Albucasis directs us to make the patient sit with his head on the

operator’s bosom, and, while an assistant presses down his tongue, the

operator is to seize the indurated tonsil with a hook, and drawing it

out, to cut it off with a sharp instrument resembling a forceps, or,

in other words, with a pair of scissors. He likewise gives a drawing

of another instrument which consists of a lunated piece of iron fixed

to a handle. He relates an interesting case in which he performed the

operation. (ii, 36.)

Rhases, upon the authority of a surgeon called Ancilisius, in the

barbarous translation of his works, which probably is a corruption of

Antyllus, briefly describes this operation. He directs us to open the

mouth and take hold of the tonsils, the fourth part of which may be cut

off. He recommends us to make the patient gargle with vinegar. He forbids

the operation when the tonsils are enlarged and red. (Contin. vii, 2.)

Haly Abbas (Pract. ix, 36,) and Mesue (de Ægr. Gutturis, 4,) describe the

operation, but not so minutely as Albucasis.

Guido de Cauliaco copies the descriptions of Albucasis and Haly Abbas.

(c. vi, 2.)

SECT. XXXI.—ON THE UVA.

The uvula being, as it were, the quill or plectrum of the organ of

speech is often the seat of defluxion from the head, and becoming

preternaturally enlarged, of a lengthened form and slender shape, it

is called columella; but when thick below and round it is named uva,

from its resemblance to a grape, as the other is so called from its

resemblance to a column. If, therefore, it cannot be made to yield to

general treatment,—I mean evacuations by bleeding and purging,—nor to

topical, such as astringents, repellents, and discutients,—we must

proceed to the operation, lest, by its constant irritation, it bring

on coughs, sleeplessness, and even suffocation. Such, therefore, as

are contracted, round, not of a lengthened shape, bloody, or somewhat

black, we must decline operating upon; but those that are slender,

long, small at the extremity, loose, not very bloody, but whitish, we

must operate upon; for the inflammation of them soon subsides. We must

only take away as much of the uva as exceeded its natural size; for the

complete extirpation of it proves greatly injurious to the parts about

the chest, and occasions the loss of voice. Wherefore, having placed

the patient on a seat in the rays of the sun, and directed him to gape

wide, we seize with the forceps adapted for this purpose, or a common

tenaculum, upon the redundant part and drag it downward, and cut it out

with the instrument called staphylotomus, or the scalpel used in the

operation for the suture of the upper eyelid. After the operation the

same things are to be done as are recommended for angiology. But since

often, from the timidity of the patient, or the fear of the hemorrhage,

or the success attending the treatment by medicines, he declines the

operation by instruments, we may rather consume it by means of a caustic

medicine. Wherefore, taking the caustic used for burning the eyelids,

or some such, we are to fill with it the hollows of the instrument

called staphylocaustos, and directing the patient to gape wide, and

getting the tongue pressed down with a tongue spatula, we open the

instrument sufficiently and grasp with it as much of the uva as we cut

off in the other operation. The medicine must neither be of too liquid

a consistence, lest it run down from the uva improperly, and burn the

adjoining parts (and, therefore, we direct the patient not to swallow

during the whole operation of burning), nor very hard, that it may soon

act upon the uva. And if from one application the extremity of the uva

become black, this will be sufficient, but if not we must use it again.

During the whole time of its action the patient must sit with his head

bent forwards, in order that the saliva which is melted down with the

portions of the medicine may flow from the mouth. The part becomes dead

in one hour, and falls off about the third or fourth day. After the

burning, having wrapped the index-finger round with soft wool or tow,

we wipe the parts about the uvula, or direct the patient to gargle with

water. But after this operation, and also that on the tonsils, soothing

fomentations from the oil of camomile are to be applied around the neck,

and in like manner we may use gargles and liniments.

* * * * *

COMMENTARY. It appears from the Hippocratic treatises that excision of

the uvula was sometimes performed in early times. (Prognost. de Morbis,

ii; De affect.)

Celsus recommends us not to meddle with the operation when the uvula is

red and enlarged, for fear of hemorrhage; but when it is slender, sharp,

and white, or when it is pale and thick below, but slender above, it may

be extirpated without danger. For this purpose he merely directs us to

seize upon it with a forceps and cut it out. (vii, 12.)

Galen describes fully the operation by medicines, but says nothing of

excision. (De Med. sec. loc. vi.) Aëtius describes the operation in

nearly the same terms as our author. He directs us to grasp the enlarged

uvula with a forceps and cut it off, using afterwards some astringent

gargle. (viii, 44.) Oribasius briefly mentions the operation, which he

directs to be performed with extreme circumspection. (Med. Collect. xxiv,

10.)

Albucasis describes the operation similarly to the Greeks. He directs the

operator to get the patient’s tongue pressed down by an assistant; when

the operator is to seize upon the uvula and cut off as much as is proper

of it. He gives a drawing of an instrument for the operation with caustic

medicines. (Chirurg. ii, 37.)

Avicenna’s description is to the same effect, but not so circumstantial.

(iii, 9, 15.) Mesue directs us to perform the operation with a heated

scalpel of gold. (De Ægr. Gutturis, 3.)

Rhases states that when the uvula is enlarged, but is not red, the

operation may be performed without danger. He mentions that some

preferred the actual or potential cautery, but that he preferred

excision. He describes, but not distinctly, an instrument for applying

the caustic medicines. He states that loss of the entire uvula impairs

the voice and exposes the lungs to danger from cold. (Contin. vii; and

Divis. i, 49.)

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

Thorns, or the bones of fishes, or other substances, are often swallowed

in eating, and fix in different places. Wherefore, such as can be seen

we are to extract with the forceps for that purpose; but those which

are lower down in the gullet we must manage differently. Some are of

opinion that the patient ought to be made to swallow large morsels, such

as the stalk of lettuces, or pieces of bread; but others direct us to

bind a thread about a small piece of clean soft sponge and give it to

the patient to swallow, and then taking hold of the thread to draw it

up, and to do this frequently in order that the thorn may get fixed in

the sponge and be brought up. Leonidas orders suppurative cataplasms to

be applied, such as those from raw barley-flour, in order that the part

may be converted into pus and the thorn fall out of its own accord. If

we see the patient at the time of swallowing, before digestion has taken

place in the stomach, and cannot perceive the substance which is fixed,

we may order him to vomit by pushing the fingers or feathers down the

throat, for sometimes the thing which is fixed will be brought up with

the matters that are vomited.

* * * * *

COMMENTARY. Our author’s directions are mostly taken from Aëtius. (viii,

50.)

Albucasis repeats our author’s directions, and further recommends us,

when they fail, to introduce an instrument made of lead, which he gives

a drawing of, and either to extract the substance or push it downwards.

(Chirurg. ii, 38.) A similar plan of treatment is recommended by Mesue

(de Ægr. Gutturis); by Avicenna (iii, 9, 43); and by Alsaharavius (Pract.

xii.) When a morsel of food sticks to the œsophagus, Alsaharavius directs

that the person should be struck on the back, which will facilitate the

descent of it. (6.)

SECT. XXXIII.—ON LARYNGOTOMY.

The most famous surgeons have also described this operation. Antyllus,

therefore, says, “In cases of cynanche (as we will explain under the

head of Dietetics) we entirely disapprove of this operation, because the

incision is utterly unavailing when all the arteries (the whole of the

trachea?) and the lungs are affected; but in inflammations about the

mouth and palate, and in cases of indurated tonsils which obstruct the

mouth of the windpipe as the trachea is unaffected, it will be proper to

have recourse to pharyngotomy, in order to avoid the risk of suffocation.

When, therefore, we engage in the operation we slit open a part of the

arteria aspera (for it is dangerous to divide the whole) below the top of

the windpipe, about the third or fourth ring. For this is a convenient

situation, as being free of flesh, and because the vessels are placed

at a distance from the part which is divided. Wherefore, bending the

patient’s head backwards, so as to bring the windpipe better into view,

we are to make a transverse incision between two of the rings, so as that

it may not be the cartilage which is divided, but the membrane connecting

the cartilages. If one be more timid in operating, one may first stretch

the skin with a hook and divide it, and then, removing the vessels aside,

if they come in the way, make the incision.” These are the words of

Antyllus. We judge that the windpipe has been opened from the air rushing

through it with a whizzing noise, and from the voice being lost. After

the urgency of the suffocation has passed over, we pare the lips of the

incision so as to make them raw surfaces again, and then have recourse

to sutures, but sew the skin only, without the cartilage. Then we use

the applications proper for bloody or fresh wounds, but if it does not

unite we must treat it with incarnants. We must follow the same plan of

treatment if we should meet with the case of a person who had cut his own

throat from a wish to commit suicide.

* * * * *

COMMENTARY. Aretæus makes mention of this operation in such terms as

proves that it must have been practised occasionally in his time. He,

however, does not approve of it, at least in cases of angina. (De Curat.

Morb. Acut. i, 7.)

Cælius Aurelianus says that Asclepiades performed the operation in cases

of cynanche; but he himself disapproves of it. (De Morb. Acut. i, 7.) We

may mention further in this place that Avicenna, Avenzoar, Haly Abbas,

Mesue, and Rhases express themselves rather favorably of the operation in

urgent cases of cynanche. From the circumstance mentioned by Pollux of

cynanche, that it mostly attacks children, we are inclined to think that

the ancients meant the _croup_ by it.

None of the Greek authorities, except our author, have left a description

of the operation. Psellus, however, mentions it in such a manner as

would lead us to infer that the operation had not been lost sight of in

his time, i. e. “Laryngotomy is a certain surgical operation.”

Avicenna and Albucasis merely copy our author’s description, and appear

to have never seen the operation performed. To show, however, that the

windpipe may be opened without occasioning death, Albucasis relates the

case of a female who cut her trachea while attempting to commit suicide;

in which case, by sewing up the wound, he effected a cure without

difficulty. (Chirurg. ii, 13.)

Rhases mentions that, in cases of cynanche which threaten instant death,

a certain physician, Ancilisius (Antyllus?) recommends the surgeon to

open the windpipe. His description of the operation is as follows: The

patient’s head being kept back the skin is to be divided, and the sides

of it separated by means of threads, so as to expose the windpipe, which

is to be opened by making an incision in the membrane which connects two

of the rings together. After the abcess bursts the wound is to be sewed

up. (Cont. vii, 2.)

Haly Abbas likewise describes the operation accurately. He directs us to

make an incision in the skin, and to separate the edges with hooks so as

to expose the windpipe, which is to be opened between two cartilages.

(Pract. ix, 38.)

The modern history of the operation is given in Van Sweiten’s Comment.

(814); Mémoires de l’Acad. Royale (ii); and Cooper’s Surgical Dictionary.

See a complete history of the operation by Sprengel. (Hist. de la Méd.

18, 6.) He says, that Anthony Benivieni, a surgeon of Florence, is the

first after Antyllus who is known for certain to have performed the

operation.

SECT. XXXIV.—ON ABSCESS.

That the abscess is a corruption and transmutation of the flesh or

fleshy parts, and what are its modes of formation, and how many kinds

of abcesses there are, we have sufficiently explained in the Fourth

Book. Now we have only to treat of the operation upon it. If it be

completely changed to pus, which we ascertain from the pains, fever (if

any was formerly present), redness, pulsation, and the other symptoms

of inflammation being diminished, from the swelling assuming a sharp

point, and from pus being felt under the fingers upon pressure, more

especially if the abscess be superficial, in that case we may proceed

to the operation. But if it is not felt to the touch, nor is elevated

to a point, owing to its being deep-seated, we must attend to the other

symptoms before operating. It is to be understood, however, that before

the conversion to pus is completed, we sometimes open abscesses when

they are unripe, on account of their being near joints or vital parts,

lest, by their continued putrefaction, a ligament or some necessary part

should be corrupted by it. And Hippocrates directs us to open abscesses

about the anus before they are completely ripened, for fear of their

perforating the intestine. In opening them we must not, in all cases,

make the incisions in the same manner, but observe the natural lines—as

on the face; and the growth of the hairs—as on the head, and taking as

much care as possible not to occasion deformity. Straight incisions

are to be made in the legs, as in the muscles and tendons; and nerves,

arteries, and vital parts are to be avoided, taking care of their safety

by sometimes making a straight incision and sometimes a transverse one

into the abscess, according to the circumstances of each case. When the

abscesses are small we make one incision, but when they are larger we

make more, always dividing the thinner parts, and those which are most

convenient for the escape of the matter. When the swelling is much raised

up to a point, unconcocted, thin, and devoid of vitality, we must cut out

a piece either like a triangle, or like a myrtle leaf, or of some other

angular figure, because the circular is unfavorable to cicatrization.

Those which are not pointed we open by a simple incision, and when we

find a sinus, if the part is fleshy and the skin proper for uniting,

we only make such incisions into the part as will allow the matter to

be discharged; but if it be thin and very devoid of flesh we make a

simple incision along its whole length; and after this simple incision,

if the parts on each side appear thin and not fleshy we must pare them

off. After the operation, having first sponged the part, if the abscess

be small, and if only one incision has been made, we may use a simple

pledget, but if it be large, and there be many incisions, we draw through

them a fillet which can be easily extracted; and when the part has been

cut out we fill it in like manner with lint. If a hemorrhage take place

we must use cold water or oxycrate, and if the bleeding continue we may

sprinkle upon the part finely powdered chalcitis, which we may also have

recourse to often when the part is gangrenous and flaccid. In winter,

and when the parts are nervous, we may soak oblong pledgets in wine and

oil and apply them; and in summer, when the parts are fleshy, we may

soak these applications in water and oil, or in the same cold wine and

oil, and binding them, on the following day we may bathe with the same

fluids; but on the third day, having loosed the dressings and sponged the

parts, we may use the application called tetrapharmacon on a pledget, and

if there be no inflammation present we may apply the same wash for the

preservation of the pledget; but if there be inflammation, we must apply

a digestive cataplasm, having first poured water on the parts. When the

inflammation abates we may effect the cure by promoting suppuration and

incarnation. Sinuses are to be cured by agglutinative remedies, as has

been said, in the Fourth Book, on sinuses.

* * * * *

COMMENTARY. All the authors quoted under this head in the Fourth Book may

be consulted.

Celsus is more than usually prolix in laying down the rules for the

surgical treatment of abcesses. Before the abscess harden, he directs us

to make incisions in the skin, and apply a cupping instrument, in order

to remove any symptoms of inflammation which may have been present,

or, in other words, to procure resolution. Sometimes, however, as he

explains, the matter is collected in a cyst (tunica), in which case it

is not to be supposed that the contents of the abscess can be removed

by a cupping instrument. When the pus ripens it is seldom proper to let

it out if seated in the armpits, or groins; nor when the collection is

superficial, or in the flesh; and it is better, as he prudently directs,

to apply cataplasms until the pus make an opening for itself. When it is

judged necessary to open an abscess, he recommends us, if not seated in

a nervous part, to perform the operation with a red-hot iron, because a

small opening made in this manner will remain longer open. Abscesses in

nervous parts are to be opened with a scalpel. In making an incision,

the form and size of it are to be considered. In general the openings

are to be made as small as possible; but large sinuses require larger

incisions, and sometimes two or three are necessary: when the skin is

livid or diseased it sometimes must be cut off to further the cure. In

this case an opening is to be made of the shape of a myrtle-leaf. When

the pus is evacuated, if in the armpit or groins, no pledget is to be

used, but a sponge out of wine is to be applied. In other places, a

little honey is first to be used; then agglutinative medicines; and above

these likewise, if necessary, a sponge squeezed out of wine. (vii, 2.)

The treatment of abscesses is fully explained by Galen. (Therap. ad

Glauc. ii.) He directs us, when an abscess is slow of ripening, to make

superficial scarifications in it, and afterwards to apply a cataplasm of

barley-meal.

Aëtius’s directions are, upon the whole, similar to our author’s, but

not quite so minute and precise. Like our author, he directs us to make

the incision long and narrow, like a myrtle-leaf. The ancients were well

aware that circular sores are slow of healing; and the causes of this

fact are fully explained by Cassius and Alexander Aphrodisiensis.

Little additional information is to be obtained from the other

authorities. Albucasis directs us, when the abscess is large, not to

evacuate all its contents at once, lest it produce dangerous prostration,

especially if the patient be weak; for, he remarks, the animal spirits

will escape along with the pus. Like our author, he forbids us to open

abscesses until they are ripe, unless seated near the anus, or some vital

part. (Chirurg. ii, 40.)

Haly Abbas justly remarks that if an abscess be opened prematurely,

the lips of it remain in an indurated state, and prevent the sore from

healing. But when seated near nerves or ligaments, he advises not to wait

until it is ripe. His treatment upon the whole does not differ from our

author’s. (Pract. ix, 8.)

The method of opening abscesses, by means of caustic applications, is

described in the Fourth Book, 18.

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

The chœras, or scrofula, is an indurated gland, mostly forming in the

neck, armpits, and groins, deriving its name either from a Greek word,

signifying a species of rock, or from swine, because they are fruitful

animals, or because swine have swellings of the neck. The strumæ are

formed either on the anterior part of the neck, or on either side of

it, or on both, and they consist of one, two, or more, all contained

in their proper membranes, like the steatoma, atheroma, and meliceris.

Those, therefore, which are painful to the touch, and on the application

of medicine, are of a malignant nature, are to be considered as

carcinomatous and it is obvious that they do not readily yield to a

surgical operation. But such as are mild to the touch and the seasonable

application of medicines, may be operated upon in this manner. To such as

are superficial and incline towards the skin we use a simple section, and

free them from the surrounding bodies, and stretching the skin with hooks

we flay the lips of the incision, as we said in describing the operation

of angiology, and by degrees remove them entirely. But such as are

larger, having transfixed them with hooks, we raise up, and dissecting

away the skin from them in like manner, we must free them entirely from

the surrounding bodies, avoiding in particular the carotid arteries and

recurrent nerves. If any divided vessel obscure the operation, we may

include it in a ligature, or cut it asunder, if not large. And when

the base of the scrofulous tumour runs out into a narrow point, we may

cut it away readily, and introducing the index finger search if there

be any other strumæ lying there, and remove them in the same manner.

But if we suspect that a large vessel or vessels are situated at the

bottom of the scrofulous tumour, we need not cut it out from the base,

but include it in a ligature, so that it may fall off spontaneously in

pieces without danger, when we may effect the cure by the application of

lint; but if cut away at once we may unite the lips of the incisions. The

incisions are to be made direct, and if there be nothing redundant we

may immediately sew them up. But, if owing to the size of the scrofulous

swelling there be a redundancy of skin, having cut away a part of it like

a myrtle-leaf, we may have recourse to sutures, and use the applications

for recent wounds.

* * * * *

COMMENTARY. See all the authors referred to in the 34th section of the

Fourth Book.

Galen briefly recommends incision or septic applications. He relates an

unfortunate case in which an ignorant surgeon, by cutting the recurrent

nerve, occasioned loss of speech. (See Meth. Méd. xvi; and Loc. Affect.

i, 6.)

Aëtius gives a long extract from Leonidas on the treatment of scrofula.

His directions for dissecting out the tumours in the neck are such as

experience alone could have dictated. In operating on the neck, he

cautions us to avoid the jugular veins, carotid arteries, and the nerves

of speech, and with this intention he recommends us rather to make the

incisions longitudinal than transverse. When the tumour is small a simple

incision, he says, will be sufficient; but if large, the skin is to be

cut in the form of a myrtle-leaf, and the lips of the incision being

stretched with hooks, the skin is to be separated from the struma with

the fingers and a scalpel; but the base of the tumour is to be cut with

great caution. He does not, like our author, make any mention of the

ligature. When there is a discharge of blood he recommends styptics. (xv,

5.)

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

Haly Abbas, Avicenna, and most of the Arabian authorities approve of

excision, and describe the operation in much the same terms as our

author. Albucasis directs us when there is a large vein at the bottom of

the tumour to apply a ligature round its root, and allow it to drop out

by putrefaction. When the contents of the tumour are fluid, he recommends

us to open it, and apply an ointment to consume the corrupted flesh;

after which incarnants and detergents are to be used. When scrofulous

tumours resist, the ordinary treatment, he directs us to burn them with a

red-hot iron.

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

These also belong to the class of abscesses, but differ from them in

this respect, that those which are properly called abscesses are of an

inflammatory nature, painful, and contain an acrid and corroding fluid;

neither are they surrounded by a proper membrane or tunic. They differ

from one another, in as much as that which is contained in the steatoma

is, as its name implies, like suet; that which is in the atheroma is

like pap made from corn; while the fluid in the meliceris is like honey.

You may distinguish them from one another thus. The steatoma is harder

than the others, is unyielding to the touch, and has a narrower base.

The meliceris conveys to the touch the sensation of a soft body, is

slowly diffused, and soon returns again to its shape. We operate upon

them as upon scrofulous tumours, by incision, dissection, sutures, and

the rest of the treatment, only avoiding to wound the membrane, lest

its fluid contents be poured out and obstruct the operation, and lest a

part of it should be left behind, which often occasions a renewal of the

complaint at the wrists, ankles, and the moveable parts about joints, as

a scrofulous tumour does in like manner, if the whole or a part of it be

left behind. If any such thing be left it will be better not to sew up

the wound, but to consume the remainder with septic applications.

* * * * *

COMMENTARY. We have given an explanation of the nature of these tumours

in the Fourth Book.

Galen states that the indications of cure in all these cases are to

discuss their contents, produce putrefaction of them, or to cut them out.

The steatoma, he remarks, being of a solid nature, can be remedied only

by an operation. (Meth. Méd. xiv.)

Celsus directs us, in extirpating steatomatous tumours, to open the cyst

and evacuate its contents; but recommends not to wound the cyst of the

others. Should the whole or part of the cyst be unavoidably left behind,

he directs suppurative applications to be used. After the operation he

directs us to unite the lips of the wound by a clasp (fibula) and an

agglutinative medicine. (vii, 6.)

The surgical treatment of these tumours is very fully laid down by

Aëtius, in an extract from Leonidas; but his description is so long that

we cannot do justice to it within our narrow limits. Like Celsus, he

directs us to avoid wounding the tunics which surround the atheroma and

meliceris; but states that this may be done in the case of the steatoma.

He judiciously directs the skin to be cut in the form of a myrtle-leaf.

(xv, 7, 8.)

Albucasis directs us, in the first place, to prick the tumour, in order

to ascertain the nature of its contents. When they are found to be fatty,

he recommends us to cut it out by making a crucial incision, and removing

it with its cyst if possible. When the cyst is wounded he directs us to

dissect it out in pieces, and to endeavour to leave no part of it behind.

He gives drawings of various instruments, namely, scalpels, tenacula, and

perforators, for dissecting out these tumours. (ii, 45, 46.)

Rhases and Avicenna give very judicious directions for the treatment of

these tumours, but they scarcely differ at all from those of Aëtius and

our author. They recommend us to avoid opening the cysts of the atheroma

and meliceris, if possible; but if any part remain they direct us to

destroy it by septics. (Contin. xxvii.)

SECT. XXXVII.—ON ANEURISM.

Aneurism is a tumour soft to the touch and yielding to the fingers,

having its origin from blood and spirits. Galen says “an artery having

become anastomosed (i. e. dilated) the affection is called an aneurism;

it arises also from a wound of the same, when the skin that lies over

it is cicatrized, but the wound in the artery remains, and neither

unites nor is blocked up by flesh. Such affections are recognised by the

pulsation of arteries; but, if compressed, the tumour disappears in so

far, the substance which forms it returning back into the arteries.” Thus

Galen.—But we distinguish them from one another in this way: That formed

from anastomosis of an artery appears longer, is deep seated, and when

pressed upon by the fingers, a sort of sound is heard; whereas no noise

is heard in the cases arising from rupture, and these, moreover, are more

rounded, and feel superficial. Those therefore which form in the armpits,

groin, and neck, and those in other parts of the body, which are very

large, we must decline operating upon, on account of the largeness of

the vessels. But those which occur in the extremities, the limbs, or the

head, we operate upon thus. We make a straight longitudinal incision in

the skin, and then having separated the lips with hooks, as we mentioned

in the operation of angiology, and having dissected away the skin, and

separated it with the instruments used for operations on membranes, we

lay bare the artery, and passing a needle under it, and tying it with

two ligatures, and having first divided the intermediate part of the

artery with a lancet used for bleeding, and evacuated its contents, we

have recourse to the suppurative treatment until the falling off of the

ligatures. If the aneurism be occasioned by rupture of the artery, we

must seize in the fingers along with the skin as much as possible of the

aneurism, and then below what we hold in our hand we push a needle having

a double thread, and after it has passed through we cut the double, and

thus with the two threads we bind the tumour on this side and on that,

as we mentioned for staphyloma. If any apprehension be entertained from

the falling off of the ligatures, we must push another needle entirely

through, in the course of the first, having in like manner a double

thread, and, cutting the noose into four pieces, we may bind the tumour.

Or, having opened the tumour in the middle, after the evacuation of its

contents, we cut away what is redundant of the skin, leaving what is

secured with the ligatures, and applying an oblong compress soaked in

wine and oil, we have recourse to the treatment by lint.

* * * * *

COMMENTARY. Galen, we believe, is the first author who treats of

aneurism. He states that he had known cases in which an aneurism had been

occasioned by a wound of the artery at the bend of the arm in performing

venesection. He relates the case of a cure having been accomplished by

the application of a sponge with bandages. (Meth. Med. v, 7.) The passage

quoted by our author is from his work De Tumoribus (11.)

Aëtius gives a most interesting account of aneurism. He states that

it arises most frequently in women during labour, owing to the breath

being violently retained, but that it may take place in any part of

the body from a wound, as when an unskilful surgeon in opening a vein

at the bend of the arm, opens an artery at the same time. It proceeds,

he says, either from rupture or dilatation, and its contents are blood

and spirits. The symptoms of an aneurism are a swelling of a smaller

or larger size, without change of colour, free from pain, of a spongy

softness, disappearing upon the pressure with the fingers, and returning

again when they are removed; this last symptom being particularly

characteristic of aneurism from dilatation. But when it arises from a

wound the tumour is not equally soft, as the blood becomes coagulated.

With regard to the treatment, he declares that aneurisms in the neck and

head ought not to be interfered with; but when the disease arises at the

bend of the arm he directs us to proceed in the following manner. In the

first place having marked the course of the artery from the armpit to

the fore-arm, we are to make a simple incision, three or four fingers’

breadth below the armpit along the inside of the arm, where the artery

is most superficial; and having laid it bare and separated it from the

surrounding parts, to seize the artery with a blunt hook and bind it

with two ligatures; after which it is to be divided between them, and

the wound filled with fine frankincense, and a suitable pledget of lint

bound over it. The swelling at the bend of the arm may then be opened

without any fear of hemorrhage. When the coagula have been cleared away

the artery from which the blood was discharged is to be seized with a

hook, secured and divided like the former; after which the wound is to be

filled with fine frankincense, and suppuration promoted. (xv, 10.)

Albucasis treats of aneurism in the following terms. When an artery

is divided, and the skin heals over it, a tumour frequently is the

consequence, and the same thing sometimes happens from the wound of a

vein. Aneurism of an artery is characterized by a deep-seated tumour in

the situation of an artery, the swelling subsiding when pressed upon by

the fingers, and being attended with a hissing sound. When it arises

from the wound of a vein it is round and exposed. He adds, to open such

tumours, especially if seated in the armpits, groins, and neck would be

a fatal mistake. When the aneurism arises from dilatation of the artery,

we are to make a longitudinal incision, and having dissected away the

artery from the surrounding parts, to pass below it a needle armed with

a double thread, and to tie the threads in two places as recommended

in angiology. The part between the two ligatures is then to be divided

and the blood evacuated. Suppurative applications are then to be made,

until the ligatures fall out; after which suitable ointments are to be

applied. If the disease arise from the opening of a vein, we are to grasp

as much as possible of the tumour in the hand, to push a needle through

it armed with a double thread, when the aneurism is to be firmly bound

with the threads in the manner described in the operation for staphyloma.

When danger is apprehended from the falling out of the threads, we are to

introduce another needle armed with another thread under the whole tumour

at the opening made by the first needle, and to tie the threads in four

places. The aneurism is then to be cut in its middle, and its contents

evacuated, when the superfluous skin is to be removed, and a compress

dipped in wine and oil applied. (Chirurg. ii, 49.) The threads which he

speaks of are meant to decussate one another like the letter Χ. This part

of his description is somewhat obscure.

We need scarcely remark that the operation of Albucasis is exactly the

same as our author’s.

Rhases borrows his account of aneurism from Antyllus and Paulus. The

operation of Antyllus consisted of tying the artery above and below the

tumour, and then evacuating its contents. (xiii, 7.) He states that

when the disease occurs in the hams, groins, or neck, it is dangerous

to meddle with it, but that when seated in the extremities it is easily

cured. All the cases in which he had known the artery to be opened during

the performance of venesection had terminated in aneurism, except one in

which a cure was effected by compression. (Cont. xxviii.)

Haly Abbas directs us when an artery has been wounded in bleeding, to

dissect away the parts about it, and having applied a silk thread on each

side of the wound, to divide the artery in the middle. When an aneurism

takes place he recommends a plan of treatment similar to that recommended

by Albucasis. (Pract. ix, 45.)

Avicenna and Alsaharavius do not describe the operation. Alsaharavius

directs us when an artery has been opened in bleeding at the arm, to

attempt a cure by means of compresses and tight bandages. (Pract. xxix,

11.)

It will be perceived from the foregoing account of the practice

recommended by Aëtius, that the ancient surgeons were aware of the

advantages of securing the artery above the seat of the aneurism, as

practised by the late Mr. John Hunter, and that they actually had

recourse to two ligatures in the manner directed by Mr. Abernethy; but

that they afterwards opened the tumour and evacuated its contents, not

having yet learned from experience to trust to the absorbent powers of

the system. It will likewise be remarked that carotid, axillary, and

inguinal aneurisms were in ancient times abandoned as incurable; so that

modern surgery may undoubtedly boast of having so far improved upon the

practice of the Greeks and Arabians.

Sprengel gives an interesting history of the operation for aneurism.

(Hist. de la Méd. xviii, 3.) According to him, John de Vigo was the first

who conceived the idea of curing aneurism by compresses and styptics.

This, however, is not exactly true, for, as mentioned above, Galen,

Rhases, and Alsaharavius recommended compresses and bandages to prevent

aneurism after the accident which most commonly gives rise to it.

SECT. XXXVIII.—ON BRONCHOCELE.

A large round tumour forms on the neck from the inner parts, whence it

obtains the appellation of bronchocele, of which there are two varieties,

the steatomatous and the aneurismatical. The aneurismatical we judge of

from the symptoms of aneurism, and abandon as hopeless, like all other

aneurisms which it is dangerous to meddle with, as is the case most

especially with those of the neck, owing to the size of the arteries.

The steatomatous we operate upon like steatomes in general,

distinguishing and avoiding the vessels, in the same manner as we

described for strumæ.

* * * * *

COMMENTARY. The surgical operation for bronchocele is described by

Celsus. He says that its contents may be evacuated by caustics, but that

the knife is a more expeditious process of cure. For this purpose he

directs us to make a single incision down to the cyst, and to dissect

it from the surrounding parts with the fingers. When its cyst cannot be

removed he recommends us to destroy it with caustic medicines. (vii, 13.)

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

author.

The poet Juvenal alludes to the prevalence of bronchocele among the

people at the foot of the Alps. (Sat. xiii, 162.)

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

Rolandus, Guy of Cauliac, and other of the earlier modern authorities,

direct us to remove the tumour by means of two cross setons.

SECT. XXXIX.—ON GANGLION.

A ganglion is a round tumour of a tendon, arising from a blow or violent

exercise, being formed most frequently about the wrists, ankles, and

the parts about a joint which are much moved, but likewise in the other

parts. It is attended with a swelling, which is free from discoloration,

unyielding, and without pain, but if strongly pressed upon it has a dull

feeling. It is not deep-seated, but takes its origin under the skin, and

may be moved laterally, but cannot by any means be forced forwards or

backwards. Those then which form in the legs, arms, and extremities it

is not safe to cut out, for there is danger lest the part be mutilated.

But those about the head or forehead we operate upon by dividing the

skin with a scalpel, and if the tumours be small, seizing them with a

flesh forceps and cutting them out by the roots. But if they are larger,

we transfix them with hooks, and remove them by dissecting them from

the skin, and uniting the lips with sutures, complete the cure by the

treatment applicable to fresh wounds.

* * * * *

COMMENTARY. We have treated of ganglion in the Fourth Book, and mentioned

the principal authorities on the subject. Hippocrates and most of the

others forbid ganglia to be opened. The hard tumour on the head, to

which likewise he applies the name, may safely be removed in the manner

described by our author. Albucasis repeats his directions. (Chirurg. ii,

50.)

Haly Abbas recommends discutients at first, and if these have not the

desired effect we are to strike the tumour with a hard body so as to

break its cyst. (ix, 10.)

Rhases recommends striking the tumour with a hammer, binding a piece of

lead on it, and excision. When excision is practised he directs us to

take pains to extirpate the cyst or tunic which surrounds it. (Cont.

xxviii.)

SECT. XL.—ON VENESECTION.

Although the mode of performing venesection be known to everybody, yet,

in order that no part of surgery may be omitted, and for the sake of its

technical distinctions, it must not be overlooked by us. The first object

then in venesection is the evacuation of a fulness of blood. It has been

shown that fulness of blood is of a twofold nature: first, with regard

to the strength, although the veins do not appear full, in which case

those affected soon become weak and enervated, nature not being able to

support, as it were, the load; and second, with regard to the containing

vessels, as is seen in the parenchymatous parts, in which case, although

the strength seems able to support the fulness without stress, the

vessels sometimes burst, and a spitting of blood or some other discharge

takes place. Plethora then as regards the strength may be ascertained

from the heaviness upon the body; and plethora of the veins from their

distension and from their appearing full. In both cases evacuation is

indicated; and, therefore, if necessity require, you must bleed on the

first attack of the disease, waiting only for the digestion of the food

in the stomach, or the complete sanguification thereof in the liver.

But if on any account venesection has not been had recourse to in the

beginning, and has been postponed until after the seventh day, there will

be no impropriety of bleeding even then when necessity requires it, and

the strength does not contra-indicate. But when about to let blood it is

necessary to ascertain that there be not a great obstruction of fæces in

the intestines, and, if there be, the bowels ought first to be evacuated

by an emollient clyster, lest the veins of the intestines suck in the

putrid matter of the excrements. Those requiring the abstraction of blood

from the presence of a disease we may bleed at any season, avoiding only

the acme of particular paroxysms in fevers. But if it be a continual

fever, the morning is by all means the fittest season for the operation.

Those who require the evacuation of blood, not from the presence of any

disease, but as a preventive, will find the spring the fittest season of

the year. With regard to age, bleeding must not be practised before the

fourteenth, nor after the seventieth year, unless some urgent necessity

compel us. And upon the whole we must avoid bleeding those persons whose

strength is reduced. In recent inflammations we must make the evacuation

from the opposite parts, but in chronic from the adjoining. We abstract

blood from many parts of the body, but more especially from the inner

part of the elbow. But it is to be recollected that in general the

artery lies below the inner vein called the alar; that below the middle

one (median) there is a nerve; whereas the upper one, called also the

humeral, is free from all risk. In diseases of the head we open the

humeral, but in those below the neck, the alar. The median is applicable

in both cases. Wherefore we must tie a narrow band around some muscular

part of the arm, and having by friction of the hands upon one another

produced the necessary fulness of the vein, we divide it transversely,

but only along its breadth; for larger incisions than this are difficult

to heal, whilst those which are very narrow occasion inflammations by

obstructing the passage of the thicker fluids. When we expect to have

to abstract blood again on the second, third, and sometimes the fourth

day, we must divide the vein more obliquely, in order that by bending

the arm the incision may be kept open and not heal speedily. Such is the

opinion of Antyllus. The quantity of the evacuation must be determined

by the strength of the patient and the magnitude of the disease. When,

therefore, there is a humeral plethora, and the matter is in a state of

inflammation, we are to make our evacuations to deliquium animi, provided

the strength be firm, and the patient does not swoon from an overflow

of the humour upon the stomach. Wherefore many at the commencement fall

into deliquium animi before a sufficient evacuation has taken place,

and, therefore, the deliquium must be judged of from the measure of

the evacuation. If there is a necessity for much evacuation, and the

strength is weak, we must husband the evacuation, and making the first

abstraction in small quantity, bleed again, or even a third time, if

required. We have recourse to general evacuation not only when the body

is in a plethoric state (as Galen says), but on account of the magnitude

of the affection, when the general system is in a moderate state with

regard to the humours, as we do also in hemorrhage from the nose or

elsewhere, when although the discharge do not proceed from plethora, we

bleed from the opposite parts in order to produce revulsion; and so also

in violent inflammations, as in colics and affections of the kidneys

from calculi, ophthalmies, and other such acute and urgent attacks; for

the heat and pain of the inflamed parts occasion a defluxion upon it,

although the general system be free from superfluities. In such cases we

must bleed more sparingly, proportioning the evacuation particularly to

the age and constitution of the patient, and also taking into account

the season, country, and habits of the person affected. When there is

a strong inflammation near the vein which is opened, as in pleurisy

and hepatitis, it will be most proper to wait the change of the blood

in colour and consistence. Blood in inflammation is different from the

natural, since being excessively heated, if it was formerly crude, it

becomes ruddier and brighter; or if it was such before, it turns black

from being over-heated. Yet we must not in every case wait for the

change, but sometimes give over before this takes place; for two reasons,

either from the weakness of the patient’s powers, which you may ascertain

to have sunk by feeling the pulse (for you will find it either unequal as

to strength and magnitude, or indistinct, the stream of the blood failing

also indicates that the strength is sunk), or from the malignity of the

inflammation; for sometimes it will not remit, but the constriction

continues strong. But if none of these circumstances contra-indicate, and

if the patient be in the vigour of age, we may wait until a change takes

place, especially if the atmosphere be mild. But if the flow of blood

stop before a sufficient evacuation has taken place (this happens from

fear, deliquium animi, and coagulum, or too tight an application of the

bandage), we must attend to each of these causes, rousing from deliquium

with strong-scented things, slackening the bandage when too tight, and a

coagulum may be dissolved by pouring in oil, or by rubbing it with the

fingers. The rest of the apparatus for phlebotomy is known to everybody.

But these things apply to venesection at the bend of the arm. When we

would abstract blood from the forehead as for headache, having first

used fomentations, we apply a bandage round the neck, placing a finger

over the windpipe to prevent suffocation, and when the frontal vein is

properly filled we divide it with the point of a lancet or scalpel. In

the same manner we may open the external jugulars for chronic ophthalmy,

producing a discharge of blood with the concave part of the scalpel.

The vessels also below the tongue we open transversely for angina, but

without the application of any bandage. Some also open in like manner

the veins which appear in the great canthi, as for chronic affections

of the head or eyes, in which cases they also sometimes rupture the

vessels within the nostrils either by rubbing them with the extremity of

a specillum, or by tickling them with rough substances. They also open

those behind the ears for the affections about the head; and those about

the top of the thighs, as in affections of the kidneys; and those in the

extremities they also open, after by the application of the ligatures

to the parts above, by friction in the case of the hands, and walking

in that of the feet, the vessels having become distended with blood;

in affections of the spleen opening the vessel in particular between

the small and middle finger of the left hand, and in affections of the

liver those of the right hand; for the evacuation of the extremities,

being from a distance, occasions a more powerful revulsion. In ischiatic

diseases, and those of the uterus, they open the vein in the foot above

the inner toe.

* * * * *

COMMENTARY. We have to regret that our limits prevent us from doing more

ample justice to the sound and enlarged views of the ancient physicians

on this subject, and we must be content with making a few desultory

observations and giving a few extracts.

We have had occasion frequently to remark that Hippocrates practised

venesection freely in various diseases. He has left no treatise, however,

expressly on the subject.

Celsus says, that to let blood was no new discovery in his day; but

that blood might be let with advantage in almost every disease was a

discovery. He states it also as a recent discovery that children, old

men, and pregnant women might be safely bled, the operation having

been anciently proscribed in all these cases. Yet, notwithstanding the

authority of Celsus, the prejudice against bleeding young and old persons

seems to have generally prevailed, for it will be perceived, that our

author, copying from Galen, forbids persons to be bled before fourteen

and after seventy, except in urgent cases. However, Averrhoes mentions

that his countryman Avenzoar had bled a child only three years old with

great success; and relates further that he had known certain persons who

had been bled at the age of eighty. Celsus properly directs us to judge

of a patient’s ability to endure venesection from his strength, and not

from his tender or advanced age. He also acutely remarks that there is

a difference between a strong body and a fat, and between a lean and a

weak; for that a lean body contains most blood, and a fat most flesh.

(See also Arist. H. A. iii, 19.) Those, therefore, who are lean bear

depletion best, and the corpulent suffer most from it. The strength

of the body, therefore, is to be estimated from the veins rather than

from the general appearance. When the nature of the disease indicates

evacuation, and the strength appears ill fitted to bear it, he advises

us first to give warning of the danger, and then to abstract blood; for,

he adds, “satius est remedium anceps experiri quam nullum.” In general

he forbids venesection when the stomach is loaded with impurities; and

upon this rule of practice all the ancient authorities, we believe, agree

with him. Thus, to give an example from the Arabians, Averrhoes says, our

famous physician, Abumeron Avenzoar, states that venesection ought not to

be had recourse to until the body is purged, for the veins being emptied

of blood attract the crude superfluities. (Collig. vii, 1.) This rule

of practice is now too little attended to. In general Celsus holds that

the second or third day of a disease is the fittest time for abstracting

blood. He forbids bleeding upon the very onset of a fever, which he says

is enough to kill a man outright. Upon the whole he approves of letting

blood as near as possible to the affected part. He admits, however, that

venesection may sometimes act by producing revulsion. The operation,

he remarks, although easy to a skilful person may prove dangerous when

performed by an unskilful one, as a nerve or artery may be wounded. In

securing the arm after the operation he directs us to bind on the wound

a compress soaked in cold water. (ii, 10.)

Galen wrote three treatises on venesection, to which operation he

was very partial. They are: _De venesectione adversus Erasistratum_;

_de venesectione adversus Erasistrateos in Româ_; and _de curatione

per venæ sectionem_. These works are deserving of great attention as

containing many judicious observations and rules of practice, but which

are delivered at so great length that we can scarcely venture even upon

an abstract of them. His principles of treatment, however, are nearly

the same as those of our author. He appears to have abstracted blood in

great quantities. Thus he mentions having seen six lib. taken away in

the course of a fever, and six heminæ at once in a case of hæmoptysis.

Now the hemina being somewhat more than a half a pint, the quantity

abstracted must have exceeded three pints. He strenuously inculcates

that venesection proves useful by occasioning revulsion, and as a proof

of this he instances the beneficial effects produced by opening a vein

of the arm in cases of epistaxis. He practised bloodletting occasionally

in cases of dropsy, as we have mentioned under that head. Bleeding from

the arm he thinks prejudicial in cases of amenorrhœa, as it causes a

determination of blood to the upper parts of the body, and, therefore, he

directs us rather to bleed at the ankle. He agrees with Celsus that lean

persons bear depletion better than such as are fat; and that venesection

is not to be performed when there are undigested matters in the stomach.

He states that persons in extreme heat or cold do not bear bleeding.

He mentions that in bleeding from the basilic vein there is danger of

wounding the artery, that a nerve lies under the median; but that the

cephalic may be opened without danger.

Oribasius gives an interesting dissertation on venesection, principally

condensed from the works of Herodotus, Antyllus, and Galen. (Med.

Collect. vii.) Antyllus directs us when going to bleed at the elbow to

apply a ligature two fingers broad round the arm, so as to produce a

swelling of the veins; and remarks that they are mistaken who affirm

that the same effect may be produced by applying the ligature below,

for that the veins will not then swell, even when the arm is fomented.

When going to bleed at the ankle he directs us to apply the ligature

above the knee; to put the limb into hot water, and make the person walk

about. When the blood does not flow readily, he advises us to slacken

the bandage if too tight; or if the opening in the vein be covered with

the skin, to turn the arm into all positions until the opening of the

vein and of the skin correspond; and if it be too small, to enlarge it.

When fear retards the flow of the blood it will be of advantage, he says,

not to allow the patient to hear the sound of it. When it stops from

deliquium animi he advises us to lay the patient in a reclining posture

on a couch; to promote vomiting, and to rouse by tight ligatures to the

extremities, and by aromatics. When a clot of blood obstructs the vein he

directs us to squeeze it out, or to dissolve it with oil or vinegar. When

coldness of the body, occasioned whether by the temperature of the air,

or the nature of the disease, prevents the flow of blood, he recommends

fomentations and frictions. When a piece of fat or flesh blocks up the

opening of the vein, he says there is no remedy for it but to cut it out

or push it aside. When the object is to produce a sudden depletion he

directs us to make a large incision in the vein, but a small one when it

is intended to procure revulsion.

According to Drs. Freind and Milward, Alexander Trallian is the first

authority who recommends bleeding by opening the jugulars. As far as we

know this statement is correct.

Aëtius’s account of this subject is similar to our author’s, but less

copious. (iii, 10.)

Actuarius in like manner has many judicious remarks on venesection, which

our limits prevent us from giving to the reader. He forbids venesection

when any natural secretion is increased, and this is in general a

very proper rule, although, as Galen and Avicenna remark, profuse

sweatings are sometimes remedied by bleeding. Bloodletting, he says, is

contra-indicated by crudities in the stomach, and a loose state of the

bowels. (Meth. Med. iii, 1.)

Little additional information is to be gleaned from the Arabians. We have

mentioned, however, that Averrhoes and Avenzoar approved of venesection

at a later and earlier period of life than the Greeks permitted it.

Avicenna with his customary accuracy collects everything of importance

which had previously been written on the subject, but makes hardly

any addition to the ancient stock of information. We can scarcely

venture upon an abstract of his important chapter on phlebotomy. We may

just mention that as a general rule he approves of bleeding after any

accident. He disapproves of bleeding both at the onset and the crisis of

a disease. In constitutions requiring bloodletting he holds that spring

is the best season for it. Even in cases in which there is a deficiency

of blood, but there is congestion in some particular part, he permits

blood to be abstracted, in order to produce revulsion, the patient’s

strength being recruited afterwards by a nourishing diet. When the colour

of the blood is dark, and it is thick in consistence, a larger amount is

to be abstracted than when it is thin and of a light colour. He makes

the important remark, that bleeding sometimes kindles up a fever. He

forbids the bath immediately before the operation, and food or exercise

immediately afterwards. When a piece of fat obstructs the flow of blood,

he directs that it should be gently pushed aside, but not cut out. (i, 4,

20.)

No author, ancient or modern, has described the modes of performing

venesection in all parts of the body more accurately than Albucasis.

Bleeding from the jugular vein he describes in much the same way that

it is now practised by veterinary surgeons, namely, by placing a sort

of scalpel, bent at the point, which he calls fossorium, upon the vein,

and striking the instrument with a hammer, or some such body. He gives

drawings of variously-shaped lancets for opening the veins of the arm.

(Chirurg. ii, 97.)

The reader is also referred to Haly Abbas for a copious account of the

operation, and the circumstances under which it may be performed. It

is contra-indicated, he says, when the bowels are loaded with vitiated

fæces. He allows it to be performed even after seventy years of age,

provided the patient be of a vigorous constitution. (Pract. ix, 2.)

Rhases, with admirable judgment, condenses all the information supplied

by preceding authorities, and mixes it up with his own personal

observations. He forbids us to give food immediately after bleeding, as

the empty veins will absorb the chyle before it is properly digested,

which will prove a pabulum of disease. For the same reason, he, like

the others, forbids bleeding when the stomach is loaded with crudities,

lest they should be absorbed, and carried over the system. In retention

of the menses he directs us to open the saphena, or to apply a cupping

instrument to the ankle. When the disease is an acute attack of

inflammation, he recommends us to abstract blood fully from an opposite

part, so as to procure revulsion; but when it is a chronic affection, he

advises to take it from the part affected. (Contin. xxviii.) He enjoins,

as a prudent precaution in bleeding a person who is intoxicated, to apply

two bandages about the arm, and to have proper attendants to restrain the

bleeding, which is often difficult to stop in such cases. (Ad Mansor.

vii, 21.)

The veterinary surgeons practised bleeding freely in the treatment of

the diseases of cattle. Vegetius, the great authority on this subject,

mentions that many persons bled their cattle every year, in the spring.

He adds, however, that the ancient and more prudent authorities

disapproved of indiscriminate depletion. (Mulom. i, 22.)

SECT. XLI.—ON CUPPING.

We must not have recourse to cupping at the commencement of complaints,

nor when the body is in a plethoric state, but when the general system

has been evacuated, and when there is no defluxion any longer to the

part, and especially when there is a necessity of removing, dislodging,

and determining something outwardly. Dry cupping then dissipates

flatulence, stops defluxions to the stomach, attracts blood to a part,

and stops it again, when determined to a part, if applied to the opposite

parts; and it also occasions a translation from the deep-seated parts to

the surface, and on the whole produces a metastasis of the fluids, and an

evacuation of the spirits. But cupping with scarifications facilitates

the evacuation of the offending causes, which it manifestly brings from

the deep-seated parts; for it produces the discharge not only of blood

but of the other humours, and especially if applied with much heat. And

if we wish to make the abstraction from parts that are fleshy, we must

first scarify and then apply the cupping instrument; but if the part is

not fleshy, we must first have recourse to dry cupping, and when the

parts becomes swelled up, we scarify and apply the cupping instrument

again. If we wish to make but a small evacuation we must be satisfied

with one incision, but if we wish much we must make several. And if we

apprehend that the contained blood is of a thinner consistence we will

make superficial scarifications, but if of a thicker, deep-seated. When

we wish to evacuate coagulated blood, occasioned by a blow, we must be

regulated as to the depth of the incisions by the thickness of the skin

above. Some have devised an instrument for this purpose, by joining three

equal lancets together, so that by one application it may produce three

incisions, but we consider it inconvenient, and use a simple lancet.

Others have used cupping instruments of glass, in order that the quantity

of blood which is evacuated may be seen; but those made of copper have

a more powerful attraction, as being able to endure a stronger fire,

whereas those of glass are apt to break. But such as draw out the blood

by sucking with the mouth through horns, evacuate less, but do not dry,

like those applied with fire. If necessary, when we are about to apply

the cupping instrument, having placed the limb in an erect posture, we

fasten it to the side; for if we apply the lamp above when lying, the

wick falling upon the skin with the flame burns in a painful manner,

whereas there is no necessity for this. Sometimes the size of the

instrument is proportioned to the part on which it is applied; and on

that account there is a great variety of cupping instruments with regard

to smallness and greatness of size. For the same reason, those which are

made with longer necks and broader bellies are possessed of a stronger

power of attraction. We must avoid applying the cupping instrument near

the breasts, for sometimes they fall into it, and swelling greatly,

render the removal difficult, and in that case sponges out of hot water

are to be applied round the cupping instrument, which make it relax. But

if even with this it do not fall off we must perforate it.

* * * * *

COMMENTARY. On this mode of abstracting blood, and of altering its

determination, the records of ancient surgery are so full of information

that our only difficulty lies in selection.

It appears that the father of medicine and his successors practised

cupping. (De Articulis, 49, and de Medico, 6.)

Celsus mentions two kinds of cupping instruments, the one being made of

horn, and the other of copper. Those of copper were open at one end and

shut at the other. Those of horn had a larger opening at one end and a

smaller at the other. A piece of cloth was set on fire and thrown into

the copper one, and its mouth was then fitted to the body and pressed

on until it fastened. In applying the one made of horn, the air was

exhausted by sucking at the smaller end, which was then covered up with

wax, and in this state it would fasten to the part. He remarks that

when the part to which the instrument is applied had been previously

scarified, blood is discharged, but otherwise nothing but spirits. He

states that the principal use of the cupping instrument is to remove

any local affection when the general constitution is sound. Upon the

whole, he considers it to be a safer but less efficacious remedy than

venesection. Cupping, he adds, is to be had recourse to in chronic

diseases, in order to remove any corrupted matter which may be seated in

a part; and in acute, when the strength will not allow of venesection.

(ii, 11.)

According to Galen, cupping is useful after evacuation, but does not

answer when there is plethora. In inflammation of the brain and its

membranes, therefore, he forbids cupping at the commencement, and also

in inflammation of other parts, until the defluxion is stopped and the

general system has been evacuated; and states that the object of cupping

in such diseases is to move and determine the inflammatory particles

outwards. In general, he advises us not to apply the instrument to the

part affected, but to the adjacent part, with the view of producing

revulsion, _de hirud. revuls. cucurb._, &c. He likewise gives an

interesting account of leeches. He recommends their tails to be clipped

off when it is wished to abstract much blood by means of a few leeches.

(Ibid.)

Oribasius is the ancient author who discusses this subject at the

greatest length, and to him Paulus is principally indebted. He mentions

that cupping instruments are made of glass, horn, or copper. Those of

silver, he says, are to be rejected; those of copper are in most general

use; those of glass answer best when we wish to see the quantity of blood

that flows into the instrument; and those of horn are to be applied to

the head because copper ones are difficult to remove; and besides, timid

persons are afraid of the flame in such cases. Those which are made

deep attract more strongly than such as are shallow; instruments of the

latter description are to be applied to the head. Before using them he

recommends us to warm the part with fomentations and cataplasms. Upon

the authority of Herodotus he enumerates the beneficial effects which

may be derived from cupping; such as evacuating the matters fixed in the

part, diminishing inflammation, recalling the appetite, strengthening

the stomach, determining to the surface, provoking menstruation, and so

forth. (Med. Coll. vii.)

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

Actuarius forbids us to apply cupping instruments until after general

evacuation, when, he says, they will be useful by producing revulsion

of the noxious humours. He also approves of cupping for strengthening

the stomach when it has lost its tone, and to discuss flatulence in the

bowels. (Meth. Med. iii, 4.)

Albucasis gives a most circumstantial and interesting account of the

methods of cupping every part of the body. He particularly recommends

cupping the nape of the neck in affections of the brain and eyes. He

gives a full account of dry cupping. He recommends it to be applied

when the disease is seated in places which do not bear cupping with

scarifications, such as the region of the liver and spleen, the kidneys,

the bowels, and the joints affected with gout. In applying the instrument

he directs us either to create a flame in it, or to fill it with hot

water. He gives drawings of various instruments for cupping. (Chirurg.

ii, 98.) He also treats fully of leeching, which, however, he recommends

only in cases in which the cupping instrument cannot be applied. When the

bleeding continues longer than is desired, he directs a piece of cloth

soaked in cold water to be applied to the place, or if that does not

prove effectual, styptics, such as galls, beans without their skins, and

the like. When the leeches will not take, the place is to be smeared with

fresh blood. When it is desired to make them drop off, powdered aloes,

salts, or ashes are to be sprinkled upon them. (ii. 99.)

Haly Abbas gives an ample enumeration of the cases in which cupping is

applicable. He recommends it particularly in such cases as do not admit

of general bleeding, for ophthalmies, cynanche, and in an especial

manner for amenorrhœa, when it is applied to the breasts.

The other Arabians, although some of them treat fully of this subject,

especially Avicenna and Rhases, yet give little additional information.

Rhases speaks of applying a glass or a cupping instrument to draw off the

blood after leeching. He gives a full account of the different kinds of

leeches. Before applying them, some, he says, smear the part with blood

and some with milk. When they are too long of falling off he directs

us to sprinkle salt upon their mouths. He recommends them to be kept

in a vessel containing water herbs. (Cont. xxviii.) When it is wished

to abstract more blood after the leeches have fallen off, Albucasis

directs us to foment the part with hot water, to rub it, and apply a

cupping instrument to it. When, on the contrary, it is wished to stop

the discharge, Avicenna recommends us to apply galls, lime, or other

astringents, to the part. For this purpose Albucasis likewise directs us

to apply a mass of beans deprived of their skins.

SECT. XLII.—ON BURNING THE ARMPIT.

In dislocation at the joint of the shoulder, it sometimes happens that

the head of the arm falls out over and over again, either from the

prevalence of too much humidity, or because the way is paved to it by

its frequent occurrence. In this case then we have recourse to burning.

Wherefore, the patient being laid on his back, or on the sound side, the

skin at the inner part of the armpit, where the dislocation mostly takes

place, is to be stretched between two fingers of the left hand, or with

hooks, and burnt with heated cauteries, of a slender and oblong shape,

until the cautery, being pushed through to the other side, occasion the

formation of two eschars at one application. And if the distance between

them is considerable, having passed the head of a specillum through them,

we make another eschar in the middle by burning down until the cautery

reach the specillum. And Hippocrates wishes two other eschars to be

formed on each side of the middle one at the same distance as they, so

as to form a quadrangular figure. We must not burn deeper than the skin,

because nerves, glands, and other substances, which may give rise to

inflammation and disturbance, lie below. The treatment may be conducted

by means of leeks applied with pounded salts, and the rest of the

treatment of eschars. Afterwards we may use the hand cautiously.

* * * * *

COMMENTARY. Hippocrates (as stated by our author) recommends this

operation for preventing the recurrence of dislocation at the

shoulder-joint: it is minutely described by him. (De Artic. xi.)

Albucasis describes the operation, but it will be readily understood from

our author’s account of it. (Chirurg. i. 27.) It is described in like

manner by Haly Abbas. (Pract. ix. 73.)

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

Preternatural fingers are formed in the hand sometimes near the thumbs,

and sometimes near the little finger, but rarely beside any of the

others. Of preternatural fingers, some are wholly fleshy, and others

have bones in them, and sometimes they have likewise nails. Of those

having bones, some derive their origin from a joint, having a common

articulation with some other finger; and some arise from the phalanx,

and these have no motion. The others sometimes have motion. Now the

excision of those which are fleshy is easy, for we cut with a scalpel the

preternatural finger all through. But on those which have their origin

from a joint the attempt is more difficult. Of those which arise from the

phalanx we must first cut away the flesh all around to the bone, and as

to the bone itself we either chop it through with a chisel, or remove it

by sawing; and in the treatment we scrape and cicatrize them as mentioned

by us with regard to the wounds of bones.

* * * * *

COMMENTARY. Galen (de Diff. Morb. 4,) and Avicenna (Cant. i, 2,) allude

to the preternatural growth of fingers.

Haly Abbas describes the operation in the same terms as our author.

(Pract. ix, 39.) Rhases repeats our author’s description of the method

of treatment, and also mentions that of Antyllus, which, however, is

little or nothing different from our author’s. Thus, he directs us

first to make an incision of the soft parts down to the bone, which is

to be sawn across; the skin is then to be united, and the part treated

with agglutinants. When the supernumerary finger grows from a joint he

directs us to make the separation cautiously; and if it grows between two

fingers, or contains a bone, he forbids it to be amputated. (Cont. xxiv.)

Albucasis’s account of preternatural fingers is evidently taken from our

author. (Chirurg. ii, 91.) When there is a preternatural adhesion of two

fingers to one another, he directs us to divide it with a scalpel, and

introduce a pledget wetted in the oil of roses, or a thin plate of lead

between them, until the parts heal. (Ibid.)

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

The most effectual remedy which has been discovered for empyema is

burning. Wherefore, the parts are to be burnt by applying the root of the

long birthwort soaked in oil, so as to form eschars, one of which we must

make between the junction of the clavicles, having stretched the skin

upwards; and two small ones a little distance from the chin and remote

from the carotids; two of considerable size below the mammæ, between

the third and fourth ribs; two others between the fifth and sixth,

inclining a little backwards; another at the middle of the sternum, and

another above the mouth of the stomach, and three behind, one at the

middle of the back, and two on each side of the spine, higher up than

the eschar in the back, and not very superficial. Others, as Leonidas

says, having passed a knobbed cautery, heated in the fire, through the

interstice between the ribs to the abscess, have carried the burning down

to the pus. Some have dared to operate upon them by making a transverse

incision, or one a little obliquely in the skin, between the fifth and

sixth ribs, then perforating with a knife the membrane lining the ribs,

and thus evacuating the pus; but they and those who burn with iron to a

considerable depth either occasion immediate death, the vital spirit

being evacuated with the pus, or occasion incurable fistulæ.

* * * * *

COMMENTARY. Galen mentions the operation of burning the chest for

phthisis. (De Morb. Vulg.)

In phthisical complaints, which do not yield to ordinary treatment,

Celsus recommends the cautery to be applied in this manner: One eschar is

to be burnt with a red-hot iron under the chin, another on the throat,

two upon each breast, and two under the scapulæ. They are to be kept open

until the cough is removed. (iii, 22.)

Aëtius directs us to burn the chest and neck much in the same manner as

recommended by our author. (viii, 73.)

This operation is described by Albucasis, who gives a drawing of an

instrument for performing it expeditiously. (Chirurg. i, 26.) See also

Rhases (Cont. ix.)

Haly Abbas recommends such an operation as that described by Celsus and

our author. He directs us to do it, not with iron, but with the root of

the long birthwort smeared with oil. (Pract. ix, 74.) The use of the

root of the birthwort (aristolochia) as a cautery is also mentioned by

Aëtius. (xii, 3.) Cornarius, by the way, seems not to have been aware of

this circumstance, which has led him into a mistake in translating the

sentence where it is mentioned.

The practice of burning the chest in chronic diseases of the lungs is

strongly advocated by Caillot. (Elemens de Physiologie, i.) It was tried

by Dr. Mudge in his own person with great success. (See Dr. M. Good’s

‘Study of Medicine,’ ii, 786.)

Our author, it will be remarked, disapproves of paracentesis thoracis.

This operation is recommended and described in one of the Hippocratic

treatises. (De Morbis, i, and ii.) It is also mentioned in the ‘Isagoge’

of Galen. Rhases likewise mentions it in brief terms. (Cont. iv, 3, and

x.) Rhases directs us to open the chest by a small orifice, that the

matter may be slowly evacuated. He mentions that Galen recommends burning

the chest, and also the operation of paracentesis in such cases.

SECT. XLV.—ON CANCER.

Cancer is an uneven swelling, rough, unseemly, darkish, painful, and

sometimes without ulceration (which Hippocrates called also concealed

cancer), and if operated upon, it becomes worse, and sometimes with

ulceration, for it derives its origin from black bile, and spreads by

erosion; forming in most parts of the body, but more especially in the

female uterus and breasts. It has the veins stretched on all sides

as the animal the crab (cancer) has its feet, whence it derives its

name. Wherefore, the treatment of it by medicine has been sufficiently

delivered by us in the Fourth Book; and cancer of the womb has been

treated of in the Third. But since putrid parts and such as are simply

altered from their natural state require amputation, cancers in the womb,

indeed, it is neither possible nor expedient to operate upon; but of

those of the external parts, and especially of the breasts, we have now

to explain the surgical treatment. Some, then, have consumed the whole

redundant matter by cauteries; but others first make an excision of the

whole breast, and then burn the place. But Galen approves only of the

excision, writing thus of the operation: “If ever you attempt to cure

cancer by an operation, begin your evacuations by purging the melancholic

humour, and having cut away the whole affected part, so that not a root

of it be left, permit the blood to be discharged, and do not speedily

restrain it, but squeeze the surrounding veins so as to force out the

thick part of the blood, and then cure the wound like other ulcers.” Such

are the words of Galen. And other malignant and putrid ulcers, such as

phagedæna, gangrene, and the like, must be treated in the same manner.

* * * * *

COMMENTARY. Hippocrates forbids the surgeon from interfering with occult

cancers, that is to say, with such as have not ulcerated, remarking that

if healed the patient soon dies, whereas, if let alone, he may live a

long time. (Aph. vi, 38.) Upon this his commentator, Theophilus, remarks

that even if the disease is eradicated by cutting or burning, many

untoward symptoms follow, and the strength of the patient does not stand

out. (Ed. Dietz. ii, 506.)

Celsus describes, we fear but too truly, the general result of

every known method of treating cancer. He says, some use corrosive

applications, some burning irons, and others cut it out with the scalpel;

but medicines are of no avail, burning only exasperates the disease, and

excision only removes the part affected, for the disease immediately

returns, (v, 28.)

Galen’s sentiments are partly explained by our author. He states, that

the disease is curable only at its commencement. When it has attained

any considerable magnitude, he says, it admits of no remedy without a

surgical operation; and when the tumour is cut out all around there is

danger of hemorrhage, which, if restrained by ligatures, may give rise to

the disease in the neighbouring parts, whereas, if cauteries be used to

burn the roots of the vessels no inconsiderable danger may result from

their application so near to the vital parts. (Therap. ad Glauc. ii;

Meth. Med. xiv; Isagoge.)

Aëtius gives from Leonidas the following description of the operation

on cancerous mammæ. Laying the patient in a supine position, he says, I

make an incision into the mammæ above the cancer, and immediately apply

a cautery until an eschar be produced to stop the bleeding. I then make

another incision deep into the substance of the mamma, and again burn

the parts, and so proceed—first cutting and then burning alternately,

in order to restrain the bleeding. In this way there is no danger of

hemorrhage. After the amputation is completed I again burn the parts

until they are quite dry. The first burnings are for the sake of the

bleedings, and the last with the intention of eradicating the disease.

(xvi, 45.) This operation, described in nearly the same words, occurs in

Soranus. (61.) He says, when the disease is scrofulous the burning may be

omitted. (Ibid.)

Avicenna mentions that after the excision of a cancerous part the actual

cautery may be required. And yet, he adds, there may be danger from the

burning provided the part affected be near any vital organ. (iv, 3, 2.)

Rhases says, that they who make an incision into a cancerous part merely

produce ulceration thereof, unless it be so seated that the disease can

be completely removed and the parts afterwards burned. (Ad Mansor. vii,

9.) In another work he expresses himself rather favorably of excision

and burning. (Contin. xiii.)

Haly Abbas approves of the operation when the cancer is seated in the

mammæ or extremities. He recommends us to allow the part to bleed until

all the melancholic humour is evacuated, and says nothing of the cautery

or ligature. (Pract. ix, 12.)

Albucasis says that he never saw a case of cancer cured unless the tumour

was small and recently formed. He directs us, when the operation is

attempted, to cut out the tumour by the roots, and if the hemorrhage from

any vein be profuse to stop it by the cautery. (Chirurg. ii, 53.)

Serapion expresses himself rather diffidently of excision. (v, 24.)

Soranus gives a full account of scirrhous breast distinct from the

cancerous. He states that when the whole breast is scirrhous and adheres

to the chest, the excision of the sound parts from the diseased ought not

to be attempted; but when only the extremity of the breast, or only the

half of it is hardened, he approves of amputation without burning, there

being no danger of bleeding in this case as in cancer. (66.)

SECT. XLVI.—ON MALE BREASTS RESEMBLING THE FEMALE.

As at the season of puberty the breasts of females swell up, so in like

manner those of the males also swell to a certain extent; but for the

most part they subside again. In some cases, however, having acquired a

beginning they go on increasing, owing to the formation of fat below.

Wherefore, as this deformity has the reproach of effeminacy, it is proper

to operate upon it. Having, therefore, made a lunated incision below

the breast, and dissected away the skin, we unite the parts by sutures.

But if, as in women, the breast incline downward, owing perhaps to its

magnitude, we make in it two lunated incisions, meeting together at the

extremities, so that the smaller may be comprehended by the larger, and

dissecting away the intermediate skin, and removing the fat, we use

sutures in like manner. But if, through mistake, we should cut away too

little, we must again remove what is redundant, and apply the remedies

for fresh wounds.

* * * * *

COMMENTARY. The description given by Albucasis is so like our author’s

that there can be no doubt of its being borrowed from him. When there is

a great redundance of fat and flesh, he directs us to make two lunated

incisions, the larger comprehending the smaller, and having dissected

away the intermediate skin to unite the edges by sutures. (Chirurg. ii,

47.)

Haly Abbas repeats the same description in almost the same words. (Pract.

ix, 40.)

Rhases recommends the operation upon the authority of Antyllus and our

author. (Contin. xiv.)

SECT. XLVII.—ON BURNING OVER THE LIVER.

If the pain be attended with weight in those who have abscess in the

liver, it is an indication that the fleshy part of the liver is affected;

but if the pain be acute the matter is rather in the coats, and we must

burn the part thus:—Having strongly heated slender, knobbed cauteries,

we apply them a little above the loins at the extremity of the liver,

making an eschar. But having burnt the whole skin and reached the coat we

must evacuate the pus: after the discharge of which, having used lentils

and honey, with the applications from honied water, and things of an

incarnative nature, we have afterwards recourse to epulotics.

* * * * *

COMMENTARY. In cases of hepatitis, which do not yield to the usual

remedies, the author of one of the Hippocratic treatises advises us to

burn the side with spindles of boxwood dipped in oil, or with fungi. (De

Morbis Internis.)

Aretæus directs us to open abscesses of the liver with red-hot irons.

(Morb. Chron. i, 13.) Celsus mentions that some open abscesses of

the liver with a scalpel, and some burn the vomica. (iv, 8.) Cælius

Aurelianus, however, disapproves of this practice. (Pass. Tard. iii, 4.)

Albucasis describes the operation like our author, and gives a drawing

of a spear-shaped instrument for opening the vomica. (Chirurg. ii, 30.)

Haly’s description is quite similar. (Pract. ix, 75.)

SECT. XLVIII.—ON BURNING OVER THE SPLEEN.

Having stretched the skin which lies over the spleen with hooks, we burn

it through by one application of a long ignited cautery so as to form

two eschars; and this we do three times so that there may be six eschars

formed altogether. But Marcellus by using a trident or trident-shaped

cautery formed six eschars at one application.

* * * * *

COMMENTARY. In cases of diseased spleen the Coan surgeons burned eschars

on the side affected. (Hippocr. de Affect. intern. and de Affect. 5.)

Aëtius directs us to burn the eschar either with the actual cautery or

with caustics. (x, 12.) The ancients used an issue paste, very like the

modern, prepared from potass. See above (s. 9.)

Avicenna recommends the same practice as the Greeks (iii, 15, 1); and so

in like manner Haly Abbas (Pract. ix, 76); Albucasis (Chirurg. i, 32);

and Rhases (Contin. xx.)

Guido de Cauliaco repeats Albucasis’s description of the process of

burning the side in cases of scirrhous spleen. (ii, 2.)

SECT. XLIX.—ON BURNING OVER THE STOMACH.

In chronic defluxions of the stomach the moderns have recourse to

burning,—some with knobbed cauteries, forming three eschars, one at the

ensiform cartilage, and the other two below, so as to make a triangle,

the depth of the burning being the thickness of the skin. Some form only

one large eschar at the mouth of the stomach. But others do not burn with

iron but with the substances called iscæ. The iscæ are spongy bodies

forming on oaks and walnuts, being mostly in use with the barbarians.

They allow the ulcers to remain for some time without cicatrizing, and

rather stimulate them in order that by the great diaphoresis thereby

occasioned, the mouth of the stomach may be freed from the defluxions.

* * * * *

COMMENTARY. Hippocrates, Galen, and Celsus say nothing about burning

over the stomach in affections of it. Aëtius’s account is similar to our

author’s. He calls the iscæ the medullary part of the wood of walnuts.

(vii, 91.) They are mentioned likewise by Haly Abbas, who says they are

called _ducanum_ in the Persian language. (Pract. ix, 77.) Albucasis

directs us to burn with iron. (Chirurg. i, 28.)

SECT. L.—ON DROPSIES.

The formation of dropsical swellings, their varieties and causes, how

they are to be distinguished from one another, and their treatment by

medicine, having been explained in the Third Book, and it having been

there shown that ascites alone falls under the province of surgery,

we are now going to give an account of it. Wherefore we must make the

patient stand erect; or if that cannot be done, we must cause him to be

seated; or if he be so weak that this cannot be done, we must abandon

the operation entirely. If then the man be standing erect we give orders

to the assistants standing behind to press with their hands and push

downwards the swelling to the pubes. Then taking a sharp-pointed knife or

lancet, if the dropsy is among the intestines, in the perpendicular line

of the navel, and about three fingers’ breadth distance from it we divide

the hypogastrium as far as the peritoneum. But if the liver be primarily

affected we must make our incision on the left side of the navel; or

if the spleen, on the right, for we must not make an incision in that

part on which the patient is disposed to lie. And having dissected with

the point of the instrument the skin that lies over it, we divide the

peritoneum a little above the first incision until the instrument comes

to an empty space. After this we introduce through the incision of the

abdomen and peritoneum a copper tube, having an opening like those of

writing-pens, and by this we must abstract the fluid in proportion to

the strength; feeling the pulse, and then removing the tube, we stop the

flow of the fluid, (for it will stop immediately from the alteration of

the incision,) and, for the sake of security, we introduce a twisted tent

into the incision of the abdominal parietes alone; and having placed

the man in a recumbent posture and recruited him, we may next day again

evacuate through the tube a small quantity of fluid proportionate to his

strength; and thus, in like manner, until very little be left, avoiding,

by all means, a sudden evacuation. For some ignorant persons having

evacuated the vital spirit with the fluid have immediately killed the

patient. Some for the sake of greater security having evacuated a small

quantity of the fluid by the operation so as to relieve the powers of

the system from its great load, procure the discharge of the remainder

by hydragogue medicines, by burying the patient in heated sand, by

insolation, abstinence from liquids, giving desiccative food; and they

have recourse likewise to burning over the stomach, liver, spleen, and

hypogastrium; and make five eschars about the navel, some by slender

cauteries of iron, and others by those substances called iscæ, or some

other such like material. And many have been rather cured by this method

alone, sometimes without paracentesis having been had recourse to at all.

* * * * *

COMMENTARY. Hippocrates declares in one of his Aphorisms, that the sudden

evacuation of the matter in empyema, or of the water in dropsy, proves

fatal. He speaks of evacuating the fluid with an instrument called

τρυπαντρωγλητήριον, which Camper thinks must have been a kind of trochar.

Galen, in his Commentary on the Aphorisms of Hippocrates, (vi, 7)

remarks, that in his time the operation of paracentesis was in general

use, instead of burning. He states, however, that he had seldom seen

recovery take place after the operation. (See in particular Meth. Med.

xiv.)

Aristotle alludes to paracentesis near the conclusion of his work on the

‘Generation of Animals.’

Cælius Aurelianus mentions that Erasistratus, Evenor, and Thessalus were

advocates for paracentesis, but that Asclepiades, Themison, and Soranus

disapproved of it. He himself approves very much of the operation,

and answers all the objections which had been made to it. He says, it

relieves the fulness and difficulty of breathing, and prepares the parts

for the action of the remedies. He agrees, however, with the other

authorities, that a sudden evacuation of the water is attended with

danger. (Pass. Tard. iii, 8.)

Celsus gives a good description of the operation. Some, he says, perform

it at a spot four fingers’ breadth below the navel in the left side;

some do it at the navel; and some burn the skin and then perforate the

abdominal parietes. He directs the operator to be careful not to wound a

vessel. The size of the point of the perforator, he says, should be the

third part of a finger’s breadth. After the perforation has been made, a

tube (canula) of lead or copper is to be introduced and the water drawn

off gradually. The whole is not to be removed at one time, but a tent

is to be introduced into the opening, unless it was made with fire, to

prevent it from healing too soon. He speaks favorably of the operation,

unless the patient be much debilitated. (vii, 15; also ii, 10.)

Aëtius and most of the medical authors subsequent to Galen, mention the

operation of paracentesis, and approve of it.

Vegetius, the veterinary surgeon, recommends paracentesis for the dropsy

of cattle, when the swelling is not removed by purging. (Mulom. iii, 25.)

Avicenna expresses himself rather unfavorably of paracentesis. He says,

it ought never to be attempted until every other remedy has proved

ineffectual, and unless the strength of the patient be good, and he

can endure exercise, abstinence from drink, and restricted diet. His

description of the operation is taken from Paulus. (iii, 14; iv, 13.)

Serapion mentions the operation in very brief terms. (iv, 7.)

Albucasis’s description is very minute; but, upon the whole, little

different from our author’s as to the place of the incision or the

instruments with which it is to be performed. After the perforation

has been made in the manner directed by our author, he recommends the

introduction of a canula made of silver, copper, or brass, and having

a small hole at the bottom and three in its sides; he advises us to

evacuate only half the water at first. He adds, that when the canula is

removed the skin will cover the opening in the abdominal muscles, and

thereby stop the discharge. The remaining part of the water is to be

removed afterwards, according to the strength of the patient. (Chirurg.

ii, 54.)

Haly Abbas does not in general approve of the operation. He mentions,

that he never saw it performed but once, and then it did not save the

patient. He adds, that Galen relates that he only knew of one case in

which it had proved successful. He directs the incision to be made three

fingers’ breadth, straight below the navel, that is to say, in the linea

alba; but if the liver is diseased he recommends it to be made in the

left side, or if the spleen, in the right. (Pract. ix, 41).

Rhases gives Antyllus’s description of the operation, which, however, is

scarcely at all different from that of our author. He directs us to make

the assistants stand behind and compress the sides of the abdomen, and,

if possible, recommends to make the patient sit on a bench. He directs

us to make the incision with a large needle below the navel, when the

collection is connected with disease of the intestines; but if from the

liver, on the left side; or if from the spleen, on the right. Like the

other authorities noticed above, he directs us to make the opening of the

peritoneum higher up than that of the skin. A canula, made of copper,

is then to be introduced into the opening. If the pulse sink during the

operation he advises us to stop the discharge of the water. (Cont. xix.)

We have mentioned in our notes on Book Third, section 48, that

Hippocrates and Aëtius approved of scarifications at the ankles. It

appears that Archigenes also was an advocate for this practice in

dropsical cases.

Dropsy of the womb and hydatids thereof are correctly described by

Soranus. It seems to be now agreed that the dropsy in this case is a

species of large hydatid. (120.)

SECT. LI.—ON EXOMPHALOS, OR PROLAPSUS OF THE NAVEL.

Protrusion of the navel takes place when the peritoneum there is ruptured

and prolapsed; or from the omentum, intestine, and sometimes an inert

fluid falling down upon the navel, sometimes from hypertrophy of the

flesh, and sometimes from a collection of blood there, proceeding from

the rupture of a vein or artery, as in aneurisms; and sometimes the

collection consists not of blood, but of spirits only. If, then, the

omentum be protruded, there appears a swelling at the navel, which is

free from discoloration, soft to the touch, without pain, and uneven; but

if it is intestine in addition to the afore-mentioned symptoms, there is

greater inequality,—the tumour, when pressed by the fingers, disappears,

sometimes with borborygmi; and it is increased by baths and straining.

If its contents be a fluid, the tumour is equally soft, not yielding to

pressure, and is neither diminished nor increased by it. If it consist

of blood, in addition to the afore-mentioned symptoms, the swelling is

more livid; but if it arise from hypertrophy of flesh, the tumour will

be harder, elastic, and will continue of the same size. Those occasioned

by flatulence are attended with softness, a certain sound when tapped,

and disappearance upon pressure. We must operate then in this manner.

Having placed the man in an erect posture, we order him to press down at

the same time that he retains his breath; then, having marked the whole

prominence of the navel with black ink, we are to lay him on his back,

and dissect around the tumour with a scalpel, agreeably to the marking;

then, stretching the middle with a hook, we must apply a thread or string

around the part which is dissected, for thus it will be prevented from

falling down, when secured with a knot. Then, at the top, having opened

the constricted tumour, we must introduce the index-finger, and search

carefully lest any fold of the intestine, or part of the omentum, be

included in the ligature; and if intestine be included, we must loosen

the fold of the thread, and push it inwards, but if it is omentum we may

draw it out, and cut off what is redundant of it, securing, as is proper,

with a thread, any vessel that may come in the way; and then taking two

needles, containing a plain thread, we pass them through the scarified

part in the form of the Greek letter Χ, and cutting the doubles of the

threads, as we mentioned for aneurism, we make constriction with the four

heads. After the bodies secured by the ligatures have become putrid and

dropped off, we complete the cure by dressing the part with pledgets, and

strive to make the cicatrix particularly hollow. Such is the operation

when the part concerned is the intestine or omentum. But if flesh, or

fluid, or blood occasions the complaint, having divided the middle of

the tumour circularly, and then removed whatever lies external to the

peritoneum at the navel, we perform the cure by incarnative applications.

But exomphalos arising from aneurism, or the presence of flatus, we must

abandon as hopeless, like other cases of aneurism.

* * * * *

COMMENTARY. Celsus gives an interesting abstract of the ancient opinions

upon this subject, but as it differs but little from our author’s

description, we shall not dwell very particularly upon it. He directs us

to cure the disease either by passing through the tumour a needle armed

with two threads, in the manner described for staphyloma, or to produce

mortification of the part by pressure between two rules. Some, he says,

first make an incision in the tumour, so as to be enabled to remove

with the greater facility whatever is protruded, but this he thinks

unnecessary, as it will be sufficient merely to return the prolapsed

substance, and apply a ligature round its base; after which the outer

part is to be destroyed by medicines or the cautery. This operation, he

adds, will be sufficient, whether the contents of the hernial tumour be

intestine, omentum, or water. He intimates, however, that the operation

is attended with some danger, and that it is only to be performed between

the ages of seven and fourteen, and when the body is in a healthy state.

He forbids to interfere with scirrhous tumours. (vii, 14.)

The description of the operation given by Albucasis is very minute, but

is to the same effect as our author’s. (Chirurg. ii, 52.) Rhases, in like

manner, recommends us to pass a needle, armed with two threads, through

the tumour, and to secure it by a crucial knot. He, Avicenna, and Haly

Abbas evidently copy our author’s description.

The operation with the ligature, as first described by Celsus, was

revived, with very slight modifications, by the celebrated Desault, of

Paris, but is now seldom practised.

SECT. LII.—ON WOUNDS OF THE PERITONEUM, AND ON FALLING DOWN OF THE

INTESTINE OR OMENTUM, WHERE GASTRORAPHÉ ALSO IS DESCRIBED: FROM THE WORKS

OF GALEN.

How wounds of the peritoneum are to be treated is next to be considered.

If then the wound be small, so that the prolapsed intestine being

distended with air, cannot be restored to its place, it will be necessary

either to evacuate the flatus or enlarge the wound. The former measure

is the better, provided one can accomplish it. But how may this be most

probably done? By removing the cause which occasions the inflation of

the intestine. But what is this? Congelation of the surrounding air; so

that the cure is to be performed by heating. Wherefore, having soaked a

soft sponge in hot water, and then squeezed it out, foment the intestine

therewith. In the meantime let hot austere wine be prepared, for it is

more heating than water, and communicates strength to the intestine.

If, after having had recourse to all these things, the intestine remain

inflated, we must divide as much of the peritoneum as the prolapsed

intestine requires. The straight instruments called syringotoma, used for

operating upon fistulæ, are very proper for this incision. A recumbent

position of the patient is the best when the wound is in the lower part;

and when in the right side, he may lie on the left, and when in the left,

on the right; and this is common both to great and small wounds. But the

replacement of the intestine into its proper place when the wound is

large, requires a skilful assistant. For he must take hold of the wound

externally with his hands, and contract and compress it a little, so as

to expose always a small portion to the sewer, and also must compress

moderately what is sewed until the whole is sewed. What is the most

proper mode of performing the operation called gastroraphé, we must next

explain. Since the abdomen must be united with the peritoneum, we have

to begin by passing a needle through the skin from without inwards; but

when it has transfixed the skin and the whole rectus muscle, passing by

the adjacent peritoneum, we must push the needle from within through

the other part of the peritoneum, and so hence from within outwards,

through the rest of the abdomen; and when it has passed out we must push

the needle again from without inwards through this part of the abdomen,

and, passing by the adjacent portion of the peritoneum, and beginning

again from the opposite side of this membrane, perforate it from within

outwards, and at the same time all the other parts of the abdomen;

then beginning again from this, sew it with the opposite membrane, and

afterwards transmit it from the neighbouring skin outwards; and do

this repeatedly until the whole wound be sewed up. The space between

the sutures required to keep the under parts together must be very

small, but the interval between those required to keep the skin from

falling asunder need not be so small. Excess in either respects must be

avoided, and a medium chosen between the two extremes. And a medium is

likewise to be observed as to the consistence of the thread, for that

which is too hard breaks the soft skin, and what is too soft is itself

first broken. In the same manner, passing the needle too near the lips

of the wound, occasions often a rupture of the remainder which is too

narrow. But if too much is taken in, much of the skin remains ununited.

These observations apply to the treatment of all ulcers, but are more

especially to be observed in gastroraphé; and, as aforesaid, we must

act, forming a conjecture as to the adhesion of the peritoneum with the

abdomen, from the circumstance that the latter being membraneous seldom

adheres; or, as some do, by bringing together the parts of the same

kind; that is to say, peritoneum to peritoneum, and abdomen to abdomen.

Or, it may be done thus: in the same manner as above, we must pass a

needle from the side of the abdomen nearest us, from without inwards,

and through it above; then passing both lips of the peritoneum, we must

again turn the needle from without inwards through both lips of the

peritoneum, and again turning it from within outwards, pass it through

the opposite part of the abdomen. This mode differs from the common and

vulgar one, inasmuch as the needle is passed through the four lips at

one perforation, and exactly conceals the peritoneum within the abdomen.

The proper applications are those formed of the same materials as the

applications for recent wounds; but in order that no vital part may be

affected sympathetically, some tender wool is to be dipped in moderately

hot oil, and the whole space between the groins and armpits wrapped in

it. It will be better, also, to evacuate the bowels by a clyster of warm

oil. But if any of the intestines be wounded, dark austere wine, in a

tepid state, should be injected, more especially if it be perforated

quite through. The large intestines are easily cured, but the small

ones with difficulty, and the jejunum is utterly incurable, from the

multitude of its convolutions and the magnitude of its vessels, and

owing to its coats being thin and nervous; besides, it receives all the

bile in an undiluted state, and is nearest to the liver. The under and

fleshy parts of the stomach we may attempt to cure, for we may succeed,

not only because these parts are thicker, but because curative medicines

are more readily applied to them, owing to their situation. The parts,

however, about the mouth of the stomach and œsophagus are affected by

the medicines only in passing down; and the exquisite sensibility of

the mouth of the stomach is an obstacle to the cure of wounds of it.

When, from a rupture of the peritoneum, the omentum is prolapsed, and

either becomes livid or black, the part anterior to the black portion

may be included in a ligature, for fear of hemorrhage, and then the part

behind the ligature is to be cut off, and the extremities of the ligature

allowed to hang from the under part of the sewed wound of the abdomen, in

order that they may readily escape when cast off by the suppuration of

the wound.

* * * * *

COMMENTARY. The description of gastroraphé here given will be

sufficiently intelligible upon an attentive perusal. It is taken from

Galen. (Meth. Med. vi, 4.) By abdomen, in this place, is to be understood

the abdominal parietes, namely, the skin and muscles. Galen explains that

ἐπιγάστριον is used in this sense.

Celsus gives a long description of a somewhat different method of

performing gastroraphé. He uses two needles. (vii, 16.)

Several modes of performing the operation are minutely described by

Albucasis. He relates the history of a case in which he practised

gastroraphé. (ii, 87.)

Haly Abbas recommends the warm bath, to facilitate reduction. The method

of performing gastroraphé which he directs, is similar to the suture now

practised upon dead bodies after dissections. (Pract. ix, 43.)

Rhases describes various modes of gastroraphé. He speaks of performing

the operation with the string of a harp. (Cont. xxviii.) That the strings

of the ancient harp were made of the guts of a sheep is clearly proved

from the following passage in the Odyssey of Homer:

ὡς ὁτ’ ἀνὴρ φορμίγγος ἐπιστάμενος καὶ ἀοιδῆς

ρηϊδίως ἐτάνυσσε νέῳ ἐπὶ κόλλοπι χορδὴν,

ἄψας ἀμφοτέρωθεν ἐυστρεφὲς ἔντερον οἶὸς.

Οδυσ. φ.

The modes of gastroraphé described by Galen and Celsus are explained

and commented upon by Van Swieten (Comment. cccxi), and by Fabricius ab

Aquapendente. (Œuv. Chir. ii, 53.) A complete history of the operation is

given by Sprengel. (Hist. de la Méd. xviii, 21.) Ambrose Paré performed

the operation exactly like Galen.

SECT. LIII.—ON DEFICIENCY OF THE PREPUCE.

When there is a small deficiency in the skin of the penis, some, in order

to repair the deformity, have attempted a double surgical operation;

sometimes cutting the skin all round above at the commencement of the

penis, in order that by this solution of continuity the skin may be drawn

downwards until the glans (as it is called) be covered; and sometimes

with a scalpel dissecting its inner surface from the root of the glans,

and then drawing it downwards, and surrounding the glans with a soft

ligature; but a piece of cloth must be interposed at the incision, in

order to prevent an adhesion of the prepuce to the glans. Antyllus

approves most of this method, of which he gives a full description, but

we have been content with a brief outline, because it is rare that this

surgical operation is required, as the complaint neither occasions any

defect of the functional office, nor such deformity that one would choose

to submit to the hazard of an operation on account of it.

* * * * *

COMMENTARY. Celsus describes the operation as follows: “Cutis circa

glandem prehenditur et extenditur, donec illam ipsam condat; ibique

deligatur: deinde, juxta pubem, in orbem tergus inciditur, donec coles

nudatur; magnâque curâ cavetur, ne vel urinæ iter, vel venæ quæ ibi sunt,

incidantur. Eo facto, cutis ad vinculum inclinatur, nudaturque circa

pubem velut circulus; eoque linamenta dantur, ut caro increscat, et id

impleat: satisque velamenti supra latitudo plagæ præstat. Sed, donec

cicatrix sit, cinctum esse id debet: in medio tantum relicto exiguo urinæ

itinere.” (vii, 25.)

Rhases directs us to put a proper piece of lead upon the glans, then

to draw the prepuce over it, and secure it with a ligature, having

previously dissected it from the parts below, if necessary. (Cont. xiv.)

This is much the same as our author’s operation for phimosis. See section

lv.

The reader will find the ancient operation described by Fabricius ab

Aquapendente. (Œuv. Chirurg. ii, 61.)

SECT. LIV.—ON HYPOSPADIÆUM, OR IMPERFORATE GLANS PENIS.

In many children the glans is not perforated at birth, but the meatus is

situated under the part called canis, at the termination of the glans.

Hence they can neither make water forwards unless they draw up the member

to the pubes, nor procreate, as the semen cannot be injected direct

into the uterus. In addition to these defects, the complaint occasions

no ordinary deformity. Wherefore, the simplest and least dangerous mode

of operation is that by amputation. Having then placed the patient in a

supine posture, we have to stretch the glans forcibly with the fingers of

the left hand, and then with the point of a scalpel we are to amputate

the glans at the corona, not making the amputation obliquely, but carving

it, as it were, all round, so that an eminence may appear in the middle

resembling the glans. And since a hemorrhage frequently takes place, we

may stop it by styptics if possible, but if not, we must have recourse to

burning with slender cauteries.

* * * * *

COMMENTARY. Galen makes mention of this deformity. (De usu Partium.) See

also Theophilus. (De Fab. Hom. v, 22.)

Albucasis evidently transcribes our author’s description. The part named

_canis_ (κυὼν) by our author is called _finis capitis virgæ_ in the

translation of Albucasis, and _finis coronæ_ in the translation of Haly

Abbas. (Pract. ix. 44.) We do not remember to have seen the term κυὼν

applied by any other medical author to a part of membrum virile. Perhaps

the proper word is ἳς _gent._ ἱνὸς which is applied by Galen to a part of

the genital member. (Meth. Med. xiv. 16.)

Guido de Cauliaco directs us to make an opening with a suitable

instrument and introduce a canula of lead or wood. (iv, 2.)

SECT. LV.—ON PHIMUS, OR PHIMOSIS.

There are two causes of phimosis; for sometimes the prepuce so covers

the glans that it cannot be retracted; and sometimes when drawn behind,

it cannot be brought forward, which last species is properly called

paraphimosis. The first variety is occasioned either from a cicatrix

formed in the prepuce, or from an adhesion by flesh. But the second

variety takes place in inflammations of the genital organs when the

skin being brought back, the glans swells, and it cannot longer allow

of being drawn forward. If it is the first species of phimosis we may

operate upon it in this manner. After having placed the patient properly,

and drawn the prepuce forwards, and having fastened three or four hooks

into its extremity and giving them to assistants to hold, we direct them

to stretch and open it; and then if the external adhesion be from a

cicatrix, we divide the prepuce from the internal parts with a lancet or

sharp knife in three or four places, making the divisions at the inner

parts direct and equally distant from one another. The prepuce at the

glans is double, wherefore we divide the mouth of the inner part; for

having thus opened the contraction formed by the cicatrix, we are enabled

to retract the prepuce. But if a preternatural adhesion of the flesh of

the internal parts occasion the phimosis we may make scarifications in

all the flesh, drawing back the prepuce and scraping away the fleshy

prominences between the incisions, and afterwards apply a tube of lead

to the whole glans, having wrapped it in dried paper (papyrus), the tube

having its opening the same everywhere; for thus, by the application of

the tube, the prepuce, when brought forwards again, is prevented from

forming adhesions, being kept separate by the lead and the paper wrapped

round it; for by getting swelled with the moisture it separates the skin

still more. This we may do whether we operate upon a phimosis occasioned

by a cicatrix, or one from a preternatural adhesion of flesh. But if the

complaint called paraphimosis take place, and become chronic, adhesions

take place, and the complaint is incurable, unless one choose to submit

to the operation for deficiency of prepuce. But if it has not yet formed

adhesions, we may make three, four, or more direct incisions circularly,

and having bathed with much tepid oil, draw the prepuce outwards.

* * * * *

COMMENTARY. Celsus describes the operation as follows: “Subter a summâ

orâ, cutis inciditur recta linea usque ad frænum; atque ita superius

tergus relaxatum, cedere retro potest. Quod si parum sic profectum est,

aut propter angustias, aut propter duritiem tergoris, protinus triangula

forma cutis ab inferiore parte excidenda est, sic ut vertex ejus ad

frænum, basis in tergo extremo sit. Tum superdanda linamenta sunt alia

que medicamenta quæ ad sanitatem perducant. Necessarium autem est, donec

cicatrix sit, conquiescere: nam ambulatio, atterendo ulcus sordidum

reddit.” (vii, 25.)

Our author’s description of the operation for keeping the prepuce

separated from the glans, by means of a leaden tube, is mostly taken from

Galen. (Meth. Med. xiv, 16.)

SECT. LVI.—ON ADHESION OF THE PREPUCE TO THE GLANS.

When there has been a previous ulceration about the glans, or prepuce, an

adhesion of the one part to the other takes place. We must, therefore,

dissect around, as far as may be, endeavouring to separate the adhesion

with the point of a scalpel, or of a polypus knife, and more especially

to free the glans completely from the prepuce, to which it adheres;

but, if this be found difficult, we must rather add of the glans to the

prepuce with which it is united, than contrariwise; for the prepuce,

being thin, is readily perforated. After the disengagement of the

adhesion, a thin cloth, dipped in cold water, is to be placed between the

glans and the prepuce, that no adhesion may again take place, and the

parts are to be healed with some astringent wine.

* * * * *

COMMENTARY. Albucasis describes the operation in exactly the same terms.

(Chirurg. ii, 56.)

SECT. LVII.—ON CIRCUMCISION.

We do not treat at present of those who are circumcised in conformity to

a heathen rite, but of those in whom the prepuce has become black from

some affection of the privy part. In such cases, it becomes necessary to

cut off the blackened portion all around; and afterwards we must have

recourse to the squama æris, with honey, or to pomegranate-rind and

tare, in the form of those applications which are made upon a pledget.

And if there be a hemorrhage, we must use lunated cauteries, which

contribute to two good purposes: I mean the stoppage of the bleeding

and of the spreading sore. But if the whole glans be consumed, having

introduced a leaden tube into the urethra, we direct the patients to make

water through it.

* * * * *

COMMENTARY. See a similar description in Albucasis. (Chirurg. ii, 57.)

Albucasis describes the mode of performing the operation on boys, as a

rite of the Jewish religion. He directs the prepuce to be cut with a

pair of scissors, and the part allowed to bleed freely. From the manner

in which he expresses himself respecting the operation, there can be no

doubt that he was a Jew, and it is equally clear that our author was a

Pagan.