SECT. I.—PREFACE TO THE SURGICAL PART.
Having divided the treatise on the surgical matters into what relates
to manual operations on the flesh, and the account of fractures and
dislocations of bones, we shall begin with what relates to the flesh,
observing there our accustomed brevity. Beginning therefore, again with
the upper parts, we shall first give an account of the operations on the
head, more particularly of the burning of the vertex.
* * * * *
COMMENTARY. This book contains the most complete system of operative
surgery which has come down to us from ancient times. We shall have
occasion also to refer frequently to Celsus, who, in the last two books
of his work, has treated of surgical operations with considerable
accuracy. Our author appears to have been wholly unacquainted with him;
but when did a Greek writer ever acknowledge himself under obligations
to a Roman? Haly Abbas, in the 9th book of his ‘Practica,’ copies
almost everything from Paulus. Albucasis gives more original matter on
surgery than any other Arabian author, and yet, as will be seen from
our commentary, he is indebted for whole chapters to Paulus. In the
‘Continens’ of Rhases, that precious repository of ancient opinions on
medical subjects, if there be any surgical information not to be found in
our author, it is mostly derived from Antyllus and Archigenes. As to the
other authorities, although we will occasionally have to explain their
opinions upon particular subjects, no one has treated of surgery in a
systematical manner; for even Avicenna, who treats so fully of everything
else connected with medicine, is defective in his account of surgical
operations; and the descriptions which he does give of them are almost
all borrowed from our author. The account of fractures and dislocations
given by Hippocrates and his commentator Galen may be pronounced almost
complete; but the information which they supply upon most other surgical
subjects is scanty.
SECT. II.—ON BURNING OF THE HEAD FOR OPHTHALMIA, DYSPNŒA, AND
ELEPHANTIASIS.
In ophthalmia, occasioned by a defluxion from above, and in dyspnœa,
produced by a redundance of a recrementitious humour which is sent from
the head down to the chest, and by lodging there proves injurious to the
parts contained in it, they burn the middle of the head in this manner.
Having first shaven the parts about the vertex, they apply cauteries
shaped like olive-kernels and burn the skin down to the bone, scraping
the bone after the falling off of the eschar. Some by burning even the
bone itself make a small scale exfoliate from it, in order to allow the
humours of the head to perspire and be evacuated the more readily; and
for this purpose they keep the ulcer open for some time and then allow
it to cicatrize. In treating elephantiasis some burn five eschars in
the head, one anteriorly above the part called the bregma; another,
below this, a little above the forehead, at the extremity of the hairs;
another, at the part called the occiput; two others at the parts called
the squamous plates, above the ears, one on the right side and another
on the left; and thus, by the removal of several scales, they procure
the evaporation and discharge of the collection of thick humours in the
deep-seated parts of the head, and prevent the sight from being injured.
They also apply another cautery on the spleen, in order to remedy the
prime organ in the formation of the melancholic humour by the eschar
formed in the skin.
* * * * *
COMMENTARY. See Hippocrates (de Visu); Aretæus (de curat. Morb. Chron.
i, 1); Celsus (iii, 23, and vi, 6); Cælius Aurelianus (Morb. Acut. i,
i, and Morb. Chron. i, 4); Aëtius (vi, 50); Actuarius (Meth. Med. iii,
2); Rhases (Cont. xxvii, 1, 24); Albucasis (Chirurg. i); Mesue (de Ægr.
Capitis); Avicenna (iii, 1); Haly Abbas (Pract. ix, 69); Avenzoar (I, 9,
17).
The use of the actual cautery in surgical practice is often alluded to
by the classical authors. See a collection of these passages in Dr.
Blomfield’s edition of the ‘Agamemnon’ of Æschylus (822.) Consult also
Gataker’s ‘Marcus Antoninus’ (v. 193); and Boissonade’s ‘Anecdota Græca’
(vol. ii, p. 311.) A very elaborate and sensible account of the use of
the cautery in the practice of surgery is given by Vegetius. (Malomed. i,
28.)
Hippocrates, or whoever was the author of the work referred to above,
applied the cautery to the head very freely in diseases of the eyes and
other complaints.
Aretæus directs us, in cases of cephalæa and epilepsy, to perforate the
bone as far as the diploe, and afterwards to burn it until the dura mater
is separated from the bone. He admits, however, that it is a harsh remedy.
Celsus directs us, as an ultimum remedium in epileptic cases, to form
issues with a burning iron upon the occiput and at the juncture of the
first vertebra with the head.
Aëtius speaks of burning the head in nearly the same terms as our author.
He directs us to avoid the muscular parts. Actuarius does the same.
Cælius Aurelianus, however, disapproves of this practice in cases of
cephalæa and epilepsy.
The Arabians were even more partial than the Greeks to burning the
head in these and other complaints. See in particular Albucasis, whose
description is very minute. In cases of cephalæa he recommends the
cautery to be applied to the occiput, but cautions against touching the
bone lest it produce violent pain. He directs us to be careful to avoid
muscles, nerves, and arteries. Avicenna, Rhases, Mesue, and Haly Abbas
recommend the operation, in the most unqualified terms, as a powerful
remedy in the cases mentioned by our author. Avenzoar, however, condemns
the unguarded application of the burning iron to the head.
Guido de Cauliaco recommends the cautery in cases of hydrocephalus (ii,
2, 10). Brunus also applied it for hydrocephalus, (ii, 17.) But see in
particular Lanfrancus (III, iii, 18.)
Fabricius ab Aquapendente states that from the most ample experience he
had ascertained the good effects of applying the cautery over the sutures
of the skull in various complaints, especially asthma, consumption, and
all cold defluxions from the head to the chest. He gives a full account
of the operation. (Œuvres Chirurg. ii, 1.) But see De Haën. (Rat. Méd. t.
iii, p. vi, c. 6.)
SECT. III.—ON HYDROCEPHALUS.
The hydrocephalic affection is so named from the peculiarity of the
fluid, it being of a watery consistence. It occurs in infants, owing to
their heads being improperly squeezed by midwives during parturition,
or from some other obscure cause; or from the rupture of a vessel or
vessels, and the extravasated blood being converted into an inert fluid;
or from rarefaction, the matter exuding and lodging between the skin and
the pericranium. For the fluid is formed either between the pericranium
and the skin, or between the pericranium and the bone, or between the
bone and the meninx. In those cases, therefore, in which the fluid is
formed between the skin and the pericranium, there is a soft tumour, all
of one colour, and without pain, accompanied with an elevated swelling,
having only a thin substance intervening between it and the fingers,
readily yielding and again resuming its form. When it is seated between
the pericranium and the bone, all the other appearances are the same,
but the swelling is harder, yields more slowly, seems to be felt through
thicker substances, and is more painful. When the fluid is seated between
the meninx and the bone, there will still be a swelling, but not of so
yielding a nature, nor so easily felt, only it yields to the application
of strong pressure; for the bones of infants, being recently formed, are
of a more yielding nature; and this is more especially the case when,
owing to enlargement of the sutures, the fluid escapes outwards. This
is readily ascertained from the circumstance, that by pressure of the
fluid it retreats to the deep-seated parts. In such cases the pain is
greater, the whole head is distended, the forehead projects outwards, the
eyes are fixed and shed tears frequently. In these cases we reprobate
any surgical interference, although some remove a piece of the bone by
trepanning, as will be described in the section on fractures of the
bones of the head. But if the fluid be formed between the skin and the
pericranium, and the swelling be small, we may make one transverse
incision through the middle. But if the fluid is seated between the
pericranium and the bone, and the tumour is large, we make two incisions
intersecting one another in the middle; or if it is still larger we
may make three imitating the form of the Greek letter Η. After the
operation, having evacuated the fluid and applied suitable compresses,
we bind it up, and soak it with wine and oil until the third day; after
which, having loosed the bandages, we may cure it by the application of
pledgets; or, if the bone is long of incarnating we may scrape it lightly.
* * * * *
COMMENTARY. See Hippocrates (de Morbis, ii, 15); Celsus (iv, 2); Aëtius
(vi, 1); Galeni (ut aiunt) Isagoge; Antyllus (apud Nicetam); Avicenna
(iii, 1; iv, 2); Avenzoar (I, 9, 17); Albucasis (Chirurg. ii, 1); Haly
Abbas (Pract. ix, 16); Rhases (Contin. xxvii; and ad Mansor. ii, 25.)
Hippocrates gives an interesting account of water in the brain, the
symptoms of which, as described by him, are pain in the opening of
the head and temples, rigor, fever, double vision, impatience of
sounds, vomiting of phlegm, &c. He recommends emetics, caputpurgia,
and afterwards purgatives. He also makes mention of hellebore and
sternutatories, and even directs us to perforate the skull, or, in other
words, to trephine it.
Celsus describes only the hydrocephalus externus. He recommends us to
use stimulant applications to the head, such as sinapisms, and if this
treatment does not succeed, he directs us to use the scalpel. The case,
otherwise, is to be treated like dropsy, with sudorifics, exercise,
friction, and diuretics.
Our author’s description is mostly abridged from Aëtius, who gives an
extract from Leonidas. Even when the fluid is collected within the skull
he directs us to let it out, provided it is in such quantity as to
occasion a separation of the suture.
The account of the disease, given by Antyllus, in the Collection of
Nicetas is nearly the same as our author’s. He speaks favorably of the
operation only in cases in which the water is collected externally to the
bone.
In the ‘Isagoge,’ generally ascribed to Galen, it is directed, when the
water is collected below the skin on the pericranium, to evacuate it by
making two or three straight incisions; and when immediately below the
bone, to perforate it; but the case in which the fluid is seated between
the membrane and the brain is pronounced to be utterly incurable.
Rhases borrows his account mostly from Antyllus and our author. Upon his
own authority, however, he recommends bandages with compresses. He also
approves of applying the actual cautery over the sutures. He further
recommends friction and burning the temporal veins.
Avicenna borrows freely from Aëtius and our author, and supplies no new
views of practice. When water is collected in the anterior ventricles
of the brain, Avenzoar, although in general no advocate for the actual
cautery, directs us to apply it over the sutures.
Albucasis says that he had only known hydrocephalus internus in
infancy, and in every case it had proved fatal. However, he describes
the operation of evacuating the collection in much the same terms as
the Greeks. He warns the operator to avoid wounding an artery, lest
the evacuation of blood should occasion immediate death. Alsaharavius
mentions the frequent occurrence of the disease in sheep. Haly’s
treatment is the same as our author’s.
The hydrocephalus externus is now scarcely mentioned, and the existence
of such a case has been even questioned. Van Swieten allows the reality
of it, but says that it is of rare occurrence. (Comment. 1217.) We are
disposed to think that the cases described by our author must have been
collections of lymph, or pus occasioned by external injuries forming
between the integuments and the bone. Modern pathologists admit the
reality of collections of serum and pus between the bone and the dura
mater. We may further mention that the earlier modern authorities approve
of the cautery in the present case. See Guido de Cauliaco (ii, 2, 10.)
The late Baron Larrey was a decided advocate for the application of
moxa in this complaint. Henricus Regius directs us to evacuate the
water slowly by making a small incision and introducing a silver
canula. (Animad. Medic. 13.) Though recent experience does not give much
encouragement to the operation, it sometimes happens that it is attended
with success.
Fabricius gives the same account of these cases as the ancients. (Œuv.
Chir. ii. 22.)
SECT. IV.—ON ARTERIOTOMY.
In chronic defluxions of the eyes, and in the affection of vertigo, we
are in the practice of dividing the arteries behind the ears. Having,
therefore, shaven the hind part of the head, and marked with the fingers
the position of the artery, which is easily discovered by its pulsation,
and then having marked out the line of an incision two fingers in length
with black ink, we cut down to the bone. When this does not succeed we
must measure a distance of three fingers’ breadth from the ears, and
then operate by making a transverse division of the artery until blood
flow _per saltum_, and the instrument strike the bone. After a moderate
evacuation of blood, the pericranium is to be divided, lest it become
inflamed from the distension; and having scraped the bone we apply a
wedge-like tent of linen to the wounds, and accomplish the cure by
pledgets. But if, after all, the bone remain bare, we must have recourse
to scraping it in like manner.
* * * * *
COMMENTARY. Our author’s description is mostly abridged from Aëtius (vi,
90), who copies from Severus.
This operation is minutely described by Albucasis. (Chirurg. ii, 2.) He
directs us to shave the head, and rub the parts behind the ears with a
rough cloth until the arteries become visible. The course of the vessels
is to be marked with ink, and they are to be divided with a sharp
scalpel, the incision penetrating down to the bone. He says, however,
that if the surgeon choose, he may introduce the scalpel below the
vessel, and cut upwards. The length of the incision is to be two fingers’
breadth. Blood, he remarks, springs from an artery per saltum. About six
ounces, more or less, may be taken.
The operation is likewise mentioned by Avicenna (Cantic. iv,) and
Averrhoes (in Cantic.); by Rhases (ad Mansor. vii, 21); and is described
in exactly the same terms as our author’s by Haly Abbas. (Pract. ix, 4.)
SECT. V.—ON ANGIOLOGY, OR SECTION OF THE TEMPORAL VESSELS, AND ON BURNING
THE SAME.
In hemicrania and in chronic or acute defluxions, when the eyes are
affected with a hot and acrid defluxion, so as to occasion heat of the
temporal muscles with swelling, every one approves of angiology for the
cure of them. Having, therefore, first shaven the hairs of the temples,
and noted the part with our fingers, we must use warm fomentations, and
apply a bandage round the neck; and, when the vessels become visible,
having marked their course with ink, we must draw the skin aside with our
left hand or the fingers of an assistant, and make a superficial incision
along the vessel; then cutting quite through, and stretching the parts
with hooks, and exposing the vessel by means of the instruments used in
operations on membranous parts, we must raise it up when it is separated
all around. If it be small, having stretched and twisted it with a blind
hook, we may divide it through, so as to be able to seize upon part of
it. But if it be large, we must apply a double ligature under it with a
needle, either a piece of raw flax, or some other strong thing; and, in
the first place, making a straight opening into the vessel with a scalpel
used in venesection, and taking away a moderate quantity of blood, we
must tie the ligatures at both extremities of the exposed vessel, and
cutting the intermediate part, we may remove it either immediately, or
at the time of loosing the dressings. Some, without dividing the vessels
at all, burn them to a sufficient depth with burning-irons shaped like
olive-kernels. After the operation we must use pledgets of dry charpie,
and put on an oblong compress (_splenium_) with a bandage. After the
removal of these dressings, we must accomplish the cure by incarnating
powders, applications on pledgets, and cicatrizing remedies; the threads
and ligatures having previously dropped out from putrefaction.
* * * * *
COMMENTARY. The author of the Hippocratic treatise (de Morbis in Homine,
c. 49) recommends us to open the temporal veins for obstinate headaches;
and, if this does not effect a cure, he directs us to burn them.
Celsus describes both operations very distinctly. He directs us to apply
a ligature round the neck, so as to make the vessels swell, and then,
having marked the course of the vessels with ink, to remove the ligature,
and open the veins. When a sufficient quantity of blood is discharged,
the part is to be burnt with slender irons cautiously about the temples,
for fear of wounding the temporal muscles, but more boldly between the
forehead and the vertex, so as to produce exfoliation of a scale of the
bone. He also speaks favorably of cutting the vessels in the temples and
upper part of the head. (vii, 7.)
Aëtius gives nearly the same description as our author. The part which
relates to the burning is taken from Leonidas (vii, 93.)
Angiology is briefly described in the ‘Isagoge’ of Galen. A minute
description is given by Albucasis. He recommends the operation as a
remedy for inveterate cases of hemicrania, catarrh, and cephalæa. He
directs us to shave the hairs about the temples, and to continue to do
so until the artery appears. It is known, he remarks, by its pulsation.
When it does not readily make its appearance, he recommends us to apply a
cloth round the patient’s head, and to rub the place with a rough towel.
Then, he says, take a scalpel, and make an incision so as to lay bare
the artery, which seize with a hook, and separate from the surrounding
parts, and if the vessel is small, cut out a proper piece of it, and
allow from three to six ounces of blood to flow. But if the vessel is
large, bind it in two places with strong silk threads, or strips of
raw cloth (_alhohod_), so that it may not drop out before the wound is
consolidated. Then cut out the part between the two ligatures. He directs
us to dress the wound as recommended by our author. He also mentions the
operation of burning the temporal veins as being one that is less serious
than angiology. (Chirurg. ii, 3.)
Jesu Haly’s account of the operations of tying and burning the temporal
arteries is very distinct. (iii, 25.)
Haly Abbas describes the operations of cutting out and burning the
temporal vessels in nearly the same terms as our author. (Pract. ix, 70.)
Rhases mentions that the celebrated Archigenes recommended the temporal
veins to be burnt for epilepsy. (Contin. i.)
The veterinary surgeons burnt the temporal veins in diseases of cattle.
See Vegetius (Mulomed. ii, 16.)
We are inclined to think that it was the temporal veins and not the
arteries which were cut out and burnt by the Greek surgeons in this
operation. It will be seen, however, that the Arabians direct us to cut
out a portion of the artery; at least this is sufficiently clear in the
description of Albucasis, for he states decidedly that the vessel to be
secured will be recognized by its pulsation, and he further recommends
us to apply beforehand a ligature about the head, and not about the neck
as directed by our author, whereby it is obvious that the arteries and
not the veins would become distended; these observations apply also to
Jesu Haly’s description. As Celsus, like our author, directs the ligature
to be applied round the neck (cervix ante modice deliganda est), we may
suppose that his operation related to the veins. From his using the word
venæ indeed no inference can be drawn, as he applies it indiscriminately
to arteries and veins. We are at a loss what to determine respecting
the description given by Haly Abbas, for although the vessel that is
secured be called arteria, the ligature or strip of cloth is directed
to be applied round the collum. Where the mistake lies in this case we
cannot venture to conjecture, and leave it to be found out by some person
who has access to the MS. of the original. For our part we may exclaim
with a celebrated German scholar,—“Felices sæpe prædicavimus Bochartum,
Plempium, Celsium, Hydium, Casirium, quibus usus codicum Arabicorum
concessus erat.” (Sprengel, Rei Herbariæ Historia, i, 239.)
Fabricius ab Aquapendente describes the operation as relating to the
veins (Œuv. Chir. ii, 3.) Tagliacozzi, however, seems to refer it to
the arteries. It thus appears that there is a good deal of uncertainty
regarding this ancient operation.
SECT. VI.—ON HYPOSPATHISMUS.
This surgical operation derived its name from the kind of instrument
used in it. We have recourse to it when a copious and hot defluxion
is determined to the eyes. The face is ruddy, and about the forehead
there is a sensation as of worms or ants passing along it. Having
therefore first shaven the hairs about the forehead, we must permit the
lower jaw to move, and avoiding the place where the temporal muscles
are seen to act, we are to make three straight and parallel incisions
on the forehead, each having the length of two fingers, and descending
to the bone, and being at the distance of about three fingers’ breadth
from one another. After the incision we apply the instrument called
hypospathister, and extend the division from the left temple to the
middle incision, dividing all the intermediate substance along with the
pericranium; then we push a spatula from the middle one to the rest, and
applying the point of a sharp-pointed knife to the first division, so
that its sharp side may be turned to the flesh within the skin, and the
blunt one to the bone, we push it as far as the middle division, cutting
through all the vessels which descend from the head to the eyes, but not
comprehending the external skin. And again we push it from the middle to
the last incision, cutting through the vessels in like manner. After a
moderate evacuation of blood, having squeezed out the coagula, and made
three twisted tents, we are to put one into each division, and applying
a compress soaked in water, we must secure it with a bandage. Next day
we bathe not only the ulcers, but likewise the temporal muscles, and
the ears with wine and oil, on account of the inflammation; and on the
third day having removed the dressings, we must have recourse to copious
affusion, and afterwards complete the cure suitably with tents out of
basilicon dissolved in rose-oil.
* * * * *
COMMENTARY. See Aëtius (vii, 92); Albucasis (Chirurg. ii, 4); Haly
Abbas (Pract. ix, 7.) This operation is better described by our author
than by any of the others. Celsus, although he describes several grave
operations for the relief of defluxions on the eyes, makes no mention of
it. Aëtius barely alludes to it in general terms. It must have been a
very formidable operation, and for that reason perhaps, has been entirely
abandoned in moderate times. Even Albucasis speaks of it as being an
operation which was performed by the ancients; from which language we may
suppose that it had been given up in his time. His description of it
is evidently taken from our author. Haly Abbas describes the operation
very distinctly. Three longitudinal incisions at the distance of three
fingers’ breadth from one another are to be made in the forehead down to
the bone, then a knife, or some such instrument, is to be introduced so
as to divide the parts between the longitudinal incisions, sparing only
the outer skin.
SECT. VII.—ON PERISCYPHISMUS.
When many deep-seated vessels send a copious defluxion to the eyes,
we have recourse to the operation called periscyphismus. These cases
are attended with such symptoms as these: in the first place you will
find the patient’s eyes atrophied and small, weak of sight, the canthi
corroded, and the eyelids ulcerated, the hairs falling off, with a
discharge of very thin, acrid, and hot tears; there is a deep-seated pain
in the head of an acute and violent character, and there is frequent
sneezing. Having first shaved the head as aforesaid, and avoiding the
place where the temporal muscles play, we make a transverse incision,
beginning at the left temple and ending at the other. The incision must
have its terminations where there are no muscles, its direction being a
little above the forehead, and we must avoid the coronal suture. Leonidas
directs the incision to be made along the middle of the forehead. When
the bone is laid bare we may keep the parts asunder with tents and
plenty of pledgets, and bind the extremities of the division; and, as
we formerly stated, bathe with wine and oil. After loosing them, if the
inflammation is on the decline, we may scrape the bone until it begin to
incarnate, and accomplish the cure by a mode of practice calculated to
promote incarnation, using the incarnative powders; among which is that
containing of wheaten flour, p. ij; of colophonian rosin, p. j; and that
called the cephalic, and those incarnatives prepared from pumice-stone.
For, when the skin is thickened by a dense cicatrix, and the mouths of
the vessels constricted, the defluxion is prevented from being determined
to the eyes as before.
* * * * *
COMMENTARY. See Aëtius (vii, 93); Pseudo Galen (Isagoge); Albucasis
(Chirurg. ii, 5); Haly Abbas (Pract. ix, 18.)
It is evident that this operation is neither more nor less than a
complete division of the integuments of the head from temple to temple;
of course it must even have been more dangerous than the operation
treated of in the last section. Aëtius, Haly Abbas, and Albucasis
describe it in the same terms as our author. The periscyphismus and
hypospathismus are briefly noticed in the ‘Isagoge.’
Fabricius ab Aquapendente treats of these operations among those of the
ancients, _qui ne sont plus en usage_ (Œ. C. ii, iv); even Tagliacozzi
speaks of them as being cruel and dangerous. However, a surgical
operation, similar in principle, called the “long issue of the scalp,”
is still practised in certain hospitals of Great Britain. See the
‘Transactions of the Provincial Association,’ (vol. xi.)
SECT. VIII.—ON SUTURE OF THE UPPER EYELID, AND OTHER MODES OF OPERATING
FOR TRICHIASIS.
Distichiasis is a preternatural growth of hairs, superadded to the
natural order of hairs of the eyelids; and derives its origin from a
defluxion, when there happens to be a flow upon the part of a humour
which is not pungent or acrid; for that which is more acrid, saltish, or
otherwise pungent, when it lodges in these parts, consumes the natural
series of hairs. For this state then we sometimes have recourse to the
suture of the upper eyelid, and sometimes also for phalangosis when the
eyelid inclines inward, the phalanx or row of the hairs being inverted;
and sometimes for relaxation of the eyelid, when the natural row of hairs
hurts the ball of the eye. Having placed the patient on a seat, either
before us or on the left hand, we turn the upper eyelid outwards, and,
if it has long hairs, we take hold of them between the index-finger and
thumb of the left hand; but if they are very short we push a needle
having a thread, through the middle of the tarsus from within outwards;
then stretching the eyelid with the left hand by means of his thread,
with the point of a scalpel held in the right hand, having folded out
the eyelid and everted it, behind the thread we make the under-incision
within the hairs which irritate the eye, extending from the larger
canthus to the smaller, along the tarsus. After this subsection, having
extracted the thread, and putting a small compress under the thumb of the
left hand, we stretch the eyebrow upwards. Then arranging other small
compresses on the canthi at the extremities, we direct the assistant
who stands behind to stretch the eyelid by means of them. Then by means
of the scalpel used for sutures we make the first incision, called the
veruted (shaped like a verutum or short dart) a little above the hairs,
which are in their natural state, extending from canthus to canthus, and
penetrating only the depth of the skin; and afterwards we perform the
incision called the lunated, beginning at the same place as the former,
and carrying it upwards to such a height as to comprehend the whole
redundant skin, and ending in like manner as it did. Thus the whole skin
comprehended within the incisions will have the shape of a myrtle leaf,
of which portion, having perforated the angle on the right hand with
a hook (tenaculum), we dissect away the whole skin: then washing away
the clots with a sponge, we unite the lips of the incision by three or
four sutures, beginning at the middle, and passing the needle itself
through the under-section. The thread should be made of wool; and having
cut away the superfluity of the thread, not close to the sutures, but
so as to leave a superfluity of three fingers’ breadth, we stretch
this remainder along the forehead and fasten it by means of any of the
agglutinative plasters. But the hairs of the eyelid are to be freed from
the sutures with the point of a needle. Such is the common and safe
mode of performing this surgical operation. Some avoid the dissection
of the skin, and therefore after the under-incision, having stretched
the redundant skin by means of the forceps used in operations on the
eyelids, they cut it off with a scalpel, and apply sutures as described
above. But if the irritation from the hairs is produced only by a part
of the eyelid, it will be proper to confine the operation to that part.
Then soaking the compresses in oxycrate, and laying them on the part,
we secure them with bandages, continuing to moisten the dressings with
diluted oxycrate until the third day; after which we remove them, and
cutting away the superfluous parts of the threads, we anoint the eyelids
either with saffron, glaucium, or some of the anti-inflammatory collyria,
such as that formed of saffron and roses. But if the sutures inflame,
we apply some one of the softening plasters, and soothe the eye by an
injection of eggs mixed with milk. When the ligatures slacken we cut and
extract them. I know a certain person who having made the dissection of
the skin of the eyelid, as mentioned above, did not have recourse to
sutures, but effected the cure with a healing ointment. For when the
wound cicatrised, the eyelid being somewhat contracted, forced the hairs
to incline outwards. In like manner, another person not practising the
dissection of the eyelid, nor the two external incisions, but only making
the under-incision, stretched with his fingers or by a hook the fold of
the eyelid, two reeds or plates of the same length as the eyelid, and
as broad as for venesection, he twisted a ligature round it at both its
extremities; and thus the whole skin behind not being nourished, and on
that account being deprived of life, fell off within ten, or at most
fifteen days along with the reeds or plates, so as to leave scarcely any
scar.
* * * * *
COMMENTARY. On suture of the upper eyelid, and other methods of operating
for distichiasis, see Hippocrates (de Victu acut. 66); Aëtius (vii, 71,
72); Celsus (vii, 7); Albucasis (Chir. ii, 11); Rhases (Divis. i, 30; ad
Mansor. ix, 26; Contin. ii, 3); Avicenna (iii, iii, 3, 32); Avenzoar (i,
8, 6); Serapion (ii, 7); Mesue (ii, 18); Jesu Hali (ii, 10); Canamusali
(vi, 26); Haly Abbas (Pract. ix, 19); Vegetius (Mulom. ii, 15.)
The description of the operation given by Aëtius from Leonidas being
nearly the same as that described by our author, we shall confine
ourselves to an abridged account of it, and merely make a few remarks
to illustrate the description of Paulus. In order to facilitate the
operation, he recommends the operator to have two assistants instead of
one, as directed by our author. He also recommends him, in the first
place, to mark with ink the portion of skin which requires to be cut
out. He then directs him to make the under-incision, by which he seems
to have meant an incision within the ciliary hairs along the tarsus, and
extending from canthus to canthus. He recommends it to be made pretty
deep, and even in certain cases suggests the propriety of making two
under-incisions, one as above described within the ciliary hairs, in
order to relax the tarsus; and the other upon the preternatural hairs.
He next directs first a transverse incision to be made along the eyelid
above the ciliary hairs, and then a lunated one beginning and ending like
the other, after which the skin, thus separated, is to be dissected out.
He recommends the edges to be united by means of five sutures, one in
the middle and two at each extremity of the incisions. The other steps
of the operation are exactly the same as those described by our author,
and cannot be misunderstood. Hippocrates describes an operation for
trichiasis, which Heister thought the same as that recommended by Aëtius,
but the description is so obscure that we must confess our inability to
explain it.
Celsus describes three methods of cure for trichiasis. 1. By burning the
roots of the hairs. 2. The anabrochismus, which will be explained in the
13th section. 3. The anarrhaphè or suture, as described by Aëtius and our
author. As the steps of the operation described by him are almost exactly
the same as those of Aëtius, we need not dwell upon the explanation
of them. Lest, however, there should be any misapprehension about
the under-incision, we shall give his directions about it in his own
language: “præter hoc, in superiore palpebrâ sub pilis ipsis incidenda
linea est ut ab inferiore parte diducti pili sursum spectant; idque si
levis inclinatio est, solum satis est.” Instead of five sutures, as
directed by Aëtius, he recommends only three.
Albucasis states that there are four modes of curing trichiasis. 1. By
the actual cautery. 2. By the potential cautery. 3. By incision and the
suture, which operation he describes at great length. He directs us in
the first place to evert the eyelid, either by taking hold of the ciliary
hairs, or by passing a needle, armed with a hair, through the tarsus, and
raising the eyelid with it. He then, like the others, directs us to make
the under-incision within the ciliary hairs, from the greater canthus to
the smaller, to cut out the redundant skin of the eyelid, and unite the
surfaces with sutures. In short, his operation is exactly the same as our
author’s. He mentions, however, another method of making the incision by
elevating the redundant fold of the skin with hooks or a trident, and
cutting it off with a pair of scissors. 4. The fourth method consists of
making the under-incision, as in the last operation, and then twisting
the redundant skin firmly about reeds or small pieces of wood until it
mortifies: after which the wound is to be cured upon general principles.
Serapion’s account of the operation is defective, and need not be
particularly noticed. Canamasuli directs us to cut out the hairs and burn
the part with a cautery of gold.
Avicenna merely mentions, in very general terms, that the cure may
be accomplished by agglutinative applications, by the cautery, or by
excision.
Mesue briefly describes four modes of cure: 1. By means of agglutinants.
2. By passing a needle, armed with a hair, through the tarsus, as will
be explained in the 13th section. 3. By plucking out the hairs and
cauterising the part. 4. By applying medicines calculated to prevent the
renewal of the hairs after they have been plucked out.
Jesu Hali’s description of these operations is very circumstantial; he
speaks of cutting out the piece of skin with a fine pair of scissors.
Rhases states that the cure of trichiasis may be effected by burning
the roots of the hairs with a red-hot needle, or by making the excision
of the superfluous skin of the eyelid. He also makes mention of the
treatment by agglutinants. In his great work, the ‘Continens,’ he briefly
notices the four operations described by Albucasis. He appears to have
approved very much of the burning. He also describes the operation with
the reeds or pieces of wood.
Avenzoar mentions four methods of curing inversion of the ciliary hairs.
1. By everting the upper eyelid and securing it with agglutinants until
the roots of the hairs have been cauterised with a rod of gold. This
method he does not approve of. 2. By extirpating the offending hairs and
applying the blood of a bat to the places from which they were torn.
3. By making an excision of the superfluous skin of the eyelid, and
afterwards applying sutures. He alludes, we suppose, to the operation of
Aëtius. 4. By twisting the skin about small reeds or tubes, in the manner
described by our author and Albucasis.
Haly Abbas accurately describes the four following operations: 1. By
excision and the suture. He directs the under-incision not to be made
deep. 2. By twisting the hairs into the fold of a silk thread and
flattening it to the forehead. 3. By the actual cautery. 4. By the
potential cautery.
We will give the description of the veterinary surgeon, Vegetius, in his
own words: “Non longe a pilis ab interiori parte scalpello plagam dabis
in cute palpebræ, post forficibus per longum ad mensuram oculi fasciolam
præcides, et impositis fibulis consucs palpebram foris versus, ut oculus
sine deformitate recipiat visum et gratiam naturalem.”
It is to be remarked that Albucasis, Jesu Hali, and Vegetius speak of
cutting out the superfluous skin of the eyelid with a pair of scissors,
as was done by Scarpa.
All the ancient operations for trichiasis are described by Guido de
Cauliaco (vi, 2.) The mode of cure by twisting the skin about small reeds
until the parts slough is still generally practised in China. The Chinese
surgeons grasp the fold between two slips of bamboo, which being tightly
fastened at their ends perform the office of a ligature.
SECT. IX.—ON BURNING OF THE EYELIDS BY MEDICINES.
The burning of the eyelids with caustic medicines was reprobated, in a
word, by all the ancients, lest the acrimony of the application should
prove injurious to the eyes; and because when the burning was carried
to too great an extent the affection called lagophthalmos was produced,
in which case the eyelids cannot be shut, and the vision is apt to be
injured by everything that comes in the way. But since many who suffer
from the irritation of the ciliary hairs are not able to endure even
the name of the operation by suture, we are compelled from necessity,
against our will, to have recourse to burning by medicine. The following
is a composition of that kind: of quicklime, p. ij; of Gallic or common
soap, p. ij; and some add of aphronitrum, p. iv. These things being
pounded with strained ley, or soap ley, or some other ley, as that of
figs or of oaks, and being mixed with the urine of a young man not come
to maturity, we apply to the eyelid, upon the knob of a specillum, the
part touched having the shape of a myrtle leaf; and we burn to the extent
comprehended in the operation by suture. The skin being burnt at the
first application, we remove so much of it with a sponge, and apply the
medicine a second time, allowing it to remain until the part blacken;
and if it does not blacken we apply it a third time. When the skin is
blackened and the eschar also formed, we must clean away the medicine and
have recourse to bathing and washing until the eschar drop off; after
which it will be proper to complete the cure by means of pledgets of
charpie and emollient collyria.
* * * * *
COMMENTARY. None of the other authorities describe this method of cure
so minutely as our author, except Haly Abbas, who evidently copies
from him. (Pract. ix, 71.) Rhases and Albucasis, however, also mention
the operation. They direct us to burn the part with a preparation of
quicklime and soap, with the addition of some caustic lixivia, _or_
leys. These ancient leys, _or_ lixivian ashes, appear to have been
preparations of potass more or less pure. We need scarcely remark that
these applications must have resembled the caustic paste, now used for
forming issues. The method of treatment here described is, in principle,
much the same as that performed by Quadri with sulphuric acid. A caustic
paste very similar to that now used is described by Guy of Caulico. (vii,
1.)
The strained ley, of which mention is made by Paulus, was probably the
same as the calx colata of Cælius Aurelianus. (Tard. Pass, v, 1.) It
appears to have been an impure preparation of potass with the addition
of some lime. It is the same, we suppose, as the πρωτόστακτον mentioned
in the Third Book of this work. The calx colata would seem to have been
identical with the Vienna paste now used in the treatment of varix. A
composition for burning the eyelids, mentioned by Jesu Hali, contains
lime, prepared beans, nitre, and sal ammoniac, formed into a paste with
the water of soap and pure myrrh. Jesu, however, does not much approve of
this method of treatment.
SECT. X.—ON LAGOPHTHALMOS OR HARE-EYE.
Those persons are said to have hare-eyes who have the eyelids drawn
upwards. This complaint arises either naturally or from the cicatrix of a
wound, and this may have occurred spontaneously, or from the operations
of the suture or burning (as just mentioned) having been improperly
performed; in which case even a moderate relief can only be accomplished
when the eyelid is sufficiently thick. For we must divide the cicatrix,
and having separated the lips with a tent, use bandages until the cure
is completed, avoiding such things as are very desiccative, and having
recourse to those which are fatty and relaxing, such as the juice of
fenugreek poured on the part, and the ointment prepared with four
ingredients called basilicon, applied on a tent.
* * * * *
COMMENTARY. See Celsus (vii, 7); Aëtius (vii, 71); Albucasis (Chirurg.
ii, 13); Avicenna (iii, 3, 3, 12); Haly Abbas (Pract. ix, 20); Rhases
(Cont. ii, 4.)
Celsus directs us to make a lunated incision below the eyebrows, the
horns of the incision being turned downwards, and care being taken not
to wound the muscles. A tent or pledget of lint is to be put into this
incision to prevent the edges of it from uniting. This simple operation
is described in nearly the same terms by Aëtius, Albucasis, Avicenna,
Haly Abbas, and Rhases.
Fabricius ab Aquapendente informs us that the operation had fallen into
disuse in his time. It is now sometimes practised. See Scultet, (Arsen.
de Chirurg. Tab. xxxiv, 8.)
SECT. XI.—ON THE SUTURE OF THE UNDER EYELID, AND THE BURNING OF IT BY
MEDICINES.
The under eyelid is subject to the same complaints from the ciliary hairs
as the upper; for, when larger than natural, it is everted; and it is
subject likewise to phalangosis and distichiasis. We must, therefore,
perform the operation of the suture in the same manner as for the upper
eyelid, but in an inverted order, beginning with the _lunated_ incision
on account of the obstruction occasioned by the blood, and then making
the _veruted_. But the _under-incision_ is to be omitted altogether,
because the lower eyelid, by its natural weight, is readily everted.
The rest of the treatment to be completed as in the suture of the upper
eyelid, except that the extremities of the ligatures are not to be glued
to the forehead. If in this case the patient is averse to an operation,
and prefers burning by medicines, you have already got a description of
this process.
* * * * *
COMMENTARY. This section requires no commentary.
SECT. XII.—ON ECTROPION, OR EVERSION OF THE LOWER EYELID.
Ectropion of the under lid is occasioned by the same causes as
lagophthalmos of the upper, only that it does not occur naturally, but
arises sometimes from relaxation produced by medicines possessed of this
property, which have been applied for inflammation; and sometimes the
eversion is occasioned by the suture or burning having been improperly
performed. Taking, therefore, a needle, armed with a double thread, we
perforate the fleshy mass, pushing it through from the left canthus
to the right, and then by means of the thread fastened to both of its
extremities, we stretch the skin with the needle, and cut down upon it
with a scalpel, removing the needle at the same time. Then, if the eyelid
resume its proper shape and is turned inwards, this operation will be
sufficient. But if the eversion continue after the removal of the flesh,
we apply the back of the specillum to the divided eyelid; and on the
inside of the eyelid, having made two incisions, beginning at the two
angles of the incision formerly made, and terminating in an acute point,
and meeting together like the Greek Λ, we remove this substance, so that
its acute point may be below at the eye, and the broad above at what is
called the tarsus. Afterwards we unite the separated parts with a needle
containing a woollen thread, being satisfied with two sutures. But if the
ectropion be occasioned by the operation of the suture or burning we make
a simple incision along the first cicatrix below the hairs of the tarsi,
and having separated its lips, we fill up the wound with pledgets, using
the same methods as for lagophthalmos (except fomentations) until the
parts which have been stitched unite.
* * * * *
COMMENTARY. See Aëtius (vii, 74); Celsus (vii, 7); Albucasis (Chirurg.
ii, 14); Haly Abbas (Pract. ix, 20.)
Aëtius gives a full account of the treatment of ectropion from
Demosthenes and Antyllus. When the disease is occasioned by fungous flesh
on the inner membrane of the eyelid, he recommends us to burn it down
with escharotics, such as misy, chalcitis, &c. (See the Third Book.) He
describes the surgical operation in the following terms:—when the fleshy
excrescences are very large they are to be dissected out with a scalpel,
and the part touched with burnt copper or the like. When the eversion is
greater, he directs us to perform an operation upon the inner part of the
eyelid, making two incisions, which unite below like the Greek letter
Λ, and afterwards dissecting out this lambdoid or triangular piece, and
along with it the flesh below, which, he remarks, is not cartilaginous
like the upper eyelid, but taking care to preserve the skin untouched.
The edges of the incisions are then to be united by one suture at the
eyelids. When the ectropion is occasioned by an external cicatrix, we
are to operate upon the inner surface of the eyelid in the manner just
now described, only avoiding to make deep incisions, and uniting the
edges of the incisions as before directed. Then stretching the cicatrix
with a hook, and pushing a needle armed with a double thread, under the
thickened flesh from the smaller canthus to the larger, we are to cut
down upon the needle and divide the thickened flesh. A pledget of lint
is then to be put into the external incision, and a compress, moistened
with cold water, applied with a bandage. He directs us to avoid warm
fomentations until the ligatures drop out. When ectropion arises from
the excrescence called encanthis, he recommends us to dissect it out.
When the disease is occasioned by paralysis, or arises from too large a
portion of the eyelid having been cut out in the operation for entropion,
he pronounces it to be incurable. It is also said to be incurable when
occasioned by the sloughing of carbuncles.
Celsus says that ectropion arises either from an operation for inversion
improperly performed or from old age. In the former case he directs us to
make an incision like that for lagophthalmos, only with this difference,
that the horns of it are to be turned to the jaws (maxillas) and not
to the eye. When it arises from old age he recommends us to burn the
excrescence with a slender piece of iron, and then to anoint it with
honey.
Albucasis describes the operation in nearly the same terms as Aëtius.
Thus, he directs us to pass a needle armed with a double thread, below
the fleshy excrescence from the left canthus to the right, and stretching
it by means of the threads to cut it out with a broad scalpel. If this
incision does not relieve the eyelid, he directs us to take the specillum
(radius) and applying it to the incision, to evert the eyelid with it,
and then to make two incisions in the inner surface of the eyelid so
that they may meet at an angle below, like the Greek letter Λ. Then this
triangular portion is to be dissected out, and the edges united by a
suture with a woollen thread. When the disease arises from a cicatrix he
directs us to divide it, and then to keep the lips of the wound separate
by the application of a pledget. He concludes with the remark that, as
the disease puts on various forms, a prudent surgeon will show his skill
by restoring the parts to their natural state.
Haly Abbas evidently borrows his description from Aëtius or our author.
The operation here described is very similar to the one practised by
the late Sir William Adams. In the days of Fabricius this operation
was condemned as cruel and troublesome. It will be remarked that the
V operation of modern times is a modification of the operation now
described.
SECT. XIII.—ON ANABROCHISMUS AND BURNING WITH IRON.
When the hairs which irritate the eye are not numerous, but only one,
two, or at most, three, close to one another, we approve of the operation
called anabrochismus. Taking, therefore, a very slender needle, we pass
through its ear (eye?) a woman’s hair or a fine flaxen thread, and
unite the two extremities together in such a manner that the thread
or hair which is passed through may have a double loop; and we pass
another such thread or hair through the loop, and pushing the needle
through the tarsus where the preternatural hairs appear, we introduce
the hair or hairs into the loop by means of an ear-specillum, and draw
it upwards. And if the hair of the eyelash be fixed in it, we draw up
the loop; but if one or more, fall out, we again, by means of the one
at first introduced, draw down the loop, and once more introducing a
hair or hairs, draw them upwards. But if there is only one slender hair
that irritates the eye we draw up another of the ciliary hairs along
with it, anointing them with gum or some other glutinous substance, and
bending them until they unite to the skin. Some preferring burning to
the operation of anabrochismus, turn the eyelid outwards, and with a
hair-forceps dragging out the offending hair, if there is but one, or
two, or three; if there be as many, they apply a double-headed specillum,
or an ear-specillum, or some such small instrument heated, to the
place whence the hair or hairs were removed. For the skin being thus
constricted, no other hair is produced.
* * * * *
COMMENTARY. We will give Celsus’s description of this operation in his
own words: “Quidam aiunt, acu transui juxta pilos exteriorem partem
palpebræ debere, eamque transmitti duplicem capillum muliebrem ducentem,
atque ubi acus transiit, in ipsius capilli sinum, qua duplicatur, pilum
esse conjiciendum, et per eum in superiorem palpebræ partem attrahendum,
ibique corpori agglutinandum, et imponendum medicamentum quo foramen
glutinetur; sic enim fore, ut is pilus in exteriorem partem postea
spectet.” However, he does not much approve of the operation. He also
describes the operation of cauterising the roots of the hairs. (vii, 7.)
Albucasis, Haly Abbas, and Rhases describe the operation in much the
same terms as Celsus and our author. Most of the Arabian authorities,
likewise, describe the operation of burning the roots of the hairs by
means of a specillum or any such instrument. Canamusali gives a short
account of both operations, that is to say, the anabrochismus and burning
the roots of the hairs.
This operation is described by the earlier of the modern writers on
surgery. The agglutinative composition recommended for this purpose by
Guido de Cauliaco consists of mastich, frankincense, aloes, sarcocol, and
tragacanth, dissolved in the white of an egg. (vi, ii.)
SECT. XIV.—ON HYDATIDS.
The hydatid is a fatty substance, naturally lodged under the skin of the
eyelid, which, in some persons, more especially in children of a more
humid temperament, increases until it become the cause of disagreeable
symptoms by encumbering the eye, and thereby occasioning defluxions.
The eyelids, therefore, under the brows appear watery and cannot be
raised in a becoming manner; and if, when we press upon them with our
fingers, we separate the fingers, the intermediate space swells up.
They are most troubled with defluxions about day-break, and cannot look
direct against the rays of the sun, but shed tears and are subject to
continued ophthalmies. Wherefore, having placed the patient in a proper
position, we compress the eyelid with the index and middle fingers a
little separated from one another, so as to form a collection of the
watery contents between the fingers, and direct the assistant, who
stands behind and holds the head, to stretch the eyelid moderately at
the middle of the brow; then taking a lancet used for bleeding, we make
a transverse incision through the middle, not longer than that made in
venesection, and of such a depth as to divide the skin or even to touch
the hydatid itself; but this is to be done with due circumspection. For
many plunging the instrument too deep, have either divided the cornea or
wounded some muscle of the eyelid. If the hydatid immediately appear, we
draw it out, or if not, we again make a slight incision. When it comes
in sight we seize on it by the fingers, with a soft cloth, and moving it
hither and thither and round about, we draw it out. After the removal of
it we soak a double compress in oxycrate, and bind it on the part. Some
apply levigated salts, upon the knob of a specillum, to the incision, in
order that if any part of the hydatid remain it may be dissolved. After
the removal, should there be no inflammation, we accomplish the cure
with collyria in the form of liniments, or with lycium, horned poppy,
or saffron. But when there is inflammation we treat it with suitable
cataplasms and the other remedies.
* * * * *
COMMENTARY. Celsus describes them by the name of vesicæ pingues
gravesque. It is clear that they are different from the tumours to
which modern surgeons apply the name. They appear to have been encysted
tumours, or perhaps enlargements of the sebaceous glands. Celsus directs
us to apply pressure with two fingers, and the skin being stretched to
make a transverse incision, taking care not to wound the bladder or
cyst. The tumour is then to be seized with the fingers and pulled out.
He remarks that when the cyst is opened, and its contents evacuated,
it renders the operation more difficult. When such a thing happens he
recommends us to encourage suppuration.
To this class of tumours we may perhaps refer the white rough bodies
resembling chalk-stones, on the inner surface of the eyelid, which are
described by Aëtius. He directs us to evert the eyelid, and, making an
incision along the vertex of the tumour, to scoop it out with an earpick,
and apply burnt copper, finely triturated, to the part. When extracted
outwardly he recommends a dressing with tetrapharmacum. (vii, 82.)
See Albucasis (Chirurg. ii, 10); Avicenna (iii, 3, 3, 18); and Haly Abbas
(Pract. ix, 21.) They evidently copy from our author. Rhases professes to
borrow his description of the operation from Antyllus and Paulus. (Cont.
ii, 3, 2.)
Fabricius ab Aquapendente, describes under the name of hydatid, two kinds
of encysted tumours, the contents of the one being of a thick and heavy
nature, and the other, an atheroma. He approves of the ancient modes
of operating. (O. L. ii, 9.) Heister incorrectly calls them vesiculæ
aquâ plenæ. (Ch. ii, 2, 9.) Tumours similar to those which we have here
treated of are described by Scarpa, in the third chapter of his work on
the Eye, and every practical surgeon must be familiar with them.
SECT. XV.—ON ADHESION OF THE EYELIDS.
The upper eyelid undergoes adhesion sometimes to the lower tarsus,
sometimes to the tunica adnata, and sometimes to the cornea itself.
This disease obstructs the motions of the eye. Wherefore, applying an
ear-specillum to the broad margin of the eyelid, or stretching it with a
hook-like instrument, we free the adhesion with the scalpel used in the
operation for pterygia, taking care that the cornea be not wounded, lest
we give rise to procidentia. After the incision, having bathed the eye,
we separate the eyelids with tents, lest adhesion again take place, and
applying wool, soaked in an egg, after the third day we have recourse to
attenuant and healing collyria.
* * * * *
COMMENTARY. See Aëtius (vii, 66); Celsus (vii, 7); Albucasis (Chirurg.
ii, 15); Avenzoar (i, 8, 5); Avicenna (iii, 3, 8, 10); Haly Abbas (Pract.
ix, 22); Alsaharavius (Pract. iv, 5); Rhases (Cont. ii); Jesu Hali (ii,
7.)
The description given by Aëtius is exactly the same as our author’s.
Celsus correctly remarks that the disease is the consequence of neglected
ulcers. He describes the operation in the following terms:—“Igitur
aversum specillum inserendum deducendæque eo palpebræ sunt: deinde
exigua penicilla interponenda, donec exulceratio ejus loci finiatur.” He
mentions that Heraclides of Tarentum directed the eyelid to be dissected
from the white of the eye when there is adhesion between them; but
recommends us to do it cautiously with an averted specillum (dos de la
spathule, Fabr. d’Aquapen.), taking care to wound the eyelid rather than
the ball of the eye. Suitable ointments are afterwards to be applied.
Yet he says that he never saw a case thus cured; and states, that Meges
likewise thought the disease incurable.
In order to understand the above description of Celsus it may be useful
to give from Fabricius some account of the ancient specillum. “Il nous
suffit scauvoir que _specillum_ (qui est le mot Latin de Celse) est un
instrument long et rond, de cuivre, d’argent, ou de plomb, duquel on
sonde les fistules, ayant un de ses bouts plus large, et l’autre plus
étroit, en vulgaire Italien _stilo_.” (Œuv. Chir. ii.) It was, therefore,
a sort of sound.
Avenzoar directs us to make the separation by means of a golden rod or
probe, and then to apply the white of an egg broken with oil of roses
and oil of almonds. When the eyelid adheres to the white of the eye he
advises us in like manner to make the separation gently with a golden
spatula, and then to apply the oil of roses and of almonds. But the
latter case, he says, is difficult to cure.
Of the other Arabians, Albucasis and Haly Abbas evidently copy the
description of the operation given by Paulus; and Rhases and Avicenna
supply no additional information. Jesu Hali’s description is accurate,
but similar to that of Celsus.
SECT. XVI.—CHALAZIA OR TUMOURS RESEMBLING HAIL-STONES.
The chalazion is a concretion of inert fluid in the eyelid. If it occur
on the external side of the eyelid, having divided the outer part of
the eyelid transversely with a scalpel, we extract the chalazion with
an ear-pick, or some such instrument, and when the incision is large
and the lips thereof separated, we unite them with a suture, and have
recourse to some plaster. But if it be small we omit the suture and
effect the cure in the same manner otherwise. But if the chalazion be
internal, so as to appear through the cartilage, having turned the eyelid
outwards, and divided it transversely within, we extract it and use an
injection of salt water.
* * * * *
COMMENTARY. Aëtius says that the contents of the chalazia, in some
cases, resemble the white of an egg. These he directs us to open, and,
having evacuated their fluid contents, to touch the part with a powder
consisting of verdigris, burnt copper, and other such escharotics. When
the contents are harder he recommends complete excision, like our author.
(vii, 83.)
Celsus describes the mode of operating with his usual terseness:—“Hæc
incidi debent, si sub cute sunt, ab exteriore parte, si sub cartilagine,
ab interiore, dein scalpelli manubrio deducenda ab integris partibus
sunt.” (vii, 7.)
The descriptions of the operation given by Albucasis and Haly Abbas, if
not literally copied from our author, are altogether to the same effect.
Rhases and Avicenna approve most of the treatment by medicines. See Book
Third. Jesu Hali directs us to avert the eyelid and extract the tumour.
Fabricius ab Aquapendente says that the fluid contained in the chalazion
(gresle) is “blanche et transparente, en quelque façon comme de la
gresle.” He repeats the directions given by Celsus. (Œuv. Chir. ii, 11.)
The chalazion is evidently an encysted tumour of a soft nature, and is
not identical with the hordeolum, as Scarpa makes it to be. The treatment
here recommended is such as admits of no improvement.
SECT. XVII.—ON ACROCHORDON AND ENCANTHIS.
Acrochordon of the eyelid and that tumour at the greater canthus called
encanthis we seize with a flesh forceps, and cutting them out with a
scalpel, apply levigated chalcitis.
* * * * *
COMMENTARY. The nature of the acrochordon is explained in the Fourth Book.
Celsus, like our author, directs us to seize the encanthis with a hook,
and cut it out, taking care not to interfere with the angle of the
eyelid. He then recommends us to apply a pledget sprinkled with calamine
or atramentum sutorium (sulphate of copper?) between the eyelids. (vii,
7.)
Aëtius recommends us either to use a forceps, or if the tumour is large,
to transfix it with a needle armed with a thread, and to tie it at its
base, and to twist the thread round it.
Albucasis and Haly Abbas evidently copy from our author. Avenzoar prefers
reducing the fleshy tumour with septics. Rhases mentions that some
recommend septics in cases of encanthis, but he prefers excision. After
the operation he recommends squama æris to the part. (Cont. ii.) Jesu
Hali directs us to remove it with septics. (ii, 33.) It will be remarked
that our author’s operation is the same as that recommended by modern
authorities.
SECT. XVIII.—ON PTERYGIA.
This disease is occasioned by a nervous (tendinous) membrane beginning
for the most part at the great canthus, and gradually spreading inwards.
It proves injurious to the eye both by obstructing the motion of the
ball, owing to the contractions it produces, and because when it
advances forwards it covers the pupil. Those therefore which are thin
and of a white colour being easiest to cure, we operate upon in this
manner: having separated the eyelids, and seized upon the pterygia with
a hook-like instrument, having a small curvature, we stretch it, and
taking a needle having a horse-hair and a strong flaxen thread in its
ear (eye?), and a little bent at the extremity, we transfix it through
the middle of the pterygium, and with the thread we bind the pterygium
and raise it upwards, while with the hair we separate and saw as it were
the part at the pupil away unto its extremity; but the remainder of it
at the great canthus we cut off from the base with the scalpel used for
the operation by suture, but leaving the natural flesh of the canthus,
lest there be a running of the eye when it is taken away. Some stretching
as aforesaid with a thread, dissect away the whole pterygium with the
instrument called pterygotomos, taking care not to touch the cornea.
After the operation, having applied some levigated salts to the part,
we bind on it some wool dipped in an egg. After the removal of this we
inject into the eye salt water for a long time. But if inflammation
supervene we have recourse to the remedies described for it.
* * * * *
COMMENTARY. Celsus gives an excellent account of the pterygium. He
correctly states that the membrane generally begins at the inner angle of
the eye. His description of the operation is very precise. The patient
being properly seated, the surgeon is to raise the membrane with a
sharp hook somewhat bent at the extremity, and is then to pass below it
a needle armed with a thread, the two ends of which he is to lay hold
of and separate the membranes everywhere from the ball of the eye. The
membrane is then to be cut out with a scalpel, care being taken not to
hurt the angle of the eye-lid. He directs us to apply to the part a piece
of sponge, or some wool, or a pledget spread with honey. (vii, 7.)
Aëtius also describes the operation very correctly, but in the same terms
as our author; that is to say, he directs us to use the needle armed with
a flaxen thread and a horse-hair, and afterwards to cut out the membrane,
using the precautions here mentioned. (vii, 60.)
Albucasis recommends the same mode of procedure as Aëtius (Chirurg. ii,
16.) Haly gives similar directions. (Pract. ix, 25.) Both caution us not
to carry the incision too near the inner canthus. Haly Abbas recommends
the use of the scissors, and not of the scalpel (in the translation read
_forficibus_ and not _forcipibus_.)
Avicenna likewise recommends the scissors. (iii, 3, 2, 23.) Rhases gives
directions for passing a needle below the membrane, and for cutting it
off. He speaks of using a pair of scissors. He mentions that he had seen
a surgeon perform it with a pen. (Divis. 25, and Cont. ii, 3.)
Jesu Hali directs us to operate either with a scalpel or pair of
scissors. (De Oculis ii, 38.)
The modern methods of treatment do not appear to differ in principle
from the ancient. Scarpa operates with a pair of scissors; but Beer
prefers the scalpel. Scarpa seems to approve of the direction given by
the ancient authors, not to carry the incision too far towards the inner
angle of the eye. See also Fabricius ab Aquapendente (Œuv. Chir. ii, 18),
and Brunus (Chir. Mag. ii, 4.)
SECT. XIX.—ON STAPHYLOMA.
Staphyloma is an incurvation of the cornea, and of the tunica choroides,
arising from debility, and being produced sometimes by a defluxion, and
sometimes by ulceration. We operate upon it not in order to restore
the eyesight, for that is impossible, but to moderate the patient’s
deformity. Wherefore having passed a needle from below upwards through
the base of the staphyloma, we are to push another needle, having a
double thread, from the canthus next the hand to the other, through
the base of the staphyloma; and the first needle remaining, we cut the
double of the thread, and tie part of the staphyloma upwards and part
downwards with the threads, and then removing the needle we apply wool
dipped in eggs. After the removal of the dressings we soothe the eyes
with emollient injections until the ligatures fall off along with the
staphyloma.
* * * * *
COMMENTARY. Celsus thus describes the disease: “In ipso autem oculo
nonnunquam summa attolitur tunica, sive ruptis intus membranis aliquibus,
sive laxatis: et similes figura acino fit: unde id σταφύλωμα Græci
vocant.” He describes two methods of cure: the first of which is by
ligatures, as recommended by our author; and the other consists in
cutting from the apex a circular portion equal in size to a lentil.
Scarpa and Guthrie concur in recommending the latter operations, the
merits of which, as they state, have not been generally appreciated
properly.
Aëtius directs us to introduce the cross threads, as recommended by our
author, and then to cut out the apex of the tumour. He is at great pains
in directing us to introduce the threads obliquely, and not at right
angles to one another. He also recommends general bleeding and emollient
fomentations, (vii, 37.)
The operation with the ligatures is briefly described in the ‘Isagoge,’
generally ascribed to Galen.
Haly Abbas and Albucasis describe the operation with the cross threads
in nearly the same terms as our author. The latter, however, makes
mention of puncturing the apex of the tumour after the application of the
ligatures. Jesu Hali gives nearly the same account of the operation.
Although Scarpa condemns in strong terms the use of the needle and
ligatures, this method of treatment is sanctioned by the authority of Mr.
Travers. This operation was approved of by William of Saliceto.
Scultet explains the descriptions given by Celsus and Paulus, but they
are sufficiently plain of themselves. (Arsen. de Chirurg. tab. 32.)
It will be perceived that the ancients applied the name staphyloma to
two distinct, or at least considerably different diseases, namely, to
enlargement with protrusion of the cornea, and to prolapsus of the iris
connected with ulceration of the cornea. Heister, Wenzel, and other
continental writers, use it in the same sense as the ancients. Scarpa and
our English oculists apply it only to protrusion of the cornea, without
ulceration.
SECT. XX.—ON HYPOPYON OF THE EYE.
Regarding hypopyon of the eyes it will be sufficient to deliver Galen’s
account, which is to this effect:—“A certain oculist of our time, named
Justus, cured many cases of hypopyon by shaking the head. Placing them,
therefore, erect upon a chair, and grasping their head on both sides
obliquely, he shook them so that we could see clearly the pus descending
downwards; and, owing to the weight of the substance, it remained below,
although cataracts will not remain unless fixed carefully.” And again, he
says below, “oftentimes we evacuate the pus freely by dividing the cornea
a little above the place where all the coats of the eye unite. This place
is called by some the iris, and by others the corona.” These are the
words of Galen in his work, ‘On the Method of Cure.’ After the discharge
of the pus, we clean the ulcer with injections of honied water, or of the
juice of fenugreek with the addition of some honey, and then apply the
other treatment conformably.
* * * * *
COMMENTARY. Galen recommends three methods of treatment for the cure of
hypopyon; namely, by discutients, shaking, and incision. (Meth. Méd. xiv.)
Aëtius, Albucasis, and Haly Abbas, like our author, are advocates for
shaking and incision. Neither of these methods is now much in use, but
both have had their advocates in modern times.
SECT. XXI.—ON CATARACTS.
The cataract is a collection of inert fluids upon the cornea at the
pupil, obstructing vision, or preventing distinct vision. It arises
most commonly from a congelation and weakness of the visual spirit,
and on that account the disease rather attacks old persons, and those
who are debilitated by protracted illness. It is occasioned also by
violent vomiting, a blow, and many other causes. Those kinds of cataract
which are but commencing, as not being proper objects of surgery, have
been treated of in the Third Book. We shall now give the characters of
those which are fairly formed and have acquired consistence. All those,
therefore, who have cataract see the light more or less, and by this we
distinguish cataract from amaurosis and glaucoma; for persons affected
with these complaints do not perceive the light at all. Wherefore, again,
Galen well instructs us as to the consistence and difference of cataracts
and which kinds ought to be operated upon. Having shut the eye affected
with the cataract, and with the large finger pressing the eyelid to the
eye, and moving it with pressure to this side and that, then opening the
eyelids and observing the cataract in the eye; if it has not yet acquired
consistence, a certain flow takes place from the pressure of the finger,
and at first it appears broader, but straightway resumes its former
figure and magnitude. But in those which have acquired consistence no
change takes place as to breadth or figure from the pressure. But since
this appearance is common to those which are of moderate consistence,
and those which are over-compacted, we distinguish these cases from
one another by their colour. For those which are of an iron, cœrulean,
or leaden colour, are of moderate consistence, and fit for couching;
but those which resemble gypsum and hailstones are over-compacted.
After ascertaining these circumstances, as directed by Galen, having
placed the patient opposite the light, but not in the sun, we bind up
carefully the sound eye, and having separated the lids of the other, at
the distance from the part called the iris towards the small canthus, of
about the size of the knob of the specillum, we then with the point of
the perforator mark the place about to be perforated; and if it is the
left eye we operate with the right hand, or if the right eye with the
left; and turning round the point of the perforator, which is bent at its
extremity, we push it strongly through the part which was marked out,
until we come to an empty place. The depth of the perforation should be
as great as the distance of the pupil from the iris. Wherefore, raising
the perforator to the apex of the cataract, (for the copper of it is seen
through the transparency of the cornea,) we push down the cataract to the
parts below, and if it is immediately carried downwards, we rest for a
little, but if it reascends we press it back again. After the depression
of the cataract we turn round the perforator and extract it gently. After
this, bathing with water and injecting into the eye a little Cappadocian
salts, we apply externally some wool soaked in the white of an egg with
rose-oil, and bind it up, and at the same time bind up the sound eye,
that it may not move. Then lodging the patient in an apartment below
ground, we order him to remain in a state of perfect rest, and upon a
spare diet; and the bandages are to be kept on, if nothing prevent, until
the seventh day, after which we loose them, and make trial of the sight
by presenting him with some object: but this we disapprove of during
the operation and immediately after it, lest by the intense exertion
the cataract reascend. If the inflammation become urgent we loose the
dressing before the seventh day, and must direct our attention to it.
* * * * *
COMMENTARY. See Celsus (vii, 7); Galen (Ars Medica, 35; Isagoge); Aëtius
(vii, 53); Albucasis (Chirurg. ii, 23), Canamusali (vi); Avenzoar (i, 8,
19); Mesue (de Ægr. Oculi; 15); Haly Abbas (Pract. ix, 28); Jesu Hali
(Tract. de Oculis, 68); Avicenna (iii, 3, 4, 20); Rhases (ad Mansor. ix,
27, and Cont. ii); Vegetius (Mulom. ii, 17.)
This disease is called _suffusio_ by the Latins, and _aqua_ by the
Arabians.
We have stated in our commentary on affections of the eye, in the Third
Book, that the ancients were aware that the crystalline lens is the seat
of one of the species of cataract. This opinion is clearly delivered by
Galen, Aëtius, Oribasius, Haly Abbas, and some of the others. As a proof
that this notion prevailed generally, we will give the words of Psellus
literally translated: “Glaucoma is a grievous and incurable affection,
being a certain change of the crystalline humour, and transmutation of
its colour to a sea-green. The suffusion is a concretion of the fluid
between the cornea and crystalline humour.” (Opus Medicum.) The other
species then, as Psellus states, was held to be a concretion between
the crystalline lens and the cornea. That such a disease, although of
comparatively rare occurrence, is sometimes met with seems undeniable.
Celsus lays it down as a rule, that when the suffusion is small,
immovable, and of the colour of sea-water, or of shining iron, and if
a small degree of light can be perceived at the side, there is reason
to hope well of the case. He forbids us to operate until the disease
has attained a proper consistence. He directs us to place the patient
opposite the operator, who is to sit on a higher seat, while the
patient’s head is firmly held by an assistant. The sound eye is to be
previously covered up with wool. If the left eye is affected the operator
must use his right hand, and vice versa. A needle which is sharp and
not too slender is to be passed direct through the two coats at a place
intermediate between the temporal angle and the black of the eye, and
towards the middle of the cataract. When the needle has perforated far
enough, which is readily known by the absence of resistance, it is to be
gently turned so as gradually to remove the cataract below the region of
the pupil, and this object being attained it is to be strongly pressed to
the lower part. If it remain there the operation is completed; but if it
return it is to be cut and torn by the needle into many pieces, in which
state they are easier depressed, and prove less troublesome. The needle
is then to be drawn out direct, and soft wool smeared with the white of
an egg, and other anti-inflammatory applications are to be used. Quiet,
restricted diet, and soothing treatment will be proper.
Galen, in his ‘Ars Medica’ alludes to the operation, but does not
describe it.
Paulus is the only Greek author who describes the operation. Sextus
Platonicus, however, just mentions that the diseased part is sometimes to
be depressed with a specillum. (De Medic. ex Animalibus.)
Mesue describes the operation of couching briefly, but nearly in the same
terms as our author. He directs us to put the patient upon a spare diet,
and to bleed him before the operation. He recommends us to be careful to
depress the cataract (aqua) properly.
Albucasis describes the operation of Paulus very minutely, and gives
drawings of the couching-needles, called by him almagda. The instrument
is to be passed down into the eye to as great a space as the pupil of the
eye is distant from the end of the black part called the corona. He says
nothing of tearing the cataract into pieces when it proves difficult to
depress. He mentions that he had heard of a certain oculist who, it was
said, sucked out the cataract through a small tube. He adds, however,
that he had never seen any person who performed this operation, nor had
read anything about it in the works of the ancients.
Avenzoar briefly mentions that when a cataract cannot be got discussed
it must be depressed. He gives directions to press it well down, but
says nothing about tearing it into pieces. He recommends retirement,
abstinence, and rest afterwards.
Avicenna’s description is evidently copied from our author. He also
mentions that some surgeons open the lower part of the cornea, and
extract by it. However, he does not approve much of this procedure.
Canamusali briefly mentions that cataract must sometimes be removed by
a surgical operation. When convulsions come on after the operation he
directs us to apply castor to the nose.
Rhases describes accurately the operations of couching, extracting,
and sucking out the cataract. He is the only ancient author, except
Celsus, who recommends the cataract to be torn in pieces when it cannot
be got properly depressed. He mentions that the famous surgeon Antyllus
practised extraction by opening the lower part of the cornea. He also
speaks of a certain surgeon who sucked it out through a glass tube.
Haly Abbas describes distinctly the operation of couching, but evidently
copies from Paulus. He makes no mention, however, of extraction, as far
as we can discover, in any part of his works. The operation of couching
the cataract is minutely described by Jesu Haly, but he makes no mention
of extraction. He was the son of Haly Abbas.
Sprengel, in his ‘History of Medicine,’ refers to Haly Abbas as one of
the ancient authorities who make mention of the operation of extracting
the cataract; but if this be the case the edition from which they quote
(Venetiis, 1492) must be considerably different from the one with which
we are acquainted. (Lyon, 1523.) Haly forbids examinations of the
eye after the operation, to ascertain whether or not the patient has
recovered his sight.
We will give the description of Vegetius in his own language: “Jumentum
igitur pridie temperabis a cibo vel potu maximè prohibebis, in loco
molli elides caputque ejus et cervicem aptè collocabis: ita patentem
oculum facies ut claudere non possit: deinde ab ipsâ fronte paracenterium
inter tunicas oculares subjicito, ne pupillam tangas, aut aliquid lædas
interius. sed ipsum album de superiori parte ubi hypochysis posita
est, capitello paracenterii deorsum deprimis ad palpebram inferiorem
subtiliter. Quod si depositum fuerit, non prius paracenterium eximas,
nisi clausum oculum penicello calido diutissime vaporaveris. solet
enim resilire. Quod si evenerit, reprimito, donec ita componatur ut
resilire non possit. Cum itaque intellexeris claritatem pupillæ sine illo
obstaculo hypochysis, tunc eximes ferrum, et invenies animal videre.”
Sprengel affirms, but not quite correctly, as will be perceived from
the account of the ancient opinions given above, that it was towards
the beginning of the 18th century that it was first discovered that the
crystalline lens is the seat of the cataract. Otherwise he gives an
admirable history of the operation, in which he does ample justice to the
ingenuity and inventive genius of the ancients. (Hist. de la Méd. xviii.
2.)
Fabricius’s description is altogether borrowed from the ancient authors.
(Œ. C. ii, 16.) Guy of Cauliac, and the other surgical writers of that
age, describe the operation in the same terms as the ancients. Guy
mentions the operation of sucking out the cataract through a cannula, but
does not approve of it. (vi, 2.)
SECT. XXII.—ON ÆGILOPS, OR FISTULA LACHRYMALIS.
The ægilops is an apostematous swelling between the great canthus and the
nose; and it is an affection difficult to cure, owing to the thinness of
the bodies, and the fear of injuring the eye by sympathy. If, therefore,
the abscess burst at the surface, we remove the whole protruberance as
far as the bone; and if the fistulous sore incline towards the cheek,
we must lay it all open, and if the bone be sound, we must scrape it;
but if diseased, we must burn it with cauteries, applying to the eye a
sponge soaked in cold water. Some, after the excision of the flesh, use a
perforator, and make a passage for the fluid or matter to the nose; but
we are contented with burning alone, using the cauteries for ægilops,
and burning down until a lamina of bone drop off; and after the burning
we have recourse to lentils and honey, or to the application consisting
of pomegranate-rind with honey, and other such desiccative remedies.
If the ægilops incline to the canthus, and do not tend at all towards
the surface, then, with a lancet for the operation on ptrygium, or one
for bleeding, we may dissect out the body between the canthus as far
as the abscess, and remove the deep-seated flesh, and have recourse to
moderately desiccative applications. Glass reduced to a fine powder is
wonderfully desiccative, and aloes with manna, in like manner. The rest
of the treatment of fistula lachrymalis we have delivered in the Third
Book.
* * * * *
COMMENTARY. Celsus remarks that the ægilops is sometimes of a
carcinomatous nature, in which case he recommends us not to interfere
with it. He refers here, no doubt, to lupus, which is of not uncommon
occurrence near the inner angle of the eye. In recent cases which are not
of this kind, he directs us to proceed in the following manner: the whole
cavity of the abscess, as in fistulæ, is to be laid open down to the
bone, which is to be burned with a red-hot iron, more especially if the
bone be carious. Others, he says, instead of the cautery, use caustics,
such as atramentum sutorium, chalcitis, or verdigris; but these things,
he adds, are more slow in their operation, and less effectual. (vii, 7.)
When the bone is diseased the celebrated Archigenes recommends it to be
pierced with a slender perforator, or a hole is to be burnt in it with a
red-hot iron. He mentions that others burned it by means of a funnel and
melted lead. (Apud Galen. sec. loc. v; and Rhases Contin. ii, 4.)
Aëtius gives a full and lengthy account of ægilops. He recommends us to
attempt the cure first with medicines (see Book Third); and if these do
not succeed, he directs us to open the abscess freely, and apply to the
fungous flesh medicines possessed of strong stypticity, such as powdered
glass, stone alum, and the like. A pledget of lint is to be placed
over the medicines. When this method of practice does not succeed, he
recommends burning, and for this purpose directs us to make a triangular
incision in the flesh, and then to touch the bone with a heated iron, so
as to produce exfoliation. Alum with turpentine is then to be applied to
the bottom of the sore. (vii, 77.)
When the disease does not yield to medicines, Albucasis directs us
to open the abscess freely, so as to make an outlet for the matter,
and expose the bone. If it is found to be diseased, he recommends us
to scrape it with an iron instrument, and then to apply styptic and
desiccative medicines to it. When this treatment does not succeed, he
directs us to perforate the bone with a triangular instrument of iron.
When air issues from the nose by the opening we know, he says, that the
operation is completed.
For the cure of ægilops, Mesue recommends the removal of all the diseased
flesh by means of strong caustics, such as arsenic, sal ammoniac,
chalcitis, alum, &c. When the bone is carious, he directs us to scrape
off the carious part. Some, he adds, perforate the bone; but the
operation had not succeeded well in his hands. He makes mention of the
cautery in the same terms as the others. (De Ægr. Oculi, 12.)
Jesu Hali approves decidedly of perforating the bone with a specillum, or
any suitable instrument. He also speaks favorably of the actual cautery.
(De Oculis, ii, 32.)
Haly Abbas directs us to lay open the swelling, and apply the cautery. We
have mentioned in another place that he was acquainted with the lachrymal
duct. (Pract. ix, 29, and ix, 72.)
It will be unnecessary to give a particular account of the treatment
recommended by Avicenna, as it does not differ from that of Albucasis.
According to circumstances he approves of perforating the bone, and of
applying the actual cautery to it. He also speaks of introducing a thread
into the lachrymal passages and of using injections. (iii, 3, 2, 14.)
Avenzoar recommends compression and injections, but does not describe the
operation. He speaks of the matter passing into the nose, from which it
may be inferred that he also was acquainted with the lachrymal duct. (i,
8, 10.)
Rhases likewise makes mention of the lachrymal duct. He recommends us
very particularly to make incisions down to the bone, to perforate it, or
to apply the actual cautery to it. He makes mention also of escharotic
applications containing arsenic, quicklime, and vitriol. He relates a
case of apostema lachrymale in which he effected a cure by the ligature
and friction. (Contin. ii, 2.)
The practice of perforating the bone as recommended by Albucasis, was
approved of by Pott, and the use of the cautery for this purpose is also
supported by the high authority of Scarpa. M. A. Severinus, Hildanus,
and Garengoit, were likewise advocates for the actual cautery. Fabricius
seems to have understood the disease very well, and treated it in the way
recommended by the ancients. (Œuv. Chirurg. ii, 21.)
Guy of Cauliac, Theodoricus, and Lanfrancus describe and appear to have
performed the ancient operations for the cure of fistula lachrymalis.
SECT. XXIII.—ON IMPERFORATE MEATUS AUDITORIUS.
This affection is sometimes congenital, being occasioned by a membrane
which blocks up the entrance into the ear; and it is sometimes
superficial and sometimes deep-seated. And it is formed in after life
by a preceding ulceration in the meatus; for a growth of fungous flesh
taking place blocks up the passage. If, therefore, the membrane which
obstructs the opening be deep-seated, the attempt at cure is hazardous;
and yet we may try with some slender instrument to divide it, but if it
is superficial we divide it with a sharp knife, and if necessary cut it
out. If there be a fleshy excrescence it may be dissected out with the
scalpel used for the operation in pterygium, or that used for polypus;
then making a twisted tent of the size of the meatus from a linen rag,
we soak it in water, and sprinkling it with levigated chalcitis, or some
such powder, we introduce it into the meatus to prevent the flesh from
growing again. Should inflammation come on we must soon take it out. If
there be a discharge of blood from the meatus we may soak a sponge in
cold water, and apply it along with other appropriate remedies.
* * * * *
COMMENTARY. Celsus describes this case with his usual terseness:
“Solet tamen evenire vel a primo natali die protinus, vel postea factâ
exulceratione, deinde per cicatricem aure repletâ ut foramen in eo nullum
sit, ideoque audiendi sensu careat.” He directs us to make an examination
with a sound (specillum) in order to ascertain whether the membrane be
superficial or deep-seated, and in the latter case recommends us not to
interfere with it, but in the former, directs us to make an opening by
means of caustics, burning iron, or scalpel. (vii, 8.)
Albucasis describes the nature of the case and the operation in nearly
the same terms as Celsus and our author. If the obstruction is occasioned
by a superficial membrane he directs us to perforate it with a slender
instrument. If a fleshy excrescence obstruct the passage he approves of
seizing it with a hook, and dissecting it out. If the obstruction be more
deeply seated he directs the membrane to be opened by means of a heated
iron, taking care not to hurt the nerves. It is to be kept open with a
tent. (Chirurg. ii, 7.)
Avicenna mostly borrows his account of the case from Paulus. When the
obstruction is occasioned by a fleshy excrescence he directs it to be
burnt down with arsenic or some other escharotic. He also approves of
perforating the membrane. (iii, 4, 1, 17.)
The account given by Haly Abbas accords very well with our author’s.
(Pract. ix, 30.)
Fabricius ab Aquapendente describes correctly the treatment recommended
by the ancients. He admits that he had never attempted to perforate the
membrane when deep-seated. (Œuv. Chirurg. ii, 41.)
SECT. XXIV.—ON SUBSTANCES THAT HAVE FALLEN INTO THE MEATUS AUDITORIUS.
Not only do stones fall into the meatus, but also glass, beans, and
the stones of carob nuts. Of these the stones and glass retain their
original magnitude, but the beans and stones of carobs being swelled with
the natural moisture of the body, occasion very severe pains. They must
therefore be extracted by an earpick, a hook, or tweezers, or by using
powerful shaking of the head, while the ear is placed upon some circular
board. In like manner we extract bodies frequently by sucking them
through a reed; and do the like with water when it falls into the ear,
covering up the outside of the reed with wax when it is applied to the
ear in order that there may be no outlet to the breath. Stones and such
like bodies we extract by wrapping wool around an earpick, and smearing
it with turpentine-rosin, or some glutinous substance and introducing
it gently into the meatus auditorius. If it does not yield we introduce
a sternutatory into the nose and close the mouth and nostrils. If it
yield to none of these, before inflammation, convulsions, and dangerous
symptoms supervene, we must bring it away by a surgical operation.
Wherefore, having placed the patient in a proper position with his ear
turned upwards, at the base of the ear, behind what is called the lobe,
we make a small lunated incision, and with the circular part of an
earpick we extract the body which is lodged there. After the extraction
the wound is to be sewed up, and the cure completed by the treatment
applicable in cases of recent wounds.
* * * * *
COMMENTARY. See Celsus (vi, 7); Aëtius (vi, 87); Alexander Trallianus
(iii, 6); Oribasius (Loc. Affect. iv, 36, 39); Galen (de Med. sec. loc.
iii); Avicenna (iii, 5, 1, 23); Mesue (ii, 7, 8); Serapion (ii, 12);
Rhases (ad Mansor. ix, 36; Contin. iii); Haly Abbas (Pract. ix, 31.)
Celsus gives nearly the same directions as our author, recommending us to
use wool wrapped round a specillum, and smeared with turpentine-rosin, or
a hook slightly bent, or an ear-syringe, or sternutatories, or shaking
the patient’s head. The last-mentioned operation he directs us to execute
in the following manner: “Tabula quoque collocatur, media adhærens,
capitibus utrinque pendentibus, superque eam homo deligatur in id latus
versus, cujus auris eo modo laborat, sic, ut extra tabulam non emineat:
tum malleo caput tabulæ, quod a pedibus est, feritur: atque ita concussa
aure, id quod inest excidet.”
The treatment recommended by Aëtius is exactly the same as our author’s.
Alexander and Oribasius also deliver similar directions. However, Aëtius,
Oribasius, Alexander, and our author, copy from Galen, who in his turn
acknowledges his obligations to Archigenes and Appollonius. (De Comp.
Med. sec. loc. iii.)
Albucasis’s directions are so judicious that we regret our limits do not
allow of our giving them fully. For the extraction of a piece of stone
he recommends us among other means to use a slender forceps, of which
he gives a drawing. It resembles the modern dissecting forceps. He also
gives a drawing of a hook slightly bent, which he commends; and also
of a brazen tube to be used for sucking out bodies. When other means
do not succeed, he directs us to make an incision at the under part of
the ear, having previously let blood in order to avert inflammation
and convulsions. Animals are to be sucked out with a tube narrow below
and wider externally, or they are to be extracted with a forceps or
hook. When these means do not succeed, an oil, to which some substance
destructive of these animals has been added, is to be injected with an
instrument, of which he gives a drawing.
The reader may likewise consult Mesue with advantage. Serapion also
recommends the same remedies as the Greeks. Avicenna supplies no new
views. Haly recommends incision when other means have failed.
Rhases directs us to pour tepid oil into the ear, and to put the patient
into a warm bath in order to lubricate and produce relaxation. His
translator, however, remarks that if the substance lodged in the ear be a
bean or a pea there may be danger of the water occasioning a swelling of
it.
SECT. XXV.—ON POLYPUS.
The polypus is a preternatural tumour forming in the nose; so called from
its resemblance to a sea polypus, because it resembles its flesh, and
because, as the animal with its fibrils resists those who would seize on
it by catching at their hands, so does this affection, in like manner,
block up the nostrils, occasioning inconvenience both in breathing and
speaking. Wherefore those kinds of polypi which are hard, unyielding,
somewhat livid and malignant, inasmuch as they partake of a carcinomatous
nature, are not to be meddled with; but such as are more friable,
spongy, insensible, and not malignant, are to be subjected to a surgical
operation. Having placed the person on a seat exposed to the rays of the
sun, and opened the nostrils with the left hand, and holding in the right
hand a polypus scalpel, having its extremity shaped like a myrtle-leaf,
we cut around the polypus or sarcomatous tumour, applying the extremity
of the instrument to the parts where it adheres to the nose. Afterwards,
turning round the instrument, we bring out the separated fleshy body
with its concave part. And if we see that the nasal passage is perfectly
cleared, we proceed to the cure; but if any part of the polypus be left
behind, we take another instrument for eradicating polypi, and, with the
extremity thereof, we bring away what remains by stretching, twisting,
and scraping it strongly. Malignant polypi we burn with cauteries,
knob-shaped; and, after the burning, we have recourse to the treatment
for burnt parts. After the operation, having sponged the parts carefully,
we inject oxycrate or wine into the nose, and, if the fluid descend
by the roof of the mouth to the pharynx, the operation will have been
rightly done; but if it does not descend, it is clear that about the
ethmoid bones, or the upper parts of the nose, there are fleshy bodies
which have not been reached with the polypus instruments. Taking, then,
a thread moderately thick, like a cord, and having tied knots upon it at
the distance of two or three fingers’ breadths, we introduce it into the
opening of a double-headed specillum, and we push the other extremity
of the specillum upwards to the ethmoid openings, passing it by the
palate and mouth, and then drawing it with both hands, we saw away, as it
were, with the knots the fleshy bodies. After the operation, we keep the
opening separate by means of a tent resembling the wick of a lamp; and
after the third day we consume whatever is left behind by the trochisk
of Musa or the like, and at the same time use desiccative applications
to the part. Afterwards, we have recourse to epulotic trochisks, and, if
necessary, during the whole treatment we keep leaden tubes in the nose.
* * * * *
COMMENTARY. For an account of the treatment by medicines we refer to
section xxiv of the Third Book.
The author of one of the Hippocratic treatises, according to
circumstances, recommends sawing it out, consuming it with septics, tying
it with a ligature, and burning it with a red-hot iron. (De Morbis, ii.)
In the ‘Isagoge’ of Galen, it is merely recommended to cut out the
tumour, and to scrape its roots.
Celsus, like our author, recommends excision with a sharp instrument of
iron, and directs us to apply afterwards to the part a tent smeared with
some styptic. A proper dressing is then to be applied for cleansing the
sore. (vii, 10.)
Oribasius briefly mentions excision as a proper remedy when medicines
fail.
Albucasis describes minutely the operations of excision and sawing out
the tumour. Like our author, he directs us to seize the tumour with a
hook, to pull it down, and cut it out. If any part remain, he recommends
us to scrape it out with a slender instrument, and then to apply
styptics, such as vinegar, water, or snow. The operation of sawing it out
with a thick knotted thread is minutely described by him. He also speaks
of cauterizing the part from which the tumour has been removed.
Mesue describes the process of sawing out the tumour, with some slight
differences. He recommends us to use three horse-hairs, which, being tied
together with knots, are to be introduced into the nose with a leaden
needle, and one end conveyed out by the openings of the palate; and then,
by pulling at both ends, the tumour is to be sawed out.
Avicenna, Haly Abbas, and Rhases make mention of excision and the process
of sawing out the tumour. Rhases relates the history of a case of
polypus, unusually large, which he had seen extracted in an hospital. He
and Albucasis recommend the part to be dressed with green ointment.
The veterinary surgeons appear to have depended principally upon the
actual cautery. See Vegetius (Mulom. ii, 38.)
The method of curing polypi of the nose, by sawing them out, seems
to have now fallen completely into disuse, whether deservedly or not
we cannot, from our own experience, venture to decide. Fabricius ab
Aquapendente disapproved of it; but he was evidently much prejudiced in
favour of the operation with a new forceps of his own invention. (Œuv.
Chir. ii, 24.) Sprengel informs us that this method was practised by the
surgeons of the middle ages. It is described by Brunus (Chir. Mag. ii.)
Sprengel thus explains the other operation described by our author:
“Il se servait d’un instrument particulier auquel il donnait le nom de
σπάθιον πολυπικὸν et qui était garni à l’une de ses extrémités d’un
ciseau, κυκλίσκος” (Hist. de la Méd. viii, 4.) Why does he substitute
κυκλίσκος for κυαθίσκος? That the instrument had a chisel (ciseau) at its
extremity is altogether improbable, and this supposition is unwarranted
by the context. Κυαθίσκος means the cup-like or concave end of the
instrument.
SECT. XXVI.—ON MAIMED PARTS.
When the ears or the lips have been mutilated, we restore them by first
dissecting the skin below, and afterwards bringing together the lips of
the wounds; then removing the callous parts, and afterwards sewing and
glueing them together.
* * * * *
COMMENTARY. This section is taken from Galen. (Meth. Med. xiv.) See,
also, the ‘Isagoge.’
Celsus’s observations are too minute and lengthy for our limits. Suffice
it to say, that he directs the edges to be pared, and then united with
sutures. (vii, 9.)
Rhases’ directions for the treatment of mutilated ears and noses are to
the same effect as our author’s. (Cont. xiv.) Similar ones are given by
Albucasis. He directs us to make the suture either with needles, as in
gastroraphe, or with a thread. (Chirurg. ii, 26.)
Celsus has been supposed, but, as we think, incorrectly, to touch on the
operation for the hare-lip. (vii, 10, 6.) See Sprengel (Hist. de la Méd.)
SECT. XXVII.—ON EPULIS AND PARULIS.
Epulis is a fleshy excrescence which forms upon the gums beside one of
the teeth; but parulis is an abscess which forms near the gums. The
epulis, then, we raise with a flesh forceps or a hook, and cut out; but
the parulis we divide circularly and fill the incision with tents. I
am aware that often when opened only with the common lancet used for
venesection and the matter evacuated, the disease has ceased. After the
operation we give orders to gargle with wine, then with honied water,
and afterwards apply to the wound the Flowery powder, until the cure is
completed. But if mortification attack the gums, and do not yield to the
suitable applications, we must burn the part with knob-shaped cauteries.
* * * * *
COMMENTARY. Parulis is the gum-boil. Epulis is a soft fleshy tumour which
forms on the gums. Aëtius treats fully of them. To the former he directs
us to apply at first such things as promote suppuration, after which it
may either be allowed to break of itself or may be opened with a lancet.
Styptic applications will then be proper. For the epulis he recommends us
at first to apply alum, verdigris, &c., and if these have not the desired
effect he directs us to cut it off with a scalpel. (viii, 24, 25.)
Celsus treats of both at considerable length by the name of parulides.
For that species which corresponds to the gum-boil, among other remedies,
he recommends us to hold in the mouth a decoction of figs, and directs to
open it before it is ripe, lest the matter should hurt the bone. Larger
tumours are to be cut out entire. (vi, 13.)
Haly Abbas recommends excision for the epulis, and to open the parulis in
due time with a lancet. (Pract. ix, 33.)
It appears to us that of all the ancient authorities Albucasis lays down
the best rules for treating the epulis. He directs us to cut it out with
a forceps and scalpel, and then to apply styptic powders to the part, or
if the tumour grow again, the actual cautery. For our own part, we have
generally found that no permanent cure could be effected without the
cautery. See Chirurg. (ii, 28, and i, 22.)
It is unnecessary to detail the treatment recommended by the other
authorities.
SECT. XXVIII.—ON THE EXTRACTION OF TEETH.
Having scarified around the tooth down to the socket, we must by degrees
shake the teeth with a tooth-extractor, and draw it out. But if it is
carious we must first plug up the hole with a small tent, that it may
not break when compressed by the instrument. After the extraction we may
consume the flesh that is left by sprinkling it with finely levigated
salts, and afterwards gargles of wine or oxycrate may be used until the
completion of the cure. And since sometimes supernumerary teeth are
formed, those that are fixed in the socket we must scrape down with a
graving-tool, but those that are not so fixed we must extract with a
tooth-extractor. If any tooth grow to an unnatural size, or is broken, we
may scrape away the projecting or redundant part of it with a file. The
laminæ which unite to them we may remove as may appear proper, with the
concave part of a specillum, a raspatory, or a file.
* * * * *
COMMENTARY. Cælius Aurelianus disapproves of extracting teeth, except in
cases of extreme necessity. Herophilus and Heraclides Ponticus, he says,
have related cases in which the operation had proved fatal; and in modern
times we hear sometimes of such occurrences. (Pass. Tard. ii, 4.)
Celsus directs us, when the pains of toothache cannot be got otherwise
alleviated, to separate the gums from the tooth by free scarifications,
and then to shake it until it is loosened, and forbids us to proceed
rashly to perform extraction, for fear of occasioning dislocation of
the jaw-bone, or, if the tooth belong to the upper jaw, of hurting the
temples or eyes. If loose, it is to be taken out with the hand, but
otherwise with a forceps, and, if eaten, the hole is to be filled with a
tent, or with lead, to prevent it from breaking during extraction. The
instrument is to be pulled direct, lest the spongy bone to which the
tooth is fixed should be broken. Of this accident occurring there is, he
adds, considerable danger; and not unfrequently when the tooth is short
and its roots long, the instrument takes hold of a piece of bone and
breaks it; in which case he directs us to extract the broken piece with
a pincers. When the teeth are carious he directs us to scrape them, and
apply to them a mixture of the flowers of roses, galls, and myrrh, and
to hold undiluted wine in the mouth. When the teeth are slackened by any
accident, he directs us to fasten them to the surrounding ones with a
golden thread, and then to hold some stringent decoction in the mouth.
When in young persons a second tooth appears before the first has fallen
out, he recommends us to scarify around the latter and pull it out, and
to endeavour to force the other gradually into its proper place. Stumps
of teeth are to be taken out with a stump-extractor. (vii, 12.)
Scribonius Largus makes some ingenious observations on the extraction of
teeth, but disapproves of the operation, except in extreme cases. (De
Comp. Med. i, 10.)
Galen, and the medical authorities subsequent to him, direct us to file
down teeth when they are diseased and project, but disapprove in general
of extraction.
Albucasis is particularly full in treating of the operations on the
teeth. Like our author, he recommends us to perform extraction by first
making free scarifications, and then pulling the tooth direct with a
forceps, the patient’s head being held between the knees of the operator.
When the tooth is hollow he directs us to stuff it beforehand with a
tent of cloth. When a piece of the alveolar process has been broken, he
properly recommends that it be taken out. He gives suitable directions
for filing down the teeth, and for fastening them with gold threads. He
gives drawings of instruments for extracting roots. (Chir. ii, 30.)
The other Arabians describe the operation, but less precisely than
Albucasis. Haly’s directions are judicious. He recommends the operator to
use a forceps, and to stuff the tooth when it is hollow. (Pract. ix, 31.)
SECT. XXIX.—ON CONSTRICTION OF THE TONGUE, OR TONGUE-TIED PERSONS.
The affection called ancyloglossus is sometimes congenital, the membrane
which fastens the tongue being originally harder and more constricted
than ordinary; but sometimes is acquired from some hard cicatrix formed
under it by ulceration. Those therefore who have this affection
naturally are distinguished by being slow in beginning to speak, and
by having the frænum linguæ larger than its moderate size, and that
without any previous ulceration. When the complaint is occasioned by a
cicatrix it is easily recognised. Wherefore the patient is to be placed
on a proper seat, the tongue raised to the roof of the mouth, and the
membranous frænum cut transversely. But if the curvature is occasioned by
a cicatrix, we transfix the callus with a hook and draw it upwards, and
making a cross incision free the bent part, taking care not to make deep
incisions of the parts; for hemorrhages which have been found difficult
to stop have thereby been occasioned. After the operation the part is to
be washed with cold water or oxycrate; and after all these things the
cure is to be completed with relaxing and incarnative applications.
* * * * *
COMMENTARY. Celsus thus describes the treatment in congenital affections:
“Horum extrema lingua vulsellâ prehendenda est, sub eâque membrana
incidenda, magnâ curâ habitâ, ne venæ quæ juxta sunt, violentur et
profusione sanguinis noceant.” (vii, 12, 4.)
Aëtius’s plan of treatment is quite similar to our author’s. (viii, 38.)
Albucasis gives a similar account of the operation. He cautions against
opening the artery below the tongue, for fear of hemorrhage. Should
this accident occur he directs the surgeon to use the actual cautery.
(Chirurg. ii, 34.)
Rhases recommends when the frænum extends to the tip of the tongue
that it be divided, so as to allow freedom of motion. However, one of
the authorities quoted by him directs us to pass through the frænum a
needle armed with a thread, which is to be tightened so as to divide
the intermediate space. He recommends this method in order to obviate
the fear of hemorrhage from the incision. Rhases himself states that a
dangerous hemorrhage will result from opening the green veins below the
tongue. (Cont. vii, 1.)
Avicenna also recommends the operation with the ligature. (iii, vi, 11.)
Haly Abbas describes very distinctly the operation of dividing the
frænum. (Pract. ix, 35.)
Alsaharavius mentions that the operation is sometimes necessary. (Pract.
ix, 35.)
SECT. XXX.—ON ANTIADES, OR INDURATED TONSILS.
As indurated glands are called strumæ, so the almonds of the ears when
inflamed, swelled, and as it were, dried, occasioning difficulty of
deglutition and of breathing, are called antiades, from their being
placed opposite one another. When therefore they are inflamed we must
not meddle with them; but when the inflammation is considerably abated,
we may operate, more especially upon such as are white, contracted, and
have a narrow base. But those which are spongy, red, and have a broad
base, are apt to bleed. Wherefore, seating the person in the light of the
sun, and directing him to open his mouth, while one assistant holds his
head, and another presses down the tongue to the lower jaw with a tongue
spatula, we take a hook (tenaculum) and perforate the tonsil with it, and
drag it outwards as much as we can without drawing its membranes along
with it; and then we cut it out by the root with the scalpel suited to
that hand, called ancylotomus, for there are two such instruments, having
opposite curvatures. After the incision of one we may operate upon the
other inversely in the same manner. After the operation the patient must
gargle with cold water or oxycrate; and if any hemorrhage come on he may
use a tepid decoction of brambles, roses, and myrtle-leaves; or if the
blood flows copiously we must give for a gargle the juice of plantain and
comfrey, and the trochisk from amber and the Lemnian earth, dissolved in
oxycrate. When the hemorrhage stops, the parts on the next day may be
anointed with the flower of roses, saffron, and starch with milk, or with
water, the white of an egg, or hydrorosatum. When sordes collect about
the ulcers, we may use injections and linctuses made from honey.
* * * * *
COMMENTARY. Celsus directs us when the tonsils are indurated to scrape
the membrane with the finger, and tear it out; or, if this does not
succeed, to seize the tumour with a hook or tenaculum, and cut it out;
then the wound is to be washed with vinegar, and a styptic medicine
applied to it. (vii, 12.)
Aëtius directs us to seize the tonsil with a hook and cut it out at
the middle. When cut out at the base, he remarks there is danger of
hemorrhage. (viii, 57.)