Chapter XVI: Book VI: Sect. I.—preface to the Surgical Part (2)

Albucasis, Haly Abbas, and Rhases describe the operation in much the same terms as Celsus and our author. Most of the Arabian authorities, likewise, describe the operation of burning the roots of the hairs by means of a specillum or any such instrument. Canamusali gives a short account of both operations, that is to say, the anabrochismus and burning the roots of the hairs.

This operation is described by the earlier of the modern writers on surgery. The agglutinative composition recommended for this purpose by Guido de Cauliaco consists of mastich, frankincense, aloes, sarcocol, and tragacanth, dissolved in the white of an egg. (vi, ii.)

SECT. XIV.—ON HYDATIDS.

The hydatid is a fatty substance, naturally lodged under the skin of the eyelid, which, in some persons, more especially in children of a more humid temperament, increases until it become the cause of disagreeable symptoms by encumbering the eye, and thereby occasioning defluxions. The eyelids, therefore, under the brows appear watery and cannot be raised in a becoming manner; and if, when we press upon them with our fingers, we separate the fingers, the intermediate space swells up. They are most troubled with defluxions about day-break, and cannot look direct against the rays of the sun, but shed tears and are subject to continued ophthalmies. Wherefore, having placed the patient in a proper position, we compress the eyelid with the index and middle fingers a little separated from one another, so as to form a collection of the watery contents between the fingers, and direct the assistant, who stands behind and holds the head, to stretch the eyelid moderately at the middle of the brow; then taking a lancet used for bleeding, we make a transverse incision through the middle, not longer than that made in venesection, and of such a depth as to divide the skin or even to touch the hydatid itself; but this is to be done with due circumspection. For many plunging the instrument too deep, have either divided the cornea or wounded some muscle of the eyelid. If the hydatid immediately appear, we draw it out, or if not, we again make a slight incision. When it comes in sight we seize on it by the fingers, with a soft cloth, and moving it hither and thither and round about, we draw it out. After the removal of it we soak a double compress in oxycrate, and bind it on the part. Some apply levigated salts, upon the knob of a specillum, to the incision, in order that if any part of the hydatid remain it may be dissolved. After the removal, should there be no inflammation, we accomplish the cure with collyria in the form of liniments, or with lycium, horned poppy, or saffron. But when there is inflammation we treat it with suitable cataplasms and the other remedies.

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COMMENTARY. Celsus describes them by the name of vesicæ pingues gravesque. It is clear that they are different from the tumours to which modern surgeons apply the name. They appear to have been encysted tumours, or perhaps enlargements of the sebaceous glands. Celsus directs us to apply pressure with two fingers, and the skin being stretched to make a transverse incision, taking care not to wound the bladder or cyst. The tumour is then to be seized with the fingers and pulled out. He remarks that when the cyst is opened, and its contents evacuated, it renders the operation more difficult. When such a thing happens he recommends us to encourage suppuration.

To this class of tumours we may perhaps refer the white rough bodies resembling chalk-stones, on the inner surface of the eyelid, which are described by Aëtius. He directs us to evert the eyelid, and, making an incision along the vertex of the tumour, to scoop it out with an earpick, and apply burnt copper, finely triturated, to the part. When extracted outwardly he recommends a dressing with tetrapharmacum. (vii, 82.)

See Albucasis (Chirurg. ii, 10); Avicenna (iii, 3, 3, 18); and Haly Abbas (Pract. ix, 21.) They evidently copy from our author. Rhases professes to borrow his description of the operation from Antyllus and Paulus. (Cont. ii, 3, 2.)

Fabricius ab Aquapendente, describes under the name of hydatid, two kinds of encysted tumours, the contents of the one being of a thick and heavy nature, and the other, an atheroma. He approves of the ancient modes of operating. (O. L. ii, 9.) Heister incorrectly calls them vesiculæ aquâ plenæ. (Ch. ii, 2, 9.) Tumours similar to those which we have here treated of are described by Scarpa, in the third chapter of his work on the Eye, and every practical surgeon must be familiar with them.

SECT. XV.—ON ADHESION OF THE EYELIDS.

The upper eyelid undergoes adhesion sometimes to the lower tarsus, sometimes to the tunica adnata, and sometimes to the cornea itself. This disease obstructs the motions of the eye. Wherefore, applying an ear-specillum to the broad margin of the eyelid, or stretching it with a hook-like instrument, we free the adhesion with the scalpel used in the operation for pterygia, taking care that the cornea be not wounded, lest we give rise to procidentia. After the incision, having bathed the eye, we separate the eyelids with tents, lest adhesion again take place, and applying wool, soaked in an egg, after the third day we have recourse to attenuant and healing collyria.

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COMMENTARY. See Aëtius (vii, 66); Celsus (vii, 7); Albucasis (Chirurg. ii, 15); Avenzoar (i, 8, 5); Avicenna (iii, 3, 8, 10); Haly Abbas (Pract. ix, 22); Alsaharavius (Pract. iv, 5); Rhases (Cont. ii); Jesu Hali (ii, 7.)

The description given by Aëtius is exactly the same as our author’s.

Celsus correctly remarks that the disease is the consequence of neglected ulcers. He describes the operation in the following terms:—“Igitur aversum specillum inserendum deducendæque eo palpebræ sunt: deinde exigua penicilla interponenda, donec exulceratio ejus loci finiatur.” He mentions that Heraclides of Tarentum directed the eyelid to be dissected from the white of the eye when there is adhesion between them; but recommends us to do it cautiously with an averted specillum (dos de la spathule, Fabr. d’Aquapen.), taking care to wound the eyelid rather than the ball of the eye. Suitable ointments are afterwards to be applied. Yet he says that he never saw a case thus cured; and states, that Meges likewise thought the disease incurable.

In order to understand the above description of Celsus it may be useful to give from Fabricius some account of the ancient specillum. “Il nous suffit scauvoir que _specillum_ (qui est le mot Latin de Celse) est un instrument long et rond, de cuivre, d’argent, ou de plomb, duquel on sonde les fistules, ayant un de ses bouts plus large, et l’autre plus étroit, en vulgaire Italien _stilo_.” (Œuv. Chir. ii.) It was, therefore, a sort of sound.

Avenzoar directs us to make the separation by means of a golden rod or probe, and then to apply the white of an egg broken with oil of roses and oil of almonds. When the eyelid adheres to the white of the eye he advises us in like manner to make the separation gently with a golden spatula, and then to apply the oil of roses and of almonds. But the latter case, he says, is difficult to cure.

Of the other Arabians, Albucasis and Haly Abbas evidently copy the description of the operation given by Paulus; and Rhases and Avicenna supply no additional information. Jesu Hali’s description is accurate, but similar to that of Celsus.

SECT. XVI.—CHALAZIA OR TUMOURS RESEMBLING HAIL-STONES.

The chalazion is a concretion of inert fluid in the eyelid. If it occur on the external side of the eyelid, having divided the outer part of the eyelid transversely with a scalpel, we extract the chalazion with an ear-pick, or some such instrument, and when the incision is large and the lips thereof separated, we unite them with a suture, and have recourse to some plaster. But if it be small we omit the suture and effect the cure in the same manner otherwise. But if the chalazion be internal, so as to appear through the cartilage, having turned the eyelid outwards, and divided it transversely within, we extract it and use an injection of salt water.

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COMMENTARY. Aëtius says that the contents of the chalazia, in some cases, resemble the white of an egg. These he directs us to open, and, having evacuated their fluid contents, to touch the part with a powder consisting of verdigris, burnt copper, and other such escharotics. When the contents are harder he recommends complete excision, like our author. (vii, 83.)

Celsus describes the mode of operating with his usual terseness:—“Hæc incidi debent, si sub cute sunt, ab exteriore parte, si sub cartilagine, ab interiore, dein scalpelli manubrio deducenda ab integris partibus sunt.” (vii, 7.)

The descriptions of the operation given by Albucasis and Haly Abbas, if not literally copied from our author, are altogether to the same effect.

Rhases and Avicenna approve most of the treatment by medicines. See Book Third. Jesu Hali directs us to avert the eyelid and extract the tumour. Fabricius ab Aquapendente says that the fluid contained in the chalazion (gresle) is “blanche et transparente, en quelque façon comme de la gresle.” He repeats the directions given by Celsus. (Œuv. Chir. ii, 11.)

The chalazion is evidently an encysted tumour of a soft nature, and is not identical with the hordeolum, as Scarpa makes it to be. The treatment here recommended is such as admits of no improvement.

SECT. XVII.—ON ACROCHORDON AND ENCANTHIS.

Acrochordon of the eyelid and that tumour at the greater canthus called encanthis we seize with a flesh forceps, and cutting them out with a scalpel, apply levigated chalcitis.

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COMMENTARY. The nature of the acrochordon is explained in the Fourth Book.

Celsus, like our author, directs us to seize the encanthis with a hook, and cut it out, taking care not to interfere with the angle of the eyelid. He then recommends us to apply a pledget sprinkled with calamine or atramentum sutorium (sulphate of copper?) between the eyelids. (vii, 7.)

Aëtius recommends us either to use a forceps, or if the tumour is large, to transfix it with a needle armed with a thread, and to tie it at its base, and to twist the thread round it.

Albucasis and Haly Abbas evidently copy from our author. Avenzoar prefers reducing the fleshy tumour with septics. Rhases mentions that some recommend septics in cases of encanthis, but he prefers excision. After the operation he recommends squama æris to the part. (Cont. ii.) Jesu Hali directs us to remove it with septics. (ii, 33.) It will be remarked that our author’s operation is the same as that recommended by modern authorities.

SECT. XVIII.—ON PTERYGIA.

This disease is occasioned by a nervous (tendinous) membrane beginning for the most part at the great canthus, and gradually spreading inwards. It proves injurious to the eye both by obstructing the motion of the ball, owing to the contractions it produces, and because when it advances forwards it covers the pupil. Those therefore which are thin and of a white colour being easiest to cure, we operate upon in this manner: having separated the eyelids, and seized upon the pterygia with a hook-like instrument, having a small curvature, we stretch it, and taking a needle having a horse-hair and a strong flaxen thread in its ear (eye?), and a little bent at the extremity, we transfix it through the middle of the pterygium, and with the thread we bind the pterygium and raise it upwards, while with the hair we separate and saw as it were the part at the pupil away unto its extremity; but the remainder of it at the great canthus we cut off from the base with the scalpel used for the operation by suture, but leaving the natural flesh of the canthus, lest there be a running of the eye when it is taken away. Some stretching as aforesaid with a thread, dissect away the whole pterygium with the instrument called pterygotomos, taking care not to touch the cornea. After the operation, having applied some levigated salts to the part, we bind on it some wool dipped in an egg. After the removal of this we inject into the eye salt water for a long time. But if inflammation supervene we have recourse to the remedies described for it.

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COMMENTARY. Celsus gives an excellent account of the pterygium. He correctly states that the membrane generally begins at the inner angle of the eye. His description of the operation is very precise. The patient being properly seated, the surgeon is to raise the membrane with a sharp hook somewhat bent at the extremity, and is then to pass below it a needle armed with a thread, the two ends of which he is to lay hold of and separate the membranes everywhere from the ball of the eye. The membrane is then to be cut out with a scalpel, care being taken not to hurt the angle of the eye-lid. He directs us to apply to the part a piece of sponge, or some wool, or a pledget spread with honey. (vii, 7.)

Aëtius also describes the operation very correctly, but in the same terms as our author; that is to say, he directs us to use the needle armed with a flaxen thread and a horse-hair, and afterwards to cut out the membrane, using the precautions here mentioned. (vii, 60.)

Albucasis recommends the same mode of procedure as Aëtius (Chirurg. ii, 16.) Haly gives similar directions. (Pract. ix, 25.) Both caution us not to carry the incision too near the inner canthus. Haly Abbas recommends the use of the scissors, and not of the scalpel (in the translation read _forficibus_ and not _forcipibus_.)

Avicenna likewise recommends the scissors. (iii, 3, 2, 23.) Rhases gives directions for passing a needle below the membrane, and for cutting it off. He speaks of using a pair of scissors. He mentions that he had seen a surgeon perform it with a pen. (Divis. 25, and Cont. ii, 3.)

Jesu Hali directs us to operate either with a scalpel or pair of scissors. (De Oculis ii, 38.)

The modern methods of treatment do not appear to differ in principle from the ancient. Scarpa operates with a pair of scissors; but Beer prefers the scalpel. Scarpa seems to approve of the direction given by the ancient authors, not to carry the incision too far towards the inner angle of the eye. See also Fabricius ab Aquapendente (Œuv. Chir. ii, 18), and Brunus (Chir. Mag. ii, 4.)

SECT. XIX.—ON STAPHYLOMA.

Staphyloma is an incurvation of the cornea, and of the tunica choroides, arising from debility, and being produced sometimes by a defluxion, and sometimes by ulceration. We operate upon it not in order to restore the eyesight, for that is impossible, but to moderate the patient’s deformity. Wherefore having passed a needle from below upwards through the base of the staphyloma, we are to push another needle, having a double thread, from the canthus next the hand to the other, through the base of the staphyloma; and the first needle remaining, we cut the double of the thread, and tie part of the staphyloma upwards and part downwards with the threads, and then removing the needle we apply wool dipped in eggs. After the removal of the dressings we soothe the eyes with emollient injections until the ligatures fall off along with the staphyloma.

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COMMENTARY. Celsus thus describes the disease: “In ipso autem oculo nonnunquam summa attolitur tunica, sive ruptis intus membranis aliquibus, sive laxatis: et similes figura acino fit: unde id σταφύλωμα Græci vocant.” He describes two methods of cure: the first of which is by ligatures, as recommended by our author; and the other consists in cutting from the apex a circular portion equal in size to a lentil.

Scarpa and Guthrie concur in recommending the latter operations, the merits of which, as they state, have not been generally appreciated properly.

Aëtius directs us to introduce the cross threads, as recommended by our author, and then to cut out the apex of the tumour. He is at great pains in directing us to introduce the threads obliquely, and not at right angles to one another. He also recommends general bleeding and emollient fomentations, (vii, 37.)

The operation with the ligatures is briefly described in the ‘Isagoge,’ generally ascribed to Galen.

Haly Abbas and Albucasis describe the operation with the cross threads in nearly the same terms as our author. The latter, however, makes mention of puncturing the apex of the tumour after the application of the ligatures. Jesu Hali gives nearly the same account of the operation.

Although Scarpa condemns in strong terms the use of the needle and ligatures, this method of treatment is sanctioned by the authority of Mr. Travers. This operation was approved of by William of Saliceto.

Scultet explains the descriptions given by Celsus and Paulus, but they are sufficiently plain of themselves. (Arsen. de Chirurg. tab. 32.)

It will be perceived that the ancients applied the name staphyloma to two distinct, or at least considerably different diseases, namely, to enlargement with protrusion of the cornea, and to prolapsus of the iris connected with ulceration of the cornea. Heister, Wenzel, and other continental writers, use it in the same sense as the ancients. Scarpa and our English oculists apply it only to protrusion of the cornea, without ulceration.

SECT. XX.—ON HYPOPYON OF THE EYE.

Regarding hypopyon of the eyes it will be sufficient to deliver Galen’s account, which is to this effect:—“A certain oculist of our time, named Justus, cured many cases of hypopyon by shaking the head. Placing them, therefore, erect upon a chair, and grasping their head on both sides obliquely, he shook them so that we could see clearly the pus descending downwards; and, owing to the weight of the substance, it remained below, although cataracts will not remain unless fixed carefully.” And again, he says below, “oftentimes we evacuate the pus freely by dividing the cornea a little above the place where all the coats of the eye unite. This place is called by some the iris, and by others the corona.” These are the words of Galen in his work, ‘On the Method of Cure.’ After the discharge of the pus, we clean the ulcer with injections of honied water, or of the juice of fenugreek with the addition of some honey, and then apply the other treatment conformably.

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COMMENTARY. Galen recommends three methods of treatment for the cure of hypopyon; namely, by discutients, shaking, and incision. (Meth. Méd. xiv.)

Aëtius, Albucasis, and Haly Abbas, like our author, are advocates for shaking and incision. Neither of these methods is now much in use, but both have had their advocates in modern times.

SECT. XXI.—ON CATARACTS.

The cataract is a collection of inert fluids upon the cornea at the pupil, obstructing vision, or preventing distinct vision. It arises most commonly from a congelation and weakness of the visual spirit, and on that account the disease rather attacks old persons, and those who are debilitated by protracted illness. It is occasioned also by violent vomiting, a blow, and many other causes. Those kinds of cataract which are but commencing, as not being proper objects of surgery, have been treated of in the Third Book. We shall now give the characters of those which are fairly formed and have acquired consistence. All those, therefore, who have cataract see the light more or less, and by this we distinguish cataract from amaurosis and glaucoma; for persons affected with these complaints do not perceive the light at all. Wherefore, again, Galen well instructs us as to the consistence and difference of cataracts and which kinds ought to be operated upon. Having shut the eye affected with the cataract, and with the large finger pressing the eyelid to the eye, and moving it with pressure to this side and that, then opening the eyelids and observing the cataract in the eye; if it has not yet acquired consistence, a certain flow takes place from the pressure of the finger, and at first it appears broader, but straightway resumes its former figure and magnitude. But in those which have acquired consistence no change takes place as to breadth or figure from the pressure. But since this appearance is common to those which are of moderate consistence, and those which are over-compacted, we distinguish these cases from one another by their colour. For those which are of an iron, cœrulean, or leaden colour, are of moderate consistence, and fit for couching; but those which resemble gypsum and hailstones are over-compacted. After ascertaining these circumstances, as directed by Galen, having placed the patient opposite the light, but not in the sun, we bind up carefully the sound eye, and having separated the lids of the other, at the distance from the part called the iris towards the small canthus, of about the size of the knob of the specillum, we then with the point of the perforator mark the place about to be perforated; and if it is the left eye we operate with the right hand, or if the right eye with the left; and turning round the point of the perforator, which is bent at its extremity, we push it strongly through the part which was marked out, until we come to an empty place. The depth of the perforation should be as great as the distance of the pupil from the iris. Wherefore, raising the perforator to the apex of the cataract, (for the copper of it is seen through the transparency of the cornea,) we push down the cataract to the parts below, and if it is immediately carried downwards, we rest for a little, but if it reascends we press it back again. After the depression of the cataract we turn round the perforator and extract it gently. After this, bathing with water and injecting into the eye a little Cappadocian salts, we apply externally some wool soaked in the white of an egg with rose-oil, and bind it up, and at the same time bind up the sound eye, that it may not move. Then lodging the patient in an apartment below ground, we order him to remain in a state of perfect rest, and upon a spare diet; and the bandages are to be kept on, if nothing prevent, until the seventh day, after which we loose them, and make trial of the sight by presenting him with some object: but this we disapprove of during the operation and immediately after it, lest by the intense exertion the cataract reascend. If the inflammation become urgent we loose the dressing before the seventh day, and must direct our attention to it.

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COMMENTARY. See Celsus (vii, 7); Galen (Ars Medica, 35; Isagoge); Aëtius (vii, 53); Albucasis (Chirurg. ii, 23), Canamusali (vi); Avenzoar (i, 8, 19); Mesue (de Ægr. Oculi; 15); Haly Abbas (Pract. ix, 28); Jesu Hali (Tract. de Oculis, 68); Avicenna (iii, 3, 4, 20); Rhases (ad Mansor. ix, 27, and Cont. ii); Vegetius (Mulom. ii, 17.)

This disease is called _suffusio_ by the Latins, and _aqua_ by the Arabians.

We have stated in our commentary on affections of the eye, in the Third Book, that the ancients were aware that the crystalline lens is the seat of one of the species of cataract. This opinion is clearly delivered by Galen, Aëtius, Oribasius, Haly Abbas, and some of the others. As a proof that this notion prevailed generally, we will give the words of Psellus literally translated: “Glaucoma is a grievous and incurable affection, being a certain change of the crystalline humour, and transmutation of its colour to a sea-green. The suffusion is a concretion of the fluid between the cornea and crystalline humour.” (Opus Medicum.) The other species then, as Psellus states, was held to be a concretion between the crystalline lens and the cornea. That such a disease, although of comparatively rare occurrence, is sometimes met with seems undeniable.

Celsus lays it down as a rule, that when the suffusion is small, immovable, and of the colour of sea-water, or of shining iron, and if a small degree of light can be perceived at the side, there is reason to hope well of the case. He forbids us to operate until the disease has attained a proper consistence. He directs us to place the patient opposite the operator, who is to sit on a higher seat, while the patient’s head is firmly held by an assistant. The sound eye is to be previously covered up with wool. If the left eye is affected the operator must use his right hand, and vice versa. A needle which is sharp and not too slender is to be passed direct through the two coats at a place intermediate between the temporal angle and the black of the eye, and towards the middle of the cataract. When the needle has perforated far enough, which is readily known by the absence of resistance, it is to be gently turned so as gradually to remove the cataract below the region of the pupil, and this object being attained it is to be strongly pressed to the lower part. If it remain there the operation is completed; but if it return it is to be cut and torn by the needle into many pieces, in which state they are easier depressed, and prove less troublesome. The needle is then to be drawn out direct, and soft wool smeared with the white of an egg, and other anti-inflammatory applications are to be used. Quiet, restricted diet, and soothing treatment will be proper.

Galen, in his ‘Ars Medica’ alludes to the operation, but does not describe it.

Paulus is the only Greek author who describes the operation. Sextus Platonicus, however, just mentions that the diseased part is sometimes to be depressed with a specillum. (De Medic. ex Animalibus.)

Mesue describes the operation of couching briefly, but nearly in the same terms as our author. He directs us to put the patient upon a spare diet, and to bleed him before the operation. He recommends us to be careful to depress the cataract (aqua) properly.

Albucasis describes the operation of Paulus very minutely, and gives drawings of the couching-needles, called by him almagda. The instrument is to be passed down into the eye to as great a space as the pupil of the eye is distant from the end of the black part called the corona. He says nothing of tearing the cataract into pieces when it proves difficult to depress. He mentions that he had heard of a certain oculist who, it was said, sucked out the cataract through a small tube. He adds, however, that he had never seen any person who performed this operation, nor had read anything about it in the works of the ancients.

Avenzoar briefly mentions that when a cataract cannot be got discussed it must be depressed. He gives directions to press it well down, but says nothing about tearing it into pieces. He recommends retirement, abstinence, and rest afterwards.

Avicenna’s description is evidently copied from our author. He also mentions that some surgeons open the lower part of the cornea, and extract by it. However, he does not approve much of this procedure.

Canamusali briefly mentions that cataract must sometimes be removed by a surgical operation. When convulsions come on after the operation he directs us to apply castor to the nose.

Rhases describes accurately the operations of couching, extracting, and sucking out the cataract. He is the only ancient author, except Celsus, who recommends the cataract to be torn in pieces when it cannot be got properly depressed. He mentions that the famous surgeon Antyllus practised extraction by opening the lower part of the cornea. He also speaks of a certain surgeon who sucked it out through a glass tube.

Haly Abbas describes distinctly the operation of couching, but evidently copies from Paulus. He makes no mention, however, of extraction, as far as we can discover, in any part of his works. The operation of couching the cataract is minutely described by Jesu Haly, but he makes no mention of extraction. He was the son of Haly Abbas.

Sprengel, in his ‘History of Medicine,’ refers to Haly Abbas as one of the ancient authorities who make mention of the operation of extracting the cataract; but if this be the case the edition from which they quote (Venetiis, 1492) must be considerably different from the one with which we are acquainted. (Lyon, 1523.) Haly forbids examinations of the eye after the operation, to ascertain whether or not the patient has recovered his sight.

We will give the description of Vegetius in his own language: “Jumentum igitur pridie temperabis a cibo vel potu maximè prohibebis, in loco molli elides caputque ejus et cervicem aptè collocabis: ita patentem oculum facies ut claudere non possit: deinde ab ipsâ fronte paracenterium inter tunicas oculares subjicito, ne pupillam tangas, aut aliquid lædas interius. sed ipsum album de superiori parte ubi hypochysis posita est, capitello paracenterii deorsum deprimis ad palpebram inferiorem subtiliter. Quod si depositum fuerit, non prius paracenterium eximas, nisi clausum oculum penicello calido diutissime vaporaveris. solet enim resilire. Quod si evenerit, reprimito, donec ita componatur ut resilire non possit. Cum itaque intellexeris claritatem pupillæ sine illo obstaculo hypochysis, tunc eximes ferrum, et invenies animal videre.”

Sprengel affirms, but not quite correctly, as will be perceived from the account of the ancient opinions given above, that it was towards the beginning of the 18th century that it was first discovered that the crystalline lens is the seat of the cataract. Otherwise he gives an admirable history of the operation, in which he does ample justice to the ingenuity and inventive genius of the ancients. (Hist. de la Méd. xviii. 2.)

Fabricius’s description is altogether borrowed from the ancient authors. (Œ. C. ii, 16.) Guy of Cauliac, and the other surgical writers of that age, describe the operation in the same terms as the ancients. Guy mentions the operation of sucking out the cataract through a cannula, but does not approve of it. (vi, 2.)

SECT. XXII.—ON ÆGILOPS, OR FISTULA LACHRYMALIS.

The ægilops is an apostematous swelling between the great canthus and the nose; and it is an affection difficult to cure, owing to the thinness of the bodies, and the fear of injuring the eye by sympathy. If, therefore, the abscess burst at the surface, we remove the whole protruberance as far as the bone; and if the fistulous sore incline towards the cheek, we must lay it all open, and if the bone be sound, we must scrape it; but if diseased, we must burn it with cauteries, applying to the eye a sponge soaked in cold water. Some, after the excision of the flesh, use a perforator, and make a passage for the fluid or matter to the nose; but we are contented with burning alone, using the cauteries for ægilops, and burning down until a lamina of bone drop off; and after the burning we have recourse to lentils and honey, or to the application consisting of pomegranate-rind with honey, and other such desiccative remedies. If the ægilops incline to the canthus, and do not tend at all towards the surface, then, with a lancet for the operation on ptrygium, or one for bleeding, we may dissect out the body between the canthus as far as the abscess, and remove the deep-seated flesh, and have recourse to moderately desiccative applications. Glass reduced to a fine powder is wonderfully desiccative, and aloes with manna, in like manner. The rest of the treatment of fistula lachrymalis we have delivered in the Third Book.

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COMMENTARY. Celsus remarks that the ægilops is sometimes of a carcinomatous nature, in which case he recommends us not to interfere with it. He refers here, no doubt, to lupus, which is of not uncommon occurrence near the inner angle of the eye. In recent cases which are not of this kind, he directs us to proceed in the following manner: the whole cavity of the abscess, as in fistulæ, is to be laid open down to the bone, which is to be burned with a red-hot iron, more especially if the bone be carious. Others, he says, instead of the cautery, use caustics, such as atramentum sutorium, chalcitis, or verdigris; but these things, he adds, are more slow in their operation, and less effectual. (vii, 7.)

When the bone is diseased the celebrated Archigenes recommends it to be pierced with a slender perforator, or a hole is to be burnt in it with a red-hot iron. He mentions that others burned it by means of a funnel and melted lead. (Apud Galen. sec. loc. v; and Rhases Contin. ii, 4.)

Aëtius gives a full and lengthy account of ægilops. He recommends us to attempt the cure first with medicines (see Book Third); and if these do not succeed, he directs us to open the abscess freely, and apply to the fungous flesh medicines possessed of strong stypticity, such as powdered glass, stone alum, and the like. A pledget of lint is to be placed over the medicines. When this method of practice does not succeed, he recommends burning, and for this purpose directs us to make a triangular incision in the flesh, and then to touch the bone with a heated iron, so as to produce exfoliation. Alum with turpentine is then to be applied to the bottom of the sore. (vii, 77.)

When the disease does not yield to medicines, Albucasis directs us to open the abscess freely, so as to make an outlet for the matter, and expose the bone. If it is found to be diseased, he recommends us to scrape it with an iron instrument, and then to apply styptic and desiccative medicines to it. When this treatment does not succeed, he directs us to perforate the bone with a triangular instrument of iron. When air issues from the nose by the opening we know, he says, that the operation is completed.

For the cure of ægilops, Mesue recommends the removal of all the diseased flesh by means of strong caustics, such as arsenic, sal ammoniac, chalcitis, alum, &c. When the bone is carious, he directs us to scrape off the carious part. Some, he adds, perforate the bone; but the operation had not succeeded well in his hands. He makes mention of the cautery in the same terms as the others. (De Ægr. Oculi, 12.)

Jesu Hali approves decidedly of perforating the bone with a specillum, or any suitable instrument. He also speaks favorably of the actual cautery. (De Oculis, ii, 32.)

Haly Abbas directs us to lay open the swelling, and apply the cautery. We have mentioned in another place that he was acquainted with the lachrymal duct. (Pract. ix, 29, and ix, 72.)

It will be unnecessary to give a particular account of the treatment recommended by Avicenna, as it does not differ from that of Albucasis. According to circumstances he approves of perforating the bone, and of applying the actual cautery to it. He also speaks of introducing a thread into the lachrymal passages and of using injections. (iii, 3, 2, 14.)

Avenzoar recommends compression and injections, but does not describe the operation. He speaks of the matter passing into the nose, from which it may be inferred that he also was acquainted with the lachrymal duct. (i, 8, 10.)

Rhases likewise makes mention of the lachrymal duct. He recommends us very particularly to make incisions down to the bone, to perforate it, or to apply the actual cautery to it. He makes mention also of escharotic applications containing arsenic, quicklime, and vitriol. He relates a case of apostema lachrymale in which he effected a cure by the ligature and friction. (Contin. ii, 2.)

The practice of perforating the bone as recommended by Albucasis, was approved of by Pott, and the use of the cautery for this purpose is also supported by the high authority of Scarpa. M. A. Severinus, Hildanus, and Garengoit, were likewise advocates for the actual cautery. Fabricius seems to have understood the disease very well, and treated it in the way recommended by the ancients. (Œuv. Chirurg. ii, 21.)

Guy of Cauliac, Theodoricus, and Lanfrancus describe and appear to have performed the ancient operations for the cure of fistula lachrymalis.

SECT. XXIII.—ON IMPERFORATE MEATUS AUDITORIUS.

This affection is sometimes congenital, being occasioned by a membrane which blocks up the entrance into the ear; and it is sometimes superficial and sometimes deep-seated. And it is formed in after life by a preceding ulceration in the meatus; for a growth of fungous flesh taking place blocks up the passage. If, therefore, the membrane which obstructs the opening be deep-seated, the attempt at cure is hazardous; and yet we may try with some slender instrument to divide it, but if it is superficial we divide it with a sharp knife, and if necessary cut it out. If there be a fleshy excrescence it may be dissected out with the scalpel used for the operation in pterygium, or that used for polypus; then making a twisted tent of the size of the meatus from a linen rag, we soak it in water, and sprinkling it with levigated chalcitis, or some such powder, we introduce it into the meatus to prevent the flesh from growing again. Should inflammation come on we must soon take it out. If there be a discharge of blood from the meatus we may soak a sponge in cold water, and apply it along with other appropriate remedies.

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COMMENTARY. Celsus describes this case with his usual terseness: “Solet tamen evenire vel a primo natali die protinus, vel postea factâ exulceratione, deinde per cicatricem aure repletâ ut foramen in eo nullum sit, ideoque audiendi sensu careat.” He directs us to make an examination with a sound (specillum) in order to ascertain whether the membrane be superficial or deep-seated, and in the latter case recommends us not to interfere with it, but in the former, directs us to make an opening by means of caustics, burning iron, or scalpel. (vii, 8.)

Albucasis describes the nature of the case and the operation in nearly the same terms as Celsus and our author. If the obstruction is occasioned by a superficial membrane he directs us to perforate it with a slender instrument. If a fleshy excrescence obstruct the passage he approves of seizing it with a hook, and dissecting it out. If the obstruction be more deeply seated he directs the membrane to be opened by means of a heated iron, taking care not to hurt the nerves. It is to be kept open with a tent. (Chirurg. ii, 7.)

Avicenna mostly borrows his account of the case from Paulus. When the obstruction is occasioned by a fleshy excrescence he directs it to be burnt down with arsenic or some other escharotic. He also approves of perforating the membrane. (iii, 4, 1, 17.)

The account given by Haly Abbas accords very well with our author’s. (Pract. ix, 30.)

Fabricius ab Aquapendente describes correctly the treatment recommended by the ancients. He admits that he had never attempted to perforate the membrane when deep-seated. (Œuv. Chirurg. ii, 41.)

SECT. XXIV.—ON SUBSTANCES THAT HAVE FALLEN INTO THE MEATUS AUDITORIUS.

Not only do stones fall into the meatus, but also glass, beans, and the stones of carob nuts. Of these the stones and glass retain their original magnitude, but the beans and stones of carobs being swelled with the natural moisture of the body, occasion very severe pains. They must therefore be extracted by an earpick, a hook, or tweezers, or by using powerful shaking of the head, while the ear is placed upon some circular board. In like manner we extract bodies frequently by sucking them through a reed; and do the like with water when it falls into the ear, covering up the outside of the reed with wax when it is applied to the ear in order that there may be no outlet to the breath. Stones and such like bodies we extract by wrapping wool around an earpick, and smearing it with turpentine-rosin, or some glutinous substance and introducing it gently into the meatus auditorius. If it does not yield we introduce a sternutatory into the nose and close the mouth and nostrils. If it yield to none of these, before inflammation, convulsions, and dangerous symptoms supervene, we must bring it away by a surgical operation. Wherefore, having placed the patient in a proper position with his ear turned upwards, at the base of the ear, behind what is called the lobe, we make a small lunated incision, and with the circular part of an earpick we extract the body which is lodged there. After the extraction the wound is to be sewed up, and the cure completed by the treatment applicable in cases of recent wounds.

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COMMENTARY. See Celsus (vi, 7); Aëtius (vi, 87); Alexander Trallianus (iii, 6); Oribasius (Loc. Affect. iv, 36, 39); Galen (de Med. sec. loc. iii); Avicenna (iii, 5, 1, 23); Mesue (ii, 7, 8); Serapion (ii, 12); Rhases (ad Mansor. ix, 36; Contin. iii); Haly Abbas (Pract. ix, 31.)

Celsus gives nearly the same directions as our author, recommending us to use wool wrapped round a specillum, and smeared with turpentine-rosin, or a hook slightly bent, or an ear-syringe, or sternutatories, or shaking the patient’s head. The last-mentioned operation he directs us to execute in the following manner: “Tabula quoque collocatur, media adhærens, capitibus utrinque pendentibus, superque eam homo deligatur in id latus versus, cujus auris eo modo laborat, sic, ut extra tabulam non emineat: tum malleo caput tabulæ, quod a pedibus est, feritur: atque ita concussa aure, id quod inest excidet.”

The treatment recommended by Aëtius is exactly the same as our author’s. Alexander and Oribasius also deliver similar directions. However, Aëtius, Oribasius, Alexander, and our author, copy from Galen, who in his turn acknowledges his obligations to Archigenes and Appollonius. (De Comp. Med. sec. loc. iii.)

Albucasis’s directions are so judicious that we regret our limits do not allow of our giving them fully. For the extraction of a piece of stone he recommends us among other means to use a slender forceps, of which he gives a drawing. It resembles the modern dissecting forceps. He also gives a drawing of a hook slightly bent, which he commends; and also of a brazen tube to be used for sucking out bodies. When other means do not succeed, he directs us to make an incision at the under part of the ear, having previously let blood in order to avert inflammation and convulsions. Animals are to be sucked out with a tube narrow below and wider externally, or they are to be extracted with a forceps or hook. When these means do not succeed, an oil, to which some substance destructive of these animals has been added, is to be injected with an instrument, of which he gives a drawing.

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

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

SECT. XXV.—ON POLYPUS.

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

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

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

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

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

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

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

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

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

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

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

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

SECT. XXVI.—ON MAIMED PARTS.

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

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

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

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

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

SECT. XXVII.—ON EPULIS AND PARULIS.

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

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

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

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

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

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

SECT. XXVIII.—ON THE EXTRACTION OF TEETH.