properly recommends that it be taken out. He gives suitable directions for filing down the teeth, and for fastening them with gold threads. He gives drawings of instruments for extracting roots. (Chir. ii, 30.)

The other Arabians describe the operation, but less precisely than Albucasis. Haly’s directions are judicious. He recommends the operator to use a forceps, and to stuff the tooth when it is hollow. (Pract. ix, 31.)

SECT. XXIX.—ON CONSTRICTION OF THE TONGUE, OR TONGUE-TIED PERSONS.

The affection called ancyloglossus is sometimes congenital, the membrane which fastens the tongue being originally harder and more constricted than ordinary; but sometimes is acquired from some hard cicatrix formed under it by ulceration. Those therefore who have this affection naturally are distinguished by being slow in beginning to speak, and by having the frænum linguæ larger than its moderate size, and that without any previous ulceration. When the complaint is occasioned by a cicatrix it is easily recognised. Wherefore the patient is to be placed on a proper seat, the tongue raised to the roof of the mouth, and the membranous frænum cut transversely. But if the curvature is occasioned by a cicatrix, we transfix the callus with a hook and draw it upwards, and making a cross incision free the bent part, taking care not to make deep incisions of the parts; for hemorrhages which have been found difficult to stop have thereby been occasioned. After the operation the part is to be washed with cold water or oxycrate; and after all these things the cure is to be completed with relaxing and incarnative applications.

Commentary. Celsus thus describes the treatment in congenital affections: “Horum extrema lingua vulsellâ prehendenda est, sub eâque membrana incidenda, magnâ curâ habitâ, ne venæ quæ juxta sunt, violentur et profusione sanguinis noceant.” (vii, 12, 4.)

Aëtius’s plan of treatment is quite similar to our author’s. (viii, 38.)

Albucasis gives a similar account of the operation. He cautions against opening the artery below the tongue, for fear of hemorrhage. Should this accident occur he directs the surgeon to use the actual cautery. (Chirurg. ii, 34.)

Rhases recommends when the frænum extends to the tip of the tongue that it be divided, so as to allow freedom of motion. However, one of the authorities quoted by him directs us to pass through the frænum a needle armed with a thread, which is to be tightened so as to divide the intermediate space. He recommends this method in order to obviate the fear of hemorrhage from the incision. Rhases himself states that a dangerous hemorrhage will result from opening the green veins below the tongue. (Cont. vii, 1.)

Avicenna also recommends the operation with the ligature. (iii, vi, 11.)

Haly Abbas describes very distinctly the operation of dividing the frænum. (Pract. ix, 35.)

Alsaharavius mentions that the operation is sometimes necessary. (Pract. ix, 35.)

SECT. XXX.—ON ANTIADES, OR INDURATED TONSILS.

As indurated glands are called strumæ, so the almonds of the ears when inflamed, swelled, and as it were, dried, occasioning difficulty of deglutition and of breathing, are called antiades, from their being placed opposite one another. When therefore they are inflamed we must not meddle with them; but when the inflammation is considerably abated, we may operate, more especially upon such as are white, contracted, and have a narrow base. But those which are spongy, red, and have a broad base, are apt to bleed. Wherefore, seating the person in the light of the sun, and directing him to open his mouth, while one assistant holds his head, and another presses down the tongue to the lower jaw with a tongue spatula, we take a hook (tenaculum) and perforate the tonsil with it, and drag it outwards as much as we can without drawing its membranes along with it; and then we cut it out by the root with the scalpel suited to that hand, called ancylotomus, for there are two such instruments, having opposite curvatures. After the incision of one we may operate upon the other inversely in the same manner. After the operation the patient must gargle with cold water or oxycrate; and if any hemorrhage come on he may use a tepid decoction of brambles, roses, and myrtle-leaves; or if the blood flows copiously we must give for a gargle the juice of plantain and comfrey, and the trochisk from amber and the Lemnian earth, dissolved in oxycrate. When the hemorrhage stops, the parts on the next day may be anointed with the flower of roses, saffron, and starch with milk, or with water, the white of an egg, or hydrorosatum. When sordes collect about the ulcers, we may use injections and linctuses made from honey.

Commentary. Celsus directs us when the tonsils are indurated to scrape the membrane with the finger, and tear it out; or, if this does not succeed, to seize the tumour with a hook or tenaculum, and cut it out; then the wound is to be washed with vinegar, and a styptic medicine applied to it. (vii, 12.)

Aëtius directs us to seize the tonsil with a hook and cut it out at the middle. When cut out at the base, he remarks there is danger of hemorrhage. (viii, 57.)

Albucasis directs us to make the patient sit with his head on the operator’s bosom, and, while an assistant presses down his tongue, the operator is to seize the indurated tonsil with a hook, and drawing it out, to cut it off with a sharp instrument resembling a forceps, or, in other words, with a pair of scissors. He likewise gives a drawing of another instrument which consists of a lunated piece of iron fixed to a handle. He relates an interesting case in which he performed the operation. (ii, 36.)

Rhases, upon the authority of a surgeon called Ancilisius, in the barbarous translation of his works, which probably is a corruption of Antyllus, briefly describes this operation. He directs us to open the mouth and take hold of the tonsils, the fourth part of which may be cut off. He recommends us to make the patient gargle with vinegar. He forbids the operation when the tonsils are enlarged and red. (Contin. vii, 2.)

Haly Abbas (Pract. ix, 36,) and Mesue (de Ægr. Gutturis, 4,) describe the operation, but not so minutely as Albucasis.

Guido de Cauliaco copies the descriptions of Albucasis and Haly Abbas. (c. vi, 2.)

SECT. XXXI.—ON THE UVA.

The uvula being, as it were, the quill or plectrum of the organ of speech is often the seat of defluxion from the head, and becoming preternaturally enlarged, of a lengthened form and slender shape, it is called columella; but when thick below and round it is named uva, from its resemblance to a grape, as the other is so called from its resemblance to a column. If, therefore, it cannot be made to yield to general treatment,—I mean evacuations by bleeding and purging,—nor to topical, such as astringents, repellents, and discutients,—we must proceed to the operation, lest, by its constant irritation, it bring on coughs, sleeplessness, and even suffocation. Such, therefore, as are contracted, round, not of a lengthened shape, bloody, or somewhat black, we must decline operating upon; but those that are slender, long, small at the extremity, loose, not very bloody, but whitish, we must operate upon; for the inflammation of them soon subsides. We must only take away as much of the uva as exceeded its natural size; for the complete extirpation of it proves greatly injurious to the parts about the chest, and occasions the loss of voice. Wherefore, having placed the patient on a seat in the rays of the sun, and directed him to gape wide, we seize with the forceps adapted for this purpose, or a common tenaculum, upon the redundant part and drag it downward, and cut it out with the instrument called staphylotomus, or the scalpel used in the operation for the suture of the upper eyelid. After the operation the same things are to be done as are recommended for angiology. But since often, from the timidity of the patient, or the fear of the hemorrhage, or the success attending the treatment by medicines, he declines the operation by instruments, we may rather consume it by means of a caustic medicine. Wherefore, taking the caustic used for burning the eyelids, or some such, we are to fill with it the hollows of the instrument called staphylocaustos, and directing the patient to gape wide, and getting the tongue pressed down with a tongue spatula, we open the instrument sufficiently and grasp with it as much of the uva as we cut off in the other operation. The medicine must neither be of too liquid a consistence, lest it run down from the uva improperly, and burn the adjoining parts (and, therefore, we direct the patient not to swallow during the whole operation of burning), nor very hard, that it may soon act upon the uva. And if from one application the extremity of the uva become black, this will be sufficient, but if not we must use it again. During the whole time of its action the patient must sit with his head bent forwards, in order that the saliva which is melted down with the portions of the medicine may flow from the mouth. The part becomes dead in one hour, and falls off about the third or fourth day. After the burning, having wrapped the index-finger round with soft wool or tow, we wipe the parts about the uvula, or direct the patient to gargle with water. But after this operation, and also that on the tonsils, soothing fomentations from the oil of camomile are to be applied around the neck, and in like manner we may use gargles and liniments.

Commentary. It appears from the Hippocratic treatises that excision of the uvula was sometimes performed in early times. (Prognost. de Morbis, ii; De affect.)

Celsus recommends us not to meddle with the operation when the uvula is red and enlarged, for fear of hemorrhage; but when it is slender, sharp, and white, or when it is pale and thick below, but slender above, it may be extirpated without danger. For this purpose he merely directs us to seize upon it with a forceps and cut it out. (vii, 12.)

Galen describes fully the operation by medicines, but says nothing of excision. (De Med. sec. loc. vi.) Aëtius describes the operation in nearly the same terms as our author. He directs us to grasp the enlarged uvula with a forceps and cut it off, using afterwards some astringent gargle. (viii, 44.) Oribasius briefly mentions the operation, which he directs to be performed with extreme circumspection. (Med. Collect. xxiv, 10.)

Albucasis describes the operation similarly to the Greeks. He directs the operator to get the patient’s tongue pressed down by an assistant; when the operator is to seize upon the uvula and cut off as much as is proper of it. He gives a drawing of an instrument for the operation with caustic medicines. (Chirurg. ii, 37.)

Avicenna’s description is to the same effect, but not so circumstantial. (iii, 9, 15.) Mesue directs us to perform the operation with a heated scalpel of gold. (De Ægr. Gutturis, 3.)

Rhases states that when the uvula is enlarged, but is not red, the operation may be performed without danger. He mentions that some preferred the actual or potential cautery, but that he preferred excision. He describes, but not distinctly, an instrument for applying the caustic medicines. He states that loss of the entire uvula impairs the voice and exposes the lungs to danger from cold. (Contin. vii; and Divis. i, 49.)

SECT. XXXII.—ON THORNY SUBSTANCES FIXED IN THE PHARYNX.

Thorns, or the bones of fishes, or other substances, are often swallowed in eating, and fix in different places. Wherefore, such as can be seen we are to extract with the forceps for that purpose; but those which are lower down in the gullet we must manage differently. Some are of opinion that the patient ought to be made to swallow large morsels, such as the stalk of lettuces, or pieces of bread; but others direct us to bind a thread about a small piece of clean soft sponge and give it to the patient to swallow, and then taking hold of the thread to draw it up, and to do this frequently in order that the thorn may get fixed in the sponge and be brought up. Leonidas orders suppurative cataplasms to be applied, such as those from raw barley-flour, in order that the part may be converted into pus and the thorn fall out of its own accord. If we see the patient at the time of swallowing, before digestion has taken place in the stomach, and cannot perceive the substance which is fixed, we may order him to vomit by pushing the fingers or feathers down the throat, for sometimes the thing which is fixed will be brought up with the matters that are vomited.

Commentary. Our author’s directions are mostly taken from Aëtius. (viii, 50.)

Albucasis repeats our author’s directions, and further recommends us, when they fail, to introduce an instrument made of lead, which he gives a drawing of, and either to extract the substance or push it downwards. (Chirurg. ii, 38.) A similar plan of treatment is recommended by Mesue (de Ægr. Gutturis); by Avicenna (iii, 9, 43); and by Alsaharavius (Pract. xii.) When a morsel of food sticks to the œsophagus, Alsaharavius directs that the person should be struck on the back, which will facilitate the descent of it. (6.)

SECT. XXXIII.—ON LARYNGOTOMY.

The most famous surgeons have also described this operation. Antyllus, therefore, says, “In cases of cynanche (as we will explain under the head of Dietetics) we entirely disapprove of this operation, because the incision is utterly unavailing when all the arteries (the whole of the trachea?) and the lungs are affected; but in inflammations about the mouth and palate, and in cases of indurated tonsils which obstruct the mouth of the windpipe as the trachea is unaffected, it will be proper to have recourse to pharyngotomy, in order to avoid the risk of suffocation. When, therefore, we engage in the operation we slit open a part of the arteria aspera (for it is dangerous to divide the whole) below the top of the windpipe, about the third or fourth ring. For this is a convenient situation, as being free of flesh, and because the vessels are placed at a distance from the part which is divided. Wherefore, bending the patient’s head backwards, so as to bring the windpipe better into view, we are to make a transverse incision between two of the rings, so as that it may not be the cartilage which is divided, but the membrane connecting the cartilages. If one be more timid in operating, one may first stretch the skin with a hook and divide it, and then, removing the vessels aside, if they come in the way, make the incision.” These are the words of Antyllus. We judge that the windpipe has been opened from the air rushing through it with a whizzing noise, and from the voice being lost. After the urgency of the suffocation has passed over, we pare the lips of the incision so as to make them raw surfaces again, and then have recourse to sutures, but sew the skin only, without the cartilage. Then we use the applications proper for bloody or fresh wounds, but if it does not unite we must treat it with incarnants. We must follow the same plan of treatment if we should meet with the case of a person who had cut his own throat from a wish to commit suicide.

Commentary. Aretæus makes mention of this operation in such terms as proves that it must have been practised occasionally in his time. He, however, does not approve of it, at least in cases of angina. (De Curat. Morb. Acut. i, 7.)

Cælius Aurelianus says that Asclepiades performed the operation in cases of cynanche; but he himself disapproves of it. (De Morb. Acut. i, 7.) We may mention further in this place that Avicenna, Avenzoar, Haly Abbas, Mesue, and Rhases express themselves rather favorably of the operation in urgent cases of cynanche. From the circumstance mentioned by Pollux of cynanche, that it mostly attacks children, we are inclined to think that the ancients meant the croup by it.

None of the Greek authorities, except our author, have left a description of the operation. Psellus, however, mentions it in such a manner as would lead us to infer that the operation had not been lost sight of in his time, i. e. “Laryngotomy is a certain surgical operation.”

Avicenna and Albucasis merely copy our author’s description, and appear to have never seen the operation performed. To show, however, that the windpipe may be opened without occasioning death, Albucasis relates the case of a female who cut her trachea while attempting to commit suicide; in which case, by sewing up the wound, he effected a cure without difficulty. (Chirurg. ii, 13.)

Rhases mentions that, in cases of cynanche which threaten instant death, a certain physician, Ancilisius (Antyllus?) recommends the surgeon to open the windpipe. His description of the operation is as follows: The patient’s head being kept back the skin is to be divided, and the sides of it separated by means of threads, so as to expose the windpipe, which is to be opened by making an incision in the membrane which connects two of the rings together. After the abcess bursts the wound is to be sewed up. (Cont. vii, 2.)

Haly Abbas likewise describes the operation accurately. He directs us to make an incision in the skin, and to separate the edges with hooks so as to expose the windpipe, which is to be opened between two cartilages. (Pract. ix, 38.)

The modern history of the operation is given in Van Sweiten’s Comment. (814); Mémoires de l’Acad. Royale (ii); and Cooper’s Surgical Dictionary. See a complete history of the operation by Sprengel. (Hist. de la Méd. 18, 6.) He says, that Anthony Benivieni, a surgeon of Florence, is the first after Antyllus who is known for certain to have performed the operation.

SECT. XXXIV.—ON ABSCESS.

That the abscess is a corruption and transmutation of the flesh or fleshy parts, and what are its modes of formation, and how many kinds of abcesses there are, we have sufficiently explained in the Fourth Book. Now we have only to treat of the operation upon it. If it be completely changed to pus, which we ascertain from the pains, fever (if any was formerly present), redness, pulsation, and the other symptoms of inflammation being diminished, from the swelling assuming a sharp point, and from pus being felt under the fingers upon pressure, more especially if the abscess be superficial, in that case we may proceed to the operation. But if it is not felt to the touch, nor is elevated to a point, owing to its being deep-seated, we must attend to the other symptoms before operating. It is to be understood, however, that before the conversion to pus is completed, we sometimes open abscesses when they are unripe, on account of their being near joints or vital parts, lest, by their continued putrefaction, a ligament or some necessary part should be corrupted by it. And Hippocrates directs us to open abscesses about the anus before they are completely ripened, for fear of their perforating the intestine. In opening them we must not, in all cases, make the incisions in the same manner, but observe the natural lines—as on the face; and the growth of the hairs—as on the head, and taking as much care as possible not to occasion deformity. Straight incisions are to be made in the legs, as in the muscles and tendons; and nerves, arteries, and vital parts are to be avoided, taking care of their safety by sometimes making a straight incision and sometimes a transverse one into the abscess, according to the circumstances of each case. When the abscesses are small we make one incision, but when they are larger we make more, always dividing the thinner parts, and those which are most convenient for the escape of the matter. When the swelling is much raised up to a point, unconcocted, thin, and devoid of vitality, we must cut out a piece either like a triangle, or like a myrtle leaf, or of some other angular figure, because the circular is unfavorable to cicatrization. Those which are not pointed we open by a simple incision, and when we find a sinus, if the part is fleshy and the skin proper for uniting, we only make such incisions into the part as will allow the matter to be discharged; but if it be thin and very devoid of flesh we make a simple incision along its whole length; and after this simple incision, if the parts on each side appear thin and not fleshy we must pare them off. After the operation, having first sponged the part, if the abscess be small, and if only one incision has been made, we may use a simple pledget, but if it be large, and there be many incisions, we draw through them a fillet which can be easily extracted; and when the part has been cut out we fill it in like manner with lint. If a hemorrhage take place we must use cold water or oxycrate, and if the bleeding continue we may sprinkle upon the part finely powdered chalcitis, which we may also have recourse to often when the part is gangrenous and flaccid. In winter, and when the parts are nervous, we may soak oblong pledgets in wine and oil and apply them; and in summer, when the parts are fleshy, we may soak these applications in water and oil, or in the same cold wine and oil, and binding them, on the following day we may bathe with the same fluids; but on the third day, having loosed the dressings and sponged the parts, we may use the application called tetrapharmacon on a pledget, and if there be no inflammation present we may apply the same wash for the preservation of the pledget; but if there be inflammation, we must apply a digestive cataplasm, having first poured water on the parts. When the inflammation abates we may effect the cure by promoting suppuration and incarnation. Sinuses are to be cured by agglutinative remedies, as has been said, in the Fourth Book, on sinuses.

Commentary. All the authors quoted under this head in the Fourth Book may be consulted.

Celsus is more than usually prolix in laying down the rules for the surgical treatment of abcesses. Before the abscess harden, he directs us to make incisions in the skin, and apply a cupping instrument, in order to remove any symptoms of inflammation which may have been present, or, in other words, to procure resolution. Sometimes, however, as he explains, the matter is collected in a cyst (tunica), in which case it is not to be supposed that the contents of the abscess can be removed by a cupping instrument. When the pus ripens it is seldom proper to let it out if seated in the armpits, or groins; nor when the collection is superficial, or in the flesh; and it is better, as he prudently directs, to apply cataplasms until the pus make an opening for itself. When it is judged necessary to open an abscess, he recommends us, if not seated in a nervous part, to perform the operation with a red-hot iron, because a small opening made in this manner will remain longer open. Abscesses in nervous parts are to be opened with a scalpel. In making an incision, the form and size of it are to be considered. In general the openings are to be made as small as possible; but large sinuses require larger incisions, and sometimes two or three are necessary: when the skin is livid or diseased it sometimes must be cut off to further the cure. In this case an opening is to be made of the shape of a myrtle-leaf. When the pus is evacuated, if in the armpit or groins, no pledget is to be used, but a sponge out of wine is to be applied. In other places, a little honey is first to be used; then agglutinative medicines; and above these likewise, if necessary, a sponge squeezed out of wine. (vii, 2.)

The treatment of abscesses is fully explained by Galen. (Therap. ad Glauc. ii.) He directs us, when an abscess is slow of ripening, to make superficial scarifications in it, and afterwards to apply a cataplasm of barley-meal.

Aëtius’s directions are, upon the whole, similar to our author’s, but not quite so minute and precise. Like our author, he directs us to make the incision long and narrow, like a myrtle-leaf. The ancients were well aware that circular sores are slow of healing; and the causes of this fact are fully explained by Cassius and Alexander Aphrodisiensis.

Little additional information is to be obtained from the other authorities. Albucasis directs us, when the abscess is large, not to evacuate all its contents at once, lest it produce dangerous prostration, especially if the patient be weak; for, he remarks, the animal spirits will escape along with the pus. Like our author, he forbids us to open abscesses until they are ripe, unless seated near the anus, or some vital part. (Chirurg. ii, 40.)

Haly Abbas justly remarks that if an abscess be opened prematurely, the lips of it remain in an indurated state, and prevent the sore from healing. But when seated near nerves or ligaments, he advises not to wait until it is ripe. His treatment upon the whole does not differ from our author’s. (Pract. ix, 8.)

The method of opening abscesses, by means of caustic applications, is described in the Fourth Book, 18.

SECT. XXXV.—ON STRUMÆ, OR SCROFULOUS GLANDS.

The chœras, or scrofula, is an indurated gland, mostly forming in the neck, armpits, and groins, deriving its name either from a Greek word, signifying a species of rock, or from swine, because they are fruitful animals, or because swine have swellings of the neck. The strumæ are formed either on the anterior part of the neck, or on either side of it, or on both, and they consist of one, two, or more, all contained in their proper membranes, like the steatoma, atheroma, and meliceris. Those, therefore, which are painful to the touch, and on the application of medicine, are of a malignant nature, are to be considered as carcinomatous and it is obvious that they do not readily yield to a surgical operation. But such as are mild to the touch and the seasonable application of medicines, may be operated upon in this manner. To such as are superficial and incline towards the skin we use a simple section, and free them from the surrounding bodies, and stretching the skin with hooks we flay the lips of the incision, as we said in describing the operation of angiology, and by degrees remove them entirely. But such as are larger, having transfixed them with hooks, we raise up, and dissecting away the skin from them in like manner, we must free them entirely from the surrounding bodies, avoiding in particular the carotid arteries and recurrent nerves. If any divided vessel obscure the operation, we may include it in a ligature, or cut it asunder, if not large. And when the base of the scrofulous tumour runs out into a narrow point, we may cut it away readily, and introducing the index finger search if there be any other strumæ lying there, and remove them in the same manner. But if we suspect that a large vessel or vessels are situated at the bottom of the scrofulous tumour, we need not cut it out from the base, but include it in a ligature, so that it may fall off spontaneously in pieces without danger, when we may effect the cure by the application of lint; but if cut away at once we may unite the lips of the incisions. The incisions are to be made direct, and if there be nothing redundant we may immediately sew them up. But, if owing to the size of the scrofulous swelling there be a redundancy of skin, having cut away a part of it like a myrtle-leaf, we may have recourse to sutures, and use the applications for recent wounds.

Commentary. See all the authors referred to in the 34th section of the Fourth Book.

Galen briefly recommends incision or septic applications. He relates an unfortunate case in which an ignorant surgeon, by cutting the recurrent nerve, occasioned loss of speech. (See Meth. Méd. xvi; and Loc. Affect. i, 6.)

Aëtius gives a long extract from Leonidas on the treatment of scrofula. His directions for dissecting out the tumours in the neck are such as experience alone could have dictated. In operating on the neck, he cautions us to avoid the jugular veins, carotid arteries, and the nerves of speech, and with this intention he recommends us rather to make the incisions longitudinal than transverse. When the tumour is small a simple incision, he says, will be sufficient; but if large, the skin is to be cut in the form of a myrtle-leaf, and the lips of the incision being stretched with hooks, the skin is to be separated from the struma with the fingers and a scalpel; but the base of the tumour is to be cut with great caution. He does not, like our author, make any mention of the ligature. When there is a discharge of blood he recommends styptics. (xv, 5.)

Celsus says nothing of the treatment by a surgical operation, (v, 28.)

Haly Abbas, Avicenna, and most of the Arabian authorities approve of excision, and describe the operation in much the same terms as our author. Albucasis directs us when there is a large vein at the bottom of the tumour to apply a ligature round its root, and allow it to drop out by putrefaction. When the contents of the tumour are fluid, he recommends us to open it, and apply an ointment to consume the corrupted flesh; after which incarnants and detergents are to be used. When scrofulous tumours resist, the ordinary treatment, he directs us to burn them with a red-hot iron.

SECT. XXXVI.—ON STEATOMA, ATHEROMA, AND MELICERIS.

These also belong to the class of abscesses, but differ from them in this respect, that those which are properly called abscesses are of an inflammatory nature, painful, and contain an acrid and corroding fluid; neither are they surrounded by a proper membrane or tunic. They differ from one another, in as much as that which is contained in the steatoma is, as its name implies, like suet; that which is in the atheroma is like pap made from corn; while the fluid in the meliceris is like honey. You may distinguish them from one another thus. The steatoma is harder than the others, is unyielding to the touch, and has a narrower base. The meliceris conveys to the touch the sensation of a soft body, is slowly diffused, and soon returns again to its shape. We operate upon them as upon scrofulous tumours, by incision, dissection, sutures, and the rest of the treatment, only avoiding to wound the membrane, lest its fluid contents be poured out and obstruct the operation, and lest a part of it should be left behind, which often occasions a renewal of the complaint at the wrists, ankles, and the moveable parts about joints, as a scrofulous tumour does in like manner, if the whole or a part of it be left behind. If any such thing be left it will be better not to sew up the wound, but to consume the remainder with septic applications.

Commentary. We have given an explanation of the nature of these tumours in the Fourth Book.

Galen states that the indications of cure in all these cases are to discuss their contents, produce putrefaction of them, or to cut them out. The steatoma, he remarks, being of a solid nature, can be remedied only by an operation. (Meth. Méd. xiv.)

Celsus directs us, in extirpating steatomatous tumours, to open the cyst and evacuate its contents; but recommends not to wound the cyst of the others. Should the whole or part of the cyst be unavoidably left behind, he directs suppurative applications to be used. After the operation he directs us to unite the lips of the wound by a clasp (fibula) and an agglutinative medicine. (vii, 6.)

The surgical treatment of these tumours is very fully laid down by Aëtius, in an extract from Leonidas; but his description is so long that we cannot do justice to it within our narrow limits. Like Celsus, he directs us to avoid wounding the tunics which surround the atheroma and meliceris; but states that this may be done in the case of the steatoma. He judiciously directs the skin to be cut in the form of a myrtle-leaf. (xv, 7, 8.)

Albucasis directs us, in the first place, to prick the tumour, in order to ascertain the nature of its contents. When they are found to be fatty, he recommends us to cut it out by making a crucial incision, and removing it with its cyst if possible. When the cyst is wounded he directs us to dissect it out in pieces, and to endeavour to leave no part of it behind. He gives drawings of various instruments, namely, scalpels, tenacula, and perforators, for dissecting out these tumours. (ii, 45, 46.)

Rhases and Avicenna give very judicious directions for the treatment of these tumours, but they scarcely differ at all from those of Aëtius and our author. They recommend us to avoid opening the cysts of the atheroma and meliceris, if possible; but if any part remain they direct us to destroy it by septics. (Contin. xxvii.)

SECT. XXXVII.—ON ANEURISM.

Aneurism is a tumour soft to the touch and yielding to the fingers, having its origin from blood and spirits. Galen says “an artery having become anastomosed (i. e. dilated) the affection is called an aneurism; it arises also from a wound of the same, when the skin that lies over it is cicatrized, but the wound in the artery remains, and neither unites nor is blocked up by flesh. Such affections are recognised by the pulsation of arteries; but, if compressed, the tumour disappears in so far, the substance which forms it returning back into the arteries.” Thus Galen.—But we distinguish them from one another in this way: That formed from anastomosis of an artery appears longer, is deep seated, and when pressed upon by the fingers, a sort of sound is heard; whereas no noise is heard in the cases arising from rupture, and these, moreover, are more rounded, and feel superficial. Those therefore which form in the armpits, groin, and neck, and those in other parts of the body, which are very large, we must decline operating upon, on account of the largeness of the vessels. But those which occur in the extremities, the limbs, or the head, we operate upon thus. We make a straight longitudinal incision in the skin, and then having separated the lips with hooks, as we mentioned in the operation of angiology, and having dissected away the skin, and separated it with the instruments used for operations on membranes, we lay bare the artery, and passing a needle under it, and tying it with two ligatures, and having first divided the intermediate part of the artery with a lancet used for bleeding, and evacuated its contents, we have recourse to the suppurative treatment until the falling off of the ligatures. If the aneurism be occasioned by rupture of the artery, we must seize in the fingers along with the skin as much as possible of the aneurism, and then below what we hold in our hand we push a needle having a double thread, and after it has passed through we cut the double, and thus with the two threads we bind the tumour on this side and on that, as we mentioned for staphyloma. If any apprehension be entertained from the falling off of the ligatures, we must push another needle entirely through, in the course of the first, having in like manner a double thread, and, cutting the noose into four pieces, we may bind the tumour. Or, having opened the tumour in the middle, after the evacuation of its contents, we cut away what is redundant of the skin, leaving what is secured with the ligatures, and applying an oblong compress soaked in wine and oil, we have recourse to the treatment by lint.

Commentary. Galen, we believe, is the first author who treats of aneurism. He states that he had known cases in which an aneurism had been occasioned by a wound of the artery at the bend of the arm in performing venesection. He relates the case of a cure having been accomplished by the application of a sponge with bandages. (Meth. Med. v, 7.) The passage quoted by our author is from his work De Tumoribus (11.)

Aëtius gives a most interesting account of aneurism. He states that it arises most frequently in women during labour, owing to the breath being violently retained, but that it may take place in any part of the body from a wound, as when an unskilful surgeon in opening a vein at the bend of the arm, opens an artery at the same time. It proceeds, he says, either from rupture or dilatation, and its contents are blood and spirits. The symptoms of an aneurism are a swelling of a smaller or larger size, without change of colour, free from pain, of a spongy softness, disappearing upon the pressure with the fingers, and returning again when they are removed; this last symptom being particularly characteristic of aneurism from dilatation. But when it arises from a wound the tumour is not equally soft, as the blood becomes coagulated. With regard to the treatment, he declares that aneurisms in the neck and head ought not to be interfered with; but when the disease arises at the bend of the arm he directs us to proceed in the following manner. In the first place having marked the course of the artery from the armpit to the fore-arm, we are to make a simple incision, three or four fingers’ breadth below the armpit along the inside of the arm, where the artery is most superficial; and having laid it bare and separated it from the surrounding parts, to seize the artery with a blunt hook and bind it with two ligatures; after which it is to be divided between them, and the wound filled with fine frankincense, and a suitable pledget of lint bound over it. The swelling at the bend of the arm may then be opened without any fear of hemorrhage. When the coagula have been cleared away the artery from which the blood was discharged is to be seized with a hook, secured and divided like the former; after which the wound is to be filled with fine frankincense, and suppuration promoted. (xv, 10.)

Albucasis treats of aneurism in the following terms. When an artery is divided, and the skin heals over it, a tumour frequently is the consequence, and the same thing sometimes happens from the wound of a vein. Aneurism of an artery is characterized by a deep-seated tumour in the situation of an artery, the swelling subsiding when pressed upon by the fingers, and being attended with a hissing sound. When it arises from the wound of a vein it is round and exposed. He adds, to open such tumours, especially if seated in the armpits, groins, and neck would be a fatal mistake. When the aneurism arises from dilatation of the artery, we are to make a longitudinal incision, and having dissected away the artery from the surrounding parts, to pass below it a needle armed with a double thread, and to tie the threads in two places as recommended in angiology. The part between the two ligatures is then to be divided and the blood evacuated. Suppurative applications are then to be made, until the ligatures fall out; after which suitable ointments are to be applied. If the disease arise from the opening of a vein, we are to grasp as much as possible of the tumour in the hand, to push a needle through it armed with a double thread, when the aneurism is to be firmly bound with the threads in the manner described in the operation for staphyloma. When danger is apprehended from the falling out of the threads, we are to introduce another needle armed with another thread under the whole tumour at the opening made by the first needle, and to tie the threads in four places. The aneurism is then to be cut in its middle, and its contents evacuated, when the superfluous skin is to be removed, and a compress dipped in wine and oil applied. (Chirurg. ii, 49.) The threads which he speaks of are meant to decussate one another like the letter Χ. This part of his description is somewhat obscure.

We need scarcely remark that the operation of Albucasis is exactly the same as our author’s.

Rhases borrows his account of aneurism from Antyllus and Paulus. The operation of Antyllus consisted of tying the artery above and below the tumour, and then evacuating its contents. (xiii, 7.) He states that when the disease occurs in the hams, groins, or neck, it is dangerous to meddle with it, but that when seated in the extremities it is easily cured. All the cases in which he had known the artery to be opened during the performance of venesection had terminated in aneurism, except one in which a cure was effected by compression. (Cont. xxviii.)

Haly Abbas directs us when an artery has been wounded in bleeding, to dissect away the parts about it, and having applied a silk thread on each side of the wound, to divide the artery in the middle. When an aneurism takes place he recommends a plan of treatment similar to that recommended by Albucasis. (Pract. ix, 45.)

Avicenna and Alsaharavius do not describe the operation. Alsaharavius directs us when an artery has been opened in bleeding at the arm, to attempt a cure by means of compresses and tight bandages. (Pract. xxix, 11.)

It will be perceived from the foregoing account of the practice recommended by Aëtius, that the ancient surgeons were aware of the advantages of securing the artery above the seat of the aneurism, as practised by the late Mr. John Hunter, and that they actually had recourse to two ligatures in the manner directed by Mr. Abernethy; but that they afterwards opened the tumour and evacuated its contents, not having yet learned from experience to trust to the absorbent powers of the system. It will likewise be remarked that carotid, axillary, and inguinal aneurisms were in ancient times abandoned as incurable; so that modern surgery may undoubtedly boast of having so far improved upon the practice of the Greeks and Arabians.

Sprengel gives an interesting history of the operation for aneurism. (Hist. de la Méd. xviii, 3.) According to him, John de Vigo was the first who conceived the idea of curing aneurism by compresses and styptics. This, however, is not exactly true, for, as mentioned above, Galen, Rhases, and Alsaharavius recommended compresses and bandages to prevent aneurism after the accident which most commonly gives rise to it.

SECT. XXXVIII.—ON BRONCHOCELE.

A large round tumour forms on the neck from the inner parts, whence it obtains the appellation of bronchocele, of which there are two varieties, the steatomatous and the aneurismatical. The aneurismatical we judge of from the symptoms of aneurism, and abandon as hopeless, like all other aneurisms which it is dangerous to meddle with, as is the case most especially with those of the neck, owing to the size of the arteries.

The steatomatous we operate upon like steatomes in general, distinguishing and avoiding the vessels, in the same manner as we described for strumæ.

Commentary. The surgical operation for bronchocele is described by Celsus. He says that its contents may be evacuated by caustics, but that the knife is a more expeditious process of cure. For this purpose he directs us to make a single incision down to the cyst, and to dissect it from the surrounding parts with the fingers. When its cyst cannot be removed he recommends us to destroy it with caustic medicines. (vii, 13.)

Aëtius and Albucasis give exactly the same account of bronchocele as our author.

The poet Juvenal alludes to the prevalence of bronchocele among the people at the foot of the Alps. (Sat. xiii, 162.)

Pliny attributes it to the corruption of the water. (xi, 37.)

Rolandus, Guy of Cauliac, and other of the earlier modern authorities, direct us to remove the tumour by means of two cross setons.

SECT. XXXIX.—ON GANGLION.

A ganglion is a round tumour of a tendon, arising from a blow or violent exercise, being formed most frequently about the wrists, ankles, and the parts about a joint which are much moved, but likewise in the other parts. It is attended with a swelling, which is free from discoloration, unyielding, and without pain, but if strongly pressed upon it has a dull feeling. It is not deep-seated, but takes its origin under the skin, and may be moved laterally, but cannot by any means be forced forwards or backwards. Those then which form in the legs, arms, and extremities it is not safe to cut out, for there is danger lest the part be mutilated. But those about the head or forehead we operate upon by dividing the skin with a scalpel, and if the tumours be small, seizing them with a flesh forceps and cutting them out by the roots. But if they are larger, we transfix them with hooks, and remove them by dissecting them from the skin, and uniting the lips with sutures, complete the cure by the treatment applicable to fresh wounds.

Commentary. We have treated of ganglion in the Fourth Book, and mentioned the principal authorities on the subject. Hippocrates and most of the others forbid ganglia to be opened. The hard tumour on the head, to which likewise he applies the name, may safely be removed in the manner described by our author. Albucasis repeats his directions. (Chirurg. ii, 50.)

Haly Abbas recommends discutients at first, and if these have not the desired effect we are to strike the tumour with a hard body so as to break its cyst. (ix, 10.)

Rhases recommends striking the tumour with a hammer, binding a piece of lead on it, and excision. When excision is practised he directs us to take pains to extirpate the cyst or tunic which surrounds it. (Cont. xxviii.)

SECT. XL.—ON VENESECTION.

Although the mode of performing venesection be known to everybody, yet, in order that no part of surgery may be omitted, and for the sake of its technical distinctions, it must not be overlooked by us. The first object then in venesection is the evacuation of a fulness of blood. It has been shown that fulness of blood is of a twofold nature: first, with regard to the strength, although the veins do not appear full, in which case those affected soon become weak and enervated, nature not being able to support, as it were, the load; and second, with regard to the containing vessels, as is seen in the parenchymatous parts, in which case, although the strength seems able to support the fulness without stress, the vessels sometimes burst, and a spitting of blood or some other discharge takes place. Plethora then as regards the strength may be ascertained from the heaviness upon the body; and plethora of the veins from their distension and from their appearing full. In both cases evacuation is indicated; and, therefore, if necessity require, you must bleed on the first attack of the disease, waiting only for the digestion of the food in the stomach, or the complete sanguification thereof in the liver. But if on any account venesection has not been had recourse to in the beginning, and has been postponed until after the seventh day, there will be no impropriety of bleeding even then when necessity requires it, and the strength does not contra-indicate. But when about to let blood it is necessary to ascertain that there be not a great obstruction of fæces in the intestines, and, if there be, the bowels ought first to be evacuated by an emollient clyster, lest the veins of the intestines suck in the putrid matter of the excrements. Those requiring the abstraction of blood from the presence of a disease we may bleed at any season, avoiding only the acme of particular paroxysms in fevers. But if it be a continual fever, the morning is by all means the fittest season for the operation. Those who require the evacuation of blood, not from the presence of any disease, but as a preventive, will find the spring the fittest season of the year. With regard to age, bleeding must not be practised before the fourteenth, nor after the seventieth year, unless some urgent necessity compel us. And upon the whole we must avoid bleeding those persons whose strength is reduced. In recent inflammations we must make the evacuation from the opposite parts, but in chronic from the adjoining. We abstract blood from many parts of the body, but more especially from the inner part of the elbow. But it is to be recollected that in general the artery lies below the inner vein called the alar; that below the middle one (median) there is a nerve; whereas the upper one, called also the humeral, is free from all risk. In diseases of the head we open the humeral, but in those below the neck, the alar. The median is applicable in both cases. Wherefore we must tie a narrow band around some muscular part of the arm, and having by friction of the hands upon one another produced the necessary fulness of the vein, we divide it transversely, but only along its breadth; for larger incisions than this are difficult to heal, whilst those which are very narrow occasion inflammations by obstructing the passage of the thicker fluids. When we expect to have to abstract blood again on the second, third, and sometimes the fourth day, we must divide the vein more obliquely, in order that by bending the arm the incision may be kept open and not heal speedily. Such is the opinion of Antyllus. The quantity of the evacuation must be determined by the strength of the patient and the magnitude of the disease. When, therefore, there is a humeral plethora, and the matter is in a state of inflammation, we are to make our evacuations to deliquium animi, provided the strength be firm, and the patient does not swoon from an overflow of the humour upon the stomach. Wherefore many at the commencement fall into deliquium animi before a sufficient evacuation has taken place, and, therefore, the deliquium must be judged of from the measure of the evacuation. If there is a necessity for much evacuation, and the strength is weak, we must husband the evacuation, and making the first abstraction in small quantity, bleed again, or even a third time, if required. We have recourse to general evacuation not only when the body is in a plethoric state (as Galen says), but on account of the magnitude of the affection, when the general system is in a moderate state with regard to the humours, as we do also in hemorrhage from the nose or elsewhere, when although the discharge do not proceed from plethora, we bleed from the opposite parts in order to produce revulsion; and so also in violent inflammations, as in colics and affections of the kidneys from calculi, ophthalmies, and other such acute and urgent attacks; for the heat and pain of the inflamed parts occasion a defluxion upon it, although the general system be free from superfluities. In such cases we must bleed more sparingly, proportioning the evacuation particularly to the age and constitution of the patient, and also taking into account the season, country, and habits of the person affected. When there is a strong inflammation near the vein which is opened, as in pleurisy and hepatitis, it will be most proper to wait the change of the blood in colour and consistence. Blood in inflammation is different from the natural, since being excessively heated, if it was formerly crude, it becomes ruddier and brighter; or if it was such before, it turns black from being over-heated. Yet we must not in every case wait for the change, but sometimes give over before this takes place; for two reasons, either from the weakness of the patient’s powers, which you may ascertain to have sunk by feeling the pulse (for you will find it either unequal as to strength and magnitude, or indistinct, the stream of the blood failing also indicates that the strength is sunk), or from the malignity of the inflammation; for sometimes it will not remit, but the constriction continues strong. But if none of these circumstances contra-indicate, and if the patient be in the vigour of age, we may wait until a change takes place, especially if the atmosphere be mild. But if the flow of blood stop before a sufficient evacuation has taken place (this happens from fear, deliquium animi, and coagulum, or too tight an application of the bandage), we must attend to each of these causes, rousing from deliquium with strong-scented things, slackening the bandage when too tight, and a coagulum may be dissolved by pouring in oil, or by rubbing it with the fingers. The rest of the apparatus for phlebotomy is known to everybody. But these things apply to venesection at the bend of the arm. When we would abstract blood from the forehead as for headache, having first used fomentations, we apply a bandage round the neck, placing a finger over the windpipe to prevent suffocation, and when the frontal vein is properly filled we divide it with the point of a lancet or scalpel. In the same manner we may open the external jugulars for chronic ophthalmy, producing a discharge of blood with the concave part of the scalpel. The vessels also below the tongue we open transversely for angina, but without the application of any bandage. Some also open in like manner the veins which appear in the great canthi, as for chronic affections of the head or eyes, in which cases they also sometimes rupture the vessels within the nostrils either by rubbing them with the extremity of a specillum, or by tickling them with rough substances. They also open those behind the ears for the affections about the head; and those about the top of the thighs, as in affections of the kidneys; and those in the extremities they also open, after by the application of the ligatures to the parts above, by friction in the case of the hands, and walking in that of the feet, the vessels having become distended with blood; in affections of the spleen opening the vessel in particular between the small and middle finger of the left hand, and in affections of the liver those of the right hand; for the evacuation of the extremities, being from a distance, occasions a more powerful revulsion. In ischiatic diseases, and those of the uterus, they open the vein in the foot above the inner toe.

Commentary. We have to regret that our limits prevent us from doing more ample justice to the sound and enlarged views of the ancient physicians on this subject, and we must be content with making a few desultory observations and giving a few extracts.

We have had occasion frequently to remark that Hippocrates practised venesection freely in various diseases. He has left no treatise, however, expressly on the subject.

Celsus says, that to let blood was no new discovery in his day; but that blood might be let with advantage in almost every disease was a discovery. He states it also as a recent discovery that children, old men, and pregnant women might be safely bled, the operation having been anciently proscribed in all these cases. Yet, notwithstanding the authority of Celsus, the prejudice against bleeding young and old persons seems to have generally prevailed, for it will be perceived, that our author, copying from Galen, forbids persons to be bled before fourteen and after seventy, except in urgent cases. However, Averrhoes mentions that his countryman Avenzoar had bled a child only three years old with great success; and relates further that he had known certain persons who had been bled at the age of eighty. Celsus properly directs us to judge of a patient’s ability to endure venesection from his strength, and not from his tender or advanced age. He also acutely remarks that there is a difference between a strong body and a fat, and between a lean and a weak; for that a lean body contains most blood, and a fat most flesh. (See also Arist. H. A. iii, 19.) Those, therefore, who are lean bear depletion best, and the corpulent suffer most from it. The strength of the body, therefore, is to be estimated from the veins rather than from the general appearance. When the nature of the disease indicates evacuation, and the strength appears ill fitted to bear it, he advises us first to give warning of the danger, and then to abstract blood; for, he adds, “satius est remedium anceps experiri quam nullum.” In general he forbids venesection when the stomach is loaded with impurities; and upon this rule of practice all the ancient authorities, we believe, agree with him. Thus, to give an example from the Arabians, Averrhoes says, our famous physician, Abumeron Avenzoar, states that venesection ought not to be had recourse to until the body is purged, for the veins being emptied of blood attract the crude superfluities. (Collig. vii, 1.) This rule of practice is now too little attended to. In general Celsus holds that the second or third day of a disease is the fittest time for abstracting blood. He forbids bleeding upon the very onset of a fever, which he says is enough to kill a man outright. Upon the whole he approves of letting blood as near as possible to the affected part. He admits, however, that venesection may sometimes act by producing revulsion. The operation, he remarks, although easy to a skilful person may prove dangerous when performed by an unskilful one, as a nerve or artery may be wounded. In securing the arm after the operation he directs us to bind on the wound a compress soaked in cold water. (ii, 10.)

Galen wrote three treatises on venesection, to which operation he was very partial. They are: De venesectione adversus Erasistratum; de venesectione adversus Erasistrateos in Româ; and de curatione per venæ sectionem. These works are deserving of great attention as containing many judicious observations and rules of practice, but which are delivered at so great length that we can scarcely venture even upon an abstract of them. His principles of treatment, however, are nearly the same as those of our author. He appears to have abstracted blood in great quantities. Thus he mentions having seen six lib. taken away in the course of a fever, and six heminæ at once in a case of hæmoptysis. Now the hemina being somewhat more than a half a pint, the quantity abstracted must have exceeded three pints. He strenuously inculcates that venesection proves useful by occasioning revulsion, and as a proof of this he instances the beneficial effects produced by opening a vein of the arm in cases of epistaxis. He practised bloodletting occasionally in cases of dropsy, as we have mentioned under that head. Bleeding from the arm he thinks prejudicial in cases of amenorrhœa, as it causes a determination of blood to the upper parts of the body, and, therefore, he directs us rather to bleed at the ankle. He agrees with Celsus that lean persons bear depletion better than such as are fat; and that venesection is not to be performed when there are undigested matters in the stomach. He states that persons in extreme heat or cold do not bear bleeding. He mentions that in bleeding from the basilic vein there is danger of wounding the artery, that a nerve lies under the median; but that the cephalic may be opened without danger.

Oribasius gives an interesting dissertation on venesection, principally condensed from the works of Herodotus, Antyllus, and Galen. (Med. Collect. vii.) Antyllus directs us when going to bleed at the elbow to apply a ligature two fingers broad round the arm, so as to produce a swelling of the veins; and remarks that they are mistaken who affirm that the same effect may be produced by applying the ligature below, for that the veins will not then swell, even when the arm is fomented. When going to bleed at the ankle he directs us to apply the ligature above the knee; to put the limb into hot water, and make the person walk about. When the blood does not flow readily, he advises us to slacken the bandage if too tight; or if the opening in the vein be covered with the skin, to turn the arm into all positions until the opening of the vein and of the skin correspond; and if it be too small, to enlarge it. When fear retards the flow of the blood it will be of advantage, he says, not to allow the patient to hear the sound of it. When it stops from deliquium animi he advises us to lay the patient in a reclining posture on a couch; to promote vomiting, and to rouse by tight ligatures to the extremities, and by aromatics. When a clot of blood obstructs the vein he directs us to squeeze it out, or to dissolve it with oil or vinegar. When coldness of the body, occasioned whether by the temperature of the air, or the nature of the disease, prevents the flow of blood, he recommends fomentations and frictions. When a piece of fat or flesh blocks up the opening of the vein, he says there is no remedy for it but to cut it out or push it aside. When the object is to produce a sudden depletion he directs us to make a large incision in the vein, but a small one when it is intended to procure revulsion.

According to Drs. Freind and Milward, Alexander Trallian is the first authority who recommends bleeding by opening the jugulars. As far as we know this statement is correct.

Aëtius’s account of this subject is similar to our author’s, but less copious. (iii, 10.)

Actuarius in like manner has many judicious remarks on venesection, which our limits prevent us from giving to the reader. He forbids venesection when any natural secretion is increased, and this is in general a very proper rule, although, as Galen and Avicenna remark, profuse sweatings are sometimes remedied by bleeding. Bloodletting, he says, is contra-indicated by crudities in the stomach, and a loose state of the bowels. (Meth. Med. iii, 1.)

Little additional information is to be gleaned from the Arabians. We have mentioned, however, that Averrhoes and Avenzoar approved of venesection at a later and earlier period of life than the Greeks permitted it.

Avicenna with his customary accuracy collects everything of importance which had previously been written on the subject, but makes hardly any addition to the ancient stock of information. We can scarcely venture upon an abstract of his important chapter on phlebotomy. We may just mention that as a general rule he approves of bleeding after any accident. He disapproves of bleeding both at the onset and the crisis of a disease. In constitutions requiring bloodletting he holds that spring is the best season for it. Even in cases in which there is a deficiency of blood, but there is congestion in some particular part, he permits blood to be abstracted, in order to produce revulsion, the patient’s strength being recruited afterwards by a nourishing diet. When the colour of the blood is dark, and it is thick in consistence, a larger amount is to be abstracted than when it is thin and of a light colour. He makes the important remark, that bleeding sometimes kindles up a fever. He forbids the bath immediately before the operation, and food or exercise immediately afterwards. When a piece of fat obstructs the flow of blood, he directs that it should be gently pushed aside, but not cut out. (i, 4, 20.)

No author, ancient or modern, has described the modes of performing venesection in all parts of the body more accurately than Albucasis. Bleeding from the jugular vein he describes in much the same way that it is now practised by veterinary surgeons, namely, by placing a sort of scalpel, bent at the point, which he calls fossorium, upon the vein, and striking the instrument with a hammer, or some such body. He gives drawings of variously-shaped lancets for opening the veins of the arm. (Chirurg. ii, 97.)

The reader is also referred to Haly Abbas for a copious account of the operation, and the circumstances under which it may be performed. It is contra-indicated, he says, when the bowels are loaded with vitiated fæces. He allows it to be performed even after seventy years of age, provided the patient be of a vigorous constitution. (Pract. ix, 2.)

Rhases, with admirable judgment, condenses all the information supplied by preceding authorities, and mixes it up with his own personal observations. He forbids us to give food immediately after bleeding, as the empty veins will absorb the chyle before it is properly digested, which will prove a pabulum of disease. For the same reason, he, like the others, forbids bleeding when the stomach is loaded with crudities, lest they should be absorbed, and carried over the system. In retention of the menses he directs us to open the saphena, or to apply a cupping instrument to the ankle. When the disease is an acute attack of inflammation, he recommends us to abstract blood fully from an opposite part, so as to procure revulsion; but when it is a chronic affection, he advises to take it from the part affected. (Contin. xxviii.) He enjoins, as a prudent precaution in bleeding a person who is intoxicated, to apply two bandages about the arm, and to have proper attendants to restrain the bleeding, which is often difficult to stop in such cases. (Ad Mansor. vii, 21.)

The veterinary surgeons practised bleeding freely in the treatment of the diseases of cattle. Vegetius, the great authority on this subject, mentions that many persons bled their cattle every year, in the spring. He adds, however, that the ancient and more prudent authorities disapproved of indiscriminate depletion. (Mulom. i, 22.)

SECT. XLI.—ON CUPPING.

We must not have recourse to cupping at the commencement of complaints, nor when the body is in a plethoric state, but when the general system has been evacuated, and when there is no defluxion any longer to the part, and especially when there is a necessity of removing, dislodging, and determining something outwardly. Dry cupping then dissipates flatulence, stops defluxions to the stomach, attracts blood to a part, and stops it again, when determined to a part, if applied to the opposite parts; and it also occasions a translation from the deep-seated parts to the surface, and on the whole produces a metastasis of the fluids, and an evacuation of the spirits. But cupping with scarifications facilitates the evacuation of the offending causes, which it manifestly brings from the deep-seated parts; for it produces the discharge not only of blood but of the other humours, and especially if applied with much heat. And if we wish to make the abstraction from parts that are fleshy, we must first scarify and then apply the cupping instrument; but if the part is not fleshy, we must first have recourse to dry cupping, and when the parts becomes swelled up, we scarify and apply the cupping instrument again. If we wish to make but a small evacuation we must be satisfied with one incision, but if we wish much we must make several. And if we apprehend that the contained blood is of a thinner consistence we will make superficial scarifications, but if of a thicker, deep-seated. When we wish to evacuate coagulated blood, occasioned by a blow, we must be regulated as to the depth of the incisions by the thickness of the skin above. Some have devised an instrument for this purpose, by joining three equal lancets together, so that by one application it may produce three incisions, but we consider it inconvenient, and use a simple lancet. Others have used cupping instruments of glass, in order that the quantity of blood which is evacuated may be seen; but those made of copper have a more powerful attraction, as being able to endure a stronger fire, whereas those of glass are apt to break. But such as draw out the blood by sucking with the mouth through horns, evacuate less, but do not dry, like those applied with fire. If necessary, when we are about to apply the cupping instrument, having placed the limb in an erect posture, we fasten it to the side; for if we apply the lamp above when lying, the wick falling upon the skin with the flame burns in a painful manner, whereas there is no necessity for this. Sometimes the size of the instrument is proportioned to the part on which it is applied; and on that account there is a great variety of cupping instruments with regard to smallness and greatness of size. For the same reason, those which are made with longer necks and broader bellies are possessed of a stronger power of attraction. We must avoid applying the cupping instrument near the breasts, for sometimes they fall into it, and swelling greatly, render the removal difficult, and in that case sponges out of hot water are to be applied round the cupping instrument, which make it relax. But if even with this it do not fall off we must perforate it.

Commentary. On this mode of abstracting blood, and of altering its determination, the records of ancient surgery are so full of information that our only difficulty lies in selection.

It appears that the father of medicine and his successors practised cupping. (De Articulis, 49, and de Medico, 6.)

Celsus mentions two kinds of cupping instruments, the one being made of horn, and the other of copper. Those of copper were open at one end and shut at the other. Those of horn had a larger opening at one end and a smaller at the other. A piece of cloth was set on fire and thrown into the copper one, and its mouth was then fitted to the body and pressed on until it fastened. In applying the one made of horn, the air was exhausted by sucking at the smaller end, which was then covered up with wax, and in this state it would fasten to the part. He remarks that when the part to which the instrument is applied had been previously scarified, blood is discharged, but otherwise nothing but spirits. He states that the principal use of the cupping instrument is to remove any local affection when the general constitution is sound. Upon the whole, he considers it to be a safer but less efficacious remedy than venesection. Cupping, he adds, is to be had recourse to in chronic diseases, in order to remove any corrupted matter which may be seated in a part; and in acute, when the strength will not allow of venesection. (ii, 11.)

According to Galen, cupping is useful after evacuation, but does not answer when there is plethora. In inflammation of the brain and its membranes, therefore, he forbids cupping at the commencement, and also in inflammation of other parts, until the defluxion is stopped and the general system has been evacuated; and states that the object of cupping in such diseases is to move and determine the inflammatory particles outwards. In general, he advises us not to apply the instrument to the part affected, but to the adjacent part, with the view of producing revulsion, de hirud. revuls. cucurb., &c. He likewise gives an interesting account of leeches. He recommends their tails to be clipped off when it is wished to abstract much blood by means of a few leeches. (Ibid.)

Oribasius is the ancient author who discusses this subject at the greatest length, and to him Paulus is principally indebted. He mentions that cupping instruments are made of glass, horn, or copper. Those of silver, he says, are to be rejected; those of copper are in most general use; those of glass answer best when we wish to see the quantity of blood that flows into the instrument; and those of horn are to be applied to the head because copper ones are difficult to remove; and besides, timid persons are afraid of the flame in such cases. Those which are made deep attract more strongly than such as are shallow; instruments of the latter description are to be applied to the head. Before using them he recommends us to warm the part with fomentations and cataplasms. Upon the authority of Herodotus he enumerates the beneficial effects which may be derived from cupping; such as evacuating the matters fixed in the part, diminishing inflammation, recalling the appetite, strengthening the stomach, determining to the surface, provoking menstruation, and so forth. (Med. Coll. vii.)

Aëtius gives a similar but less copious account of this subject. (iii.)

Actuarius forbids us to apply cupping instruments until after general evacuation, when, he says, they will be useful by producing revulsion of the noxious humours. He also approves of cupping for strengthening the stomach when it has lost its tone, and to discuss flatulence in the bowels. (Meth. Med. iii, 4.)

Albucasis gives a most circumstantial and interesting account of the methods of cupping every part of the body. He particularly recommends cupping the nape of the neck in affections of the brain and eyes. He gives a full account of dry cupping. He recommends it to be applied when the disease is seated in places which do not bear cupping with scarifications, such as the region of the liver and spleen, the kidneys, the bowels, and the joints affected with gout. In applying the instrument he directs us either to create a flame in it, or to fill it with hot water. He gives drawings of various instruments for cupping. (Chirurg. ii, 98.) He also treats fully of leeching, which, however, he recommends only in cases in which the cupping instrument cannot be applied. When the bleeding continues longer than is desired, he directs a piece of cloth soaked in cold water to be applied to the place, or if that does not prove effectual, styptics, such as galls, beans without their skins, and the like. When the leeches will not take, the place is to be smeared with fresh blood. When it is desired to make them drop off, powdered aloes, salts, or ashes are to be sprinkled upon them. (ii. 99.)

Haly Abbas gives an ample enumeration of the cases in which cupping is applicable. He recommends it particularly in such cases as do not admit of general bleeding, for ophthalmies, cynanche, and in an especial manner for amenorrhœa, when it is applied to the breasts.

The other Arabians, although some of them treat fully of this subject, especially Avicenna and Rhases, yet give little additional information. Rhases speaks of applying a glass or a cupping instrument to draw off the blood after leeching. He gives a full account of the different kinds of leeches. Before applying them, some, he says, smear the part with blood and some with milk. When they are too long of falling off he directs us to sprinkle salt upon their mouths. He recommends them to be kept in a vessel containing water herbs. (Cont. xxviii.) When it is wished to abstract more blood after the leeches have fallen off, Albucasis directs us to foment the part with hot water, to rub it, and apply a cupping instrument to it. When, on the contrary, it is wished to stop the discharge, Avicenna recommends us to apply galls, lime, or other astringents, to the part. For this purpose Albucasis likewise directs us to apply a mass of beans deprived of their skins.

SECT. XLII.—ON BURNING THE ARMPIT.

In dislocation at the joint of the shoulder, it sometimes happens that the head of the arm falls out over and over again, either from the prevalence of too much humidity, or because the way is paved to it by its frequent occurrence. In this case then we have recourse to burning. Wherefore, the patient being laid on his back, or on the sound side, the skin at the inner part of the armpit, where the dislocation mostly takes place, is to be stretched between two fingers of the left hand, or with hooks, and burnt with heated cauteries, of a slender and oblong shape, until the cautery, being pushed through to the other side, occasion the formation of two eschars at one application. And if the distance between them is considerable, having passed the head of a specillum through them, we make another eschar in the middle by burning down until the cautery reach the specillum. And Hippocrates wishes two other eschars to be formed on each side of the middle one at the same distance as they, so as to form a quadrangular figure. We must not burn deeper than the skin, because nerves, glands, and other substances, which may give rise to inflammation and disturbance, lie below. The treatment may be conducted by means of leeks applied with pounded salts, and the rest of the treatment of eschars. Afterwards we may use the hand cautiously.

Commentary. Hippocrates (as stated by our author) recommends this operation for preventing the recurrence of dislocation at the shoulder-joint: it is minutely described by him. (De Artic. xi.) Albucasis describes the operation, but it will be readily understood from our author’s account of it. (Chirurg. i. 27.) It is described in like manner by Haly Abbas. (Pract. ix. 73.)

SECT. XLIII.—ON PRETERNATURAL FINGERS, AND ON PERSONS HAVING SIX FINGERS.

Preternatural fingers are formed in the hand sometimes near the thumbs, and sometimes near the little finger, but rarely beside any of the others. Of preternatural fingers, some are wholly fleshy, and others have bones in them, and sometimes they have likewise nails. Of those having bones, some derive their origin from a joint, having a common articulation with some other finger; and some arise from the phalanx, and these have no motion. The others sometimes have motion. Now the excision of those which are fleshy is easy, for we cut with a scalpel the preternatural finger all through. But on those which have their origin from a joint the attempt is more difficult. Of those which arise from the phalanx we must first cut away the flesh all around to the bone, and as to the bone itself we either chop it through with a chisel, or remove it by sawing; and in the treatment we scrape and cicatrize them as mentioned by us with regard to the wounds of bones.

Commentary. Galen (de Diff. Morb. 4,) and Avicenna (Cant. i, 2,) allude to the preternatural growth of fingers.

Haly Abbas describes the operation in the same terms as our author. (Pract. ix, 39.) Rhases repeats our author’s description of the method of treatment, and also mentions that of Antyllus, which, however, is little or nothing different from our author’s. Thus, he directs us first to make an incision of the soft parts down to the bone, which is to be sawn across; the skin is then to be united, and the part treated with agglutinants. When the supernumerary finger grows from a joint he directs us to make the separation cautiously; and if it grows between two fingers, or contains a bone, he forbids it to be amputated. (Cont. xxiv.)

Albucasis’s account of preternatural fingers is evidently taken from our author. (Chirurg. ii, 91.) When there is a preternatural adhesion of two fingers to one another, he directs us to divide it with a scalpel, and introduce a pledget wetted in the oil of roses, or a thin plate of lead between them, until the parts heal. (Ibid.)

SECT. XLIV.—ON THE OPERATION OF BURNING FOR EMPYEMA.

The most effectual remedy which has been discovered for empyema is burning. Wherefore, the parts are to be burnt by applying the root of the long birthwort soaked in oil, so as to form eschars, one of which we must make between the junction of the clavicles, having stretched the skin upwards; and two small ones a little distance from the chin and remote from the carotids; two of considerable size below the mammæ, between the third and fourth ribs; two others between the fifth and sixth, inclining a little backwards; another at the middle of the sternum, and another above the mouth of the stomach, and three behind, one at the middle of the back, and two on each side of the spine, higher up than the eschar in the back, and not very superficial. Others, as Leonidas says, having passed a knobbed cautery, heated in the fire, through the interstice between the ribs to the abscess, have carried the burning down to the pus. Some have dared to operate upon them by making a transverse incision, or one a little obliquely in the skin, between the fifth and sixth ribs, then perforating with a knife the membrane lining the ribs, and thus evacuating the pus; but they and those who burn with iron to a considerable depth either occasion immediate death, the vital spirit being evacuated with the pus, or occasion incurable fistulæ.