BOOK VI.. Sect. I.—Preface to the Surgical Part.

SECT. I.—PREFACE TO THE SURGICAL PART.

Having divided the treatise on the surgical matters into what relates to manual operations on the flesh, and the account of fractures and dislocations of bones, we shall begin with what relates to the flesh, observing there our accustomed brevity. Beginning therefore, again with the upper parts, we shall first give an account of the operations on the head, more particularly of the burning of the vertex.

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COMMENTARY. This book contains the most complete system of operative surgery which has come down to us from ancient times. We shall have occasion also to refer frequently to Celsus, who, in the last two books of his work, has treated of surgical operations with considerable accuracy. Our author appears to have been wholly unacquainted with him; but when did a Greek writer ever acknowledge himself under obligations to a Roman? Haly Abbas, in the 9th book of his ‘Practica,’ copies almost everything from Paulus. Albucasis gives more original matter on surgery than any other Arabian author, and yet, as will be seen from our commentary, he is indebted for whole chapters to Paulus. In the ‘Continens’ of Rhases, that precious repository of ancient opinions on medical subjects, if there be any surgical information not to be found in our author, it is mostly derived from Antyllus and Archigenes. As to the other authorities, although we will occasionally have to explain their opinions upon particular subjects, no one has treated of surgery in a systematical manner; for even Avicenna, who treats so fully of everything else connected with medicine, is defective in his account of surgical operations; and the descriptions which he does give of them are almost all borrowed from our author. The account of fractures and dislocations given by Hippocrates and his commentator Galen may be pronounced almost complete; but the information which they supply upon most other surgical subjects is scanty.

SECT. II.—ON BURNING OF THE HEAD FOR OPHTHALMIA, DYSPNŒA, AND ELEPHANTIASIS.

In ophthalmia, occasioned by a defluxion from above, and in dyspnœa, produced by a redundance of a recrementitious humour which is sent from the head down to the chest, and by lodging there proves injurious to the parts contained in it, they burn the middle of the head in this manner. Having first shaven the parts about the vertex, they apply cauteries shaped like olive-kernels and burn the skin down to the bone, scraping the bone after the falling off of the eschar. Some by burning even the bone itself make a small scale exfoliate from it, in order to allow the humours of the head to perspire and be evacuated the more readily; and for this purpose they keep the ulcer open for some time and then allow it to cicatrize. In treating elephantiasis some burn five eschars in the head, one anteriorly above the part called the bregma; another, below this, a little above the forehead, at the extremity of the hairs; another, at the part called the occiput; two others at the parts called the squamous plates, above the ears, one on the right side and another on the left; and thus, by the removal of several scales, they procure the evaporation and discharge of the collection of thick humours in the deep-seated parts of the head, and prevent the sight from being injured. They also apply another cautery on the spleen, in order to remedy the prime organ in the formation of the melancholic humour by the eschar formed in the skin.

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COMMENTARY. See Hippocrates (de Visu); Aretæus (de curat. Morb. Chron. i, 1); Celsus (iii, 23, and vi, 6); Cælius Aurelianus (Morb. Acut. i, i, and Morb. Chron. i, 4); Aëtius (vi, 50); Actuarius (Meth. Med. iii, 2); Rhases (Cont. xxvii, 1, 24); Albucasis (Chirurg. i); Mesue (de Ægr. Capitis); Avicenna (iii, 1); Haly Abbas (Pract. ix, 69); Avenzoar (I, 9, 17).

The use of the actual cautery in surgical practice is often alluded to by the classical authors. See a collection of these passages in Dr. Blomfield’s edition of the ‘Agamemnon’ of Æschylus (822.) Consult also Gataker’s ‘Marcus Antoninus’ (v. 193); and Boissonade’s ‘Anecdota Græca’ (vol. ii, p. 311.) A very elaborate and sensible account of the use of the cautery in the practice of surgery is given by Vegetius. (Malomed. i, 28.)

Hippocrates, or whoever was the author of the work referred to above, applied the cautery to the head very freely in diseases of the eyes and other complaints.

Aretæus directs us, in cases of cephalæa and epilepsy, to perforate the bone as far as the diploe, and afterwards to burn it until the dura mater is separated from the bone. He admits, however, that it is a harsh remedy.

Celsus directs us, as an ultimum remedium in epileptic cases, to form issues with a burning iron upon the occiput and at the juncture of the first vertebra with the head.

Aëtius speaks of burning the head in nearly the same terms as our author. He directs us to avoid the muscular parts. Actuarius does the same.

Cælius Aurelianus, however, disapproves of this practice in cases of cephalæa and epilepsy.

The Arabians were even more partial than the Greeks to burning the head in these and other complaints. See in particular Albucasis, whose description is very minute. In cases of cephalæa he recommends the cautery to be applied to the occiput, but cautions against touching the bone lest it produce violent pain. He directs us to be careful to avoid muscles, nerves, and arteries. Avicenna, Rhases, Mesue, and Haly Abbas recommend the operation, in the most unqualified terms, as a powerful remedy in the cases mentioned by our author. Avenzoar, however, condemns the unguarded application of the burning iron to the head.

Guido de Cauliaco recommends the cautery in cases of hydrocephalus (ii, 2, 10). Brunus also applied it for hydrocephalus, (ii, 17.) But see in particular Lanfrancus (III, iii, 18.)

Fabricius ab Aquapendente states that from the most ample experience he had ascertained the good effects of applying the cautery over the sutures of the skull in various complaints, especially asthma, consumption, and all cold defluxions from the head to the chest. He gives a full account of the operation. (Œuvres Chirurg. ii, 1.) But see De Haën. (Rat. Méd. t. iii, p. vi, c. 6.)

SECT. III.—ON HYDROCEPHALUS.

The hydrocephalic affection is so named from the peculiarity of the fluid, it being of a watery consistence. It occurs in infants, owing to their heads being improperly squeezed by midwives during parturition, or from some other obscure cause; or from the rupture of a vessel or vessels, and the extravasated blood being converted into an inert fluid; or from rarefaction, the matter exuding and lodging between the skin and the pericranium. For the fluid is formed either between the pericranium and the skin, or between the pericranium and the bone, or between the bone and the meninx. In those cases, therefore, in which the fluid is formed between the skin and the pericranium, there is a soft tumour, all of one colour, and without pain, accompanied with an elevated swelling, having only a thin substance intervening between it and the fingers, readily yielding and again resuming its form. When it is seated between the pericranium and the bone, all the other appearances are the same, but the swelling is harder, yields more slowly, seems to be felt through thicker substances, and is more painful. When the fluid is seated between the meninx and the bone, there will still be a swelling, but not of so yielding a nature, nor so easily felt, only it yields to the application of strong pressure; for the bones of infants, being recently formed, are of a more yielding nature; and this is more especially the case when, owing to enlargement of the sutures, the fluid escapes outwards. This is readily ascertained from the circumstance, that by pressure of the fluid it retreats to the deep-seated parts. In such cases the pain is greater, the whole head is distended, the forehead projects outwards, the eyes are fixed and shed tears frequently. In these cases we reprobate any surgical interference, although some remove a piece of the bone by trepanning, as will be described in the section on fractures of the bones of the head. But if the fluid be formed between the skin and the pericranium, and the swelling be small, we may make one transverse incision through the middle. But if the fluid is seated between the pericranium and the bone, and the tumour is large, we make two incisions intersecting one another in the middle; or if it is still larger we may make three imitating the form of the Greek letter Η. After the operation, having evacuated the fluid and applied suitable compresses, we bind it up, and soak it with wine and oil until the third day; after which, having loosed the bandages, we may cure it by the application of pledgets; or, if the bone is long of incarnating we may scrape it lightly.

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COMMENTARY. See Hippocrates (de Morbis, ii, 15); Celsus (iv, 2); Aëtius (vi, 1); Galeni (ut aiunt) Isagoge; Antyllus (apud Nicetam); Avicenna (iii, 1; iv, 2); Avenzoar (I, 9, 17); Albucasis (Chirurg. ii, 1); Haly Abbas (Pract. ix, 16); Rhases (Contin. xxvii; and ad Mansor. ii, 25.)

Hippocrates gives an interesting account of water in the brain, the symptoms of which, as described by him, are pain in the opening of the head and temples, rigor, fever, double vision, impatience of sounds, vomiting of phlegm, &c. He recommends emetics, caputpurgia, and afterwards purgatives. He also makes mention of hellebore and sternutatories, and even directs us to perforate the skull, or, in other words, to trephine it.

Celsus describes only the hydrocephalus externus. He recommends us to use stimulant applications to the head, such as sinapisms, and if this treatment does not succeed, he directs us to use the scalpel. The case, otherwise, is to be treated like dropsy, with sudorifics, exercise, friction, and diuretics.

Our author’s description is mostly abridged from Aëtius, who gives an extract from Leonidas. Even when the fluid is collected within the skull he directs us to let it out, provided it is in such quantity as to occasion a separation of the suture.

The account of the disease, given by Antyllus, in the Collection of Nicetas is nearly the same as our author’s. He speaks favorably of the operation only in cases in which the water is collected externally to the bone.

In the ‘Isagoge,’ generally ascribed to Galen, it is directed, when the water is collected below the skin on the pericranium, to evacuate it by making two or three straight incisions; and when immediately below the bone, to perforate it; but the case in which the fluid is seated between the membrane and the brain is pronounced to be utterly incurable.

Rhases borrows his account mostly from Antyllus and our author. Upon his own authority, however, he recommends bandages with compresses. He also approves of applying the actual cautery over the sutures. He further recommends friction and burning the temporal veins.

Avicenna borrows freely from Aëtius and our author, and supplies no new views of practice. When water is collected in the anterior ventricles of the brain, Avenzoar, although in general no advocate for the actual cautery, directs us to apply it over the sutures.

Albucasis says that he had only known hydrocephalus internus in infancy, and in every case it had proved fatal. However, he describes the operation of evacuating the collection in much the same terms as the Greeks. He warns the operator to avoid wounding an artery, lest the evacuation of blood should occasion immediate death. Alsaharavius mentions the frequent occurrence of the disease in sheep. Haly’s treatment is the same as our author’s.

The hydrocephalus externus is now scarcely mentioned, and the existence of such a case has been even questioned. Van Swieten allows the reality of it, but says that it is of rare occurrence. (Comment. 1217.) We are disposed to think that the cases described by our author must have been collections of lymph, or pus occasioned by external injuries forming between the integuments and the bone. Modern pathologists admit the reality of collections of serum and pus between the bone and the dura mater. We may further mention that the earlier modern authorities approve of the cautery in the present case. See Guido de Cauliaco (ii, 2, 10.)

The late Baron Larrey was a decided advocate for the application of moxa in this complaint. Henricus Regius directs us to evacuate the water slowly by making a small incision and introducing a silver canula. (Animad. Medic. 13.) Though recent experience does not give much encouragement to the operation, it sometimes happens that it is attended with success.

Fabricius gives the same account of these cases as the ancients. (Œuv. Chir. ii. 22.)

SECT. IV.—ON ARTERIOTOMY.

In chronic defluxions of the eyes, and in the affection of vertigo, we are in the practice of dividing the arteries behind the ears. Having, therefore, shaven the hind part of the head, and marked with the fingers the position of the artery, which is easily discovered by its pulsation, and then having marked out the line of an incision two fingers in length with black ink, we cut down to the bone. When this does not succeed we must measure a distance of three fingers’ breadth from the ears, and then operate by making a transverse division of the artery until blood flow per saltum, and the instrument strike the bone. After a moderate evacuation of blood, the pericranium is to be divided, lest it become inflamed from the distension; and having scraped the bone we apply a wedge-like tent of linen to the wounds, and accomplish the cure by pledgets. But if, after all, the bone remain bare, we must have recourse to scraping it in like manner.

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COMMENTARY. Our author’s description is mostly abridged from Aëtius (vi, 90), who copies from Severus.

This operation is minutely described by Albucasis. (Chirurg. ii, 2.) He directs us to shave the head, and rub the parts behind the ears with a rough cloth until the arteries become visible. The course of the vessels is to be marked with ink, and they are to be divided with a sharp scalpel, the incision penetrating down to the bone. He says, however, that if the surgeon choose, he may introduce the scalpel below the vessel, and cut upwards. The length of the incision is to be two fingers’ breadth. Blood, he remarks, springs from an artery per saltum. About six ounces, more or less, may be taken.

The operation is likewise mentioned by Avicenna (Cantic. iv,) and Averrhoes (in Cantic.); by Rhases (ad Mansor. vii, 21); and is described in exactly the same terms as our author’s by Haly Abbas. (Pract. ix, 4.)

SECT. V.—ON ANGIOLOGY, OR SECTION OF THE TEMPORAL VESSELS, AND ON BURNING THE SAME.

In hemicrania and in chronic or acute defluxions, when the eyes are affected with a hot and acrid defluxion, so as to occasion heat of the temporal muscles with swelling, every one approves of angiology for the cure of them. Having, therefore, first shaven the hairs of the temples, and noted the part with our fingers, we must use warm fomentations, and apply a bandage round the neck; and, when the vessels become visible, having marked their course with ink, we must draw the skin aside with our left hand or the fingers of an assistant, and make a superficial incision along the vessel; then cutting quite through, and stretching the parts with hooks, and exposing the vessel by means of the instruments used in operations on membranous parts, we must raise it up when it is separated all around. If it be small, having stretched and twisted it with a blind hook, we may divide it through, so as to be able to seize upon part of it. But if it be large, we must apply a double ligature under it with a needle, either a piece of raw flax, or some other strong thing; and, in the first place, making a straight opening into the vessel with a scalpel used in venesection, and taking away a moderate quantity of blood, we must tie the ligatures at both extremities of the exposed vessel, and cutting the intermediate part, we may remove it either immediately, or at the time of loosing the dressings. Some, without dividing the vessels at all, burn them to a sufficient depth with burning-irons shaped like olive-kernels. After the operation we must use pledgets of dry charpie, and put on an oblong compress (splenium) with a bandage. After the removal of these dressings, we must accomplish the cure by incarnating powders, applications on pledgets, and cicatrizing remedies; the threads and ligatures having previously dropped out from putrefaction.

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COMMENTARY. The author of the Hippocratic treatise (de Morbis in Homine, c. 49) recommends us to open the temporal veins for obstinate headaches; and, if this does not effect a cure, he directs us to burn them.

Celsus describes both operations very distinctly. He directs us to apply a ligature round the neck, so as to make the vessels swell, and then, having marked the course of the vessels with ink, to remove the ligature, and open the veins. When a sufficient quantity of blood is discharged, the part is to be burnt with slender irons cautiously about the temples, for fear of wounding the temporal muscles, but more boldly between the forehead and the vertex, so as to produce exfoliation of a scale of the bone. He also speaks favorably of cutting the vessels in the temples and upper part of the head. (vii, 7.)

Aëtius gives nearly the same description as our author. The part which relates to the burning is taken from Leonidas (vii, 93.)

Angiology is briefly described in the ‘Isagoge’ of Galen. A minute description is given by Albucasis. He recommends the operation as a remedy for inveterate cases of hemicrania, catarrh, and cephalæa. He directs us to shave the hairs about the temples, and to continue to do so until the artery appears. It is known, he remarks, by its pulsation. When it does not readily make its appearance, he recommends us to apply a cloth round the patient’s head, and to rub the place with a rough towel. Then, he says, take a scalpel, and make an incision so as to lay bare the artery, which seize with a hook, and separate from the surrounding parts, and if the vessel is small, cut out a proper piece of it, and allow from three to six ounces of blood to flow. But if the vessel is large, bind it in two places with strong silk threads, or strips of raw cloth (alhohod), so that it may not drop out before the wound is consolidated. Then cut out the part between the two ligatures. He directs us to dress the wound as recommended by our author. He also mentions the operation of burning the temporal veins as being one that is less serious than angiology. (Chirurg. ii, 3.)

Jesu Haly’s account of the operations of tying and burning the temporal arteries is very distinct. (iii, 25.)

Haly Abbas describes the operations of cutting out and burning the temporal vessels in nearly the same terms as our author. (Pract. ix, 70.)

Rhases mentions that the celebrated Archigenes recommended the temporal veins to be burnt for epilepsy. (Contin. i.)

The veterinary surgeons burnt the temporal veins in diseases of cattle. See Vegetius (Mulomed. ii, 16.)

We are inclined to think that it was the temporal veins and not the arteries which were cut out and burnt by the Greek surgeons in this operation. It will be seen, however, that the Arabians direct us to cut out a portion of the artery; at least this is sufficiently clear in the description of Albucasis, for he states decidedly that the vessel to be secured will be recognized by its pulsation, and he further recommends us to apply beforehand a ligature about the head, and not about the neck as directed by our author, whereby it is obvious that the arteries and not the veins would become distended; these observations apply also to Jesu Haly’s description. As Celsus, like our author, directs the ligature to be applied round the neck (cervix ante modice deliganda est), we may suppose that his operation related to the veins. From his using the word venæ indeed no inference can be drawn, as he applies it indiscriminately to arteries and veins. We are at a loss what to determine respecting the description given by Haly Abbas, for although the vessel that is secured be called arteria, the ligature or strip of cloth is directed to be applied round the collum. Where the mistake lies in this case we cannot venture to conjecture, and leave it to be found out by some person who has access to the MS. of the original. For our part we may exclaim with a celebrated German scholar,—“Felices sæpe prædicavimus Bochartum, Plempium, Celsium, Hydium, Casirium, quibus usus codicum Arabicorum concessus erat.” (Sprengel, Rei Herbariæ Historia, i, 239.)

Fabricius ab Aquapendente describes the operation as relating to the veins (Œuv. Chir. ii, 3.) Tagliacozzi, however, seems to refer it to the arteries. It thus appears that there is a good deal of uncertainty regarding this ancient operation.

SECT. VI.—ON HYPOSPATHISMUS.

This surgical operation derived its name from the kind of instrument used in it. We have recourse to it when a copious and hot defluxion is determined to the eyes. The face is ruddy, and about the forehead there is a sensation as of worms or ants passing along it. Having therefore first shaven the hairs about the forehead, we must permit the lower jaw to move, and avoiding the place where the temporal muscles are seen to act, we are to make three straight and parallel incisions on the forehead, each having the length of two fingers, and descending to the bone, and being at the distance of about three fingers’ breadth from one another. After the incision we apply the instrument called hypospathister, and extend the division from the left temple to the middle incision, dividing all the intermediate substance along with the pericranium; then we push a spatula from the middle one to the rest, and applying the point of a sharp-pointed knife to the first division, so that its sharp side may be turned to the flesh within the skin, and the blunt one to the bone, we push it as far as the middle division, cutting through all the vessels which descend from the head to the eyes, but not comprehending the external skin. And again we push it from the middle to the last incision, cutting through the vessels in like manner. After a moderate evacuation of blood, having squeezed out the coagula, and made three twisted tents, we are to put one into each division, and applying a compress soaked in water, we must secure it with a bandage. Next day we bathe not only the ulcers, but likewise the temporal muscles, and the ears with wine and oil, on account of the inflammation; and on the third day having removed the dressings, we must have recourse to copious affusion, and afterwards complete the cure suitably with tents out of basilicon dissolved in rose-oil.

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COMMENTARY. See Aëtius (vii, 92); Albucasis (Chirurg. ii, 4); Haly Abbas (Pract. ix, 7.) This operation is better described by our author than by any of the others. Celsus, although he describes several grave operations for the relief of defluxions on the eyes, makes no mention of it. Aëtius barely alludes to it in general terms. It must have been a very formidable operation, and for that reason perhaps, has been entirely abandoned in moderate times. Even Albucasis speaks of it as being an operation which was performed by the ancients; from which language we may suppose that it had been given up in his time. His description of it is evidently taken from our author. Haly Abbas describes the operation very distinctly. Three longitudinal incisions at the distance of three fingers’ breadth from one another are to be made in the forehead down to the bone, then a knife, or some such instrument, is to be introduced so as to divide the parts between the longitudinal incisions, sparing only the outer skin.

SECT. VII.—ON PERISCYPHISMUS.

When many deep-seated vessels send a copious defluxion to the eyes, we have recourse to the operation called periscyphismus. These cases are attended with such symptoms as these: in the first place you will find the patient’s eyes atrophied and small, weak of sight, the canthi corroded, and the eyelids ulcerated, the hairs falling off, with a discharge of very thin, acrid, and hot tears; there is a deep-seated pain in the head of an acute and violent character, and there is frequent sneezing. Having first shaved the head as aforesaid, and avoiding the place where the temporal muscles play, we make a transverse incision, beginning at the left temple and ending at the other. The incision must have its terminations where there are no muscles, its direction being a little above the forehead, and we must avoid the coronal suture. Leonidas directs the incision to be made along the middle of the forehead. When the bone is laid bare we may keep the parts asunder with tents and plenty of pledgets, and bind the extremities of the division; and, as we formerly stated, bathe with wine and oil. After loosing them, if the inflammation is on the decline, we may scrape the bone until it begin to incarnate, and accomplish the cure by a mode of practice calculated to promote incarnation, using the incarnative powders; among which is that containing of wheaten flour, p. ij; of colophonian rosin, p. j; and that called the cephalic, and those incarnatives prepared from pumice-stone. For, when the skin is thickened by a dense cicatrix, and the mouths of the vessels constricted, the defluxion is prevented from being determined to the eyes as before.

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COMMENTARY. See Aëtius (vii, 93); Pseudo Galen (Isagoge); Albucasis (Chirurg. ii, 5); Haly Abbas (Pract. ix, 18.)

It is evident that this operation is neither more nor less than a complete division of the integuments of the head from temple to temple; of course it must even have been more dangerous than the operation treated of in the last section. Aëtius, Haly Abbas, and Albucasis describe it in the same terms as our author. The periscyphismus and hypospathismus are briefly noticed in the ‘Isagoge.’

Fabricius ab Aquapendente treats of these operations among those of the ancients, qui ne sont plus en usage (Œ. C. ii, iv); even Tagliacozzi speaks of them as being cruel and dangerous. However, a surgical operation, similar in principle, called the “long issue of the scalp,” is still practised in certain hospitals of Great Britain. See the ‘Transactions of the Provincial Association,’ (vol. xi.)

SECT. VIII.—ON SUTURE OF THE UPPER EYELID, AND OTHER MODES OF OPERATING FOR TRICHIASIS.

Distichiasis is a preternatural growth of hairs, superadded to the natural order of hairs of the eyelids; and derives its origin from a defluxion, when there happens to be a flow upon the part of a humour which is not pungent or acrid; for that which is more acrid, saltish, or otherwise pungent, when it lodges in these parts, consumes the natural series of hairs. For this state then we sometimes have recourse to the suture of the upper eyelid, and sometimes also for phalangosis when the eyelid inclines inward, the phalanx or row of the hairs being inverted; and sometimes for relaxation of the eyelid, when the natural row of hairs hurts the ball of the eye. Having placed the patient on a seat, either before us or on the left hand, we turn the upper eyelid outwards, and, if it has long hairs, we take hold of them between the index-finger and thumb of the left hand; but if they are very short we push a needle having a thread, through the middle of the tarsus from within outwards; then stretching the eyelid with the left hand by means of his thread, with the point of a scalpel held in the right hand, having folded out the eyelid and everted it, behind the thread we make the under-incision within the hairs which irritate the eye, extending from the larger canthus to the smaller, along the tarsus. After this subsection, having extracted the thread, and putting a small compress under the thumb of the left hand, we stretch the eyebrow upwards. Then arranging other small compresses on the canthi at the extremities, we direct the assistant who stands behind to stretch the eyelid by means of them. Then by means of the scalpel used for sutures we make the first incision, called the veruted (shaped like a verutum or short dart) a little above the hairs, which are in their natural state, extending from canthus to canthus, and penetrating only the depth of the skin; and afterwards we perform the incision called the lunated, beginning at the same place as the former, and carrying it upwards to such a height as to comprehend the whole redundant skin, and ending in like manner as it did. Thus the whole skin comprehended within the incisions will have the shape of a myrtle leaf, of which portion, having perforated the angle on the right hand with a hook (tenaculum), we dissect away the whole skin: then washing away the clots with a sponge, we unite the lips of the incision by three or four sutures, beginning at the middle, and passing the needle itself through the under-section. The thread should be made of wool; and having cut away the superfluity of the thread, not close to the sutures, but so as to leave a superfluity of three fingers’ breadth, we stretch this remainder along the forehead and fasten it by means of any of the agglutinative plasters. But the hairs of the eyelid are to be freed from the sutures with the point of a needle. Such is the common and safe mode of performing this surgical operation. Some avoid the dissection of the skin, and therefore after the under-incision, having stretched the redundant skin by means of the forceps used in operations on the eyelids, they cut it off with a scalpel, and apply sutures as described above. But if the irritation from the hairs is produced only by a part of the eyelid, it will be proper to confine the operation to that part. Then soaking the compresses in oxycrate, and laying them on the part, we secure them with bandages, continuing to moisten the dressings with diluted oxycrate until the third day; after which we remove them, and cutting away the superfluous parts of the threads, we anoint the eyelids either with saffron, glaucium, or some of the anti-inflammatory collyria, such as that formed of saffron and roses. But if the sutures inflame, we apply some one of the softening plasters, and soothe the eye by an injection of eggs mixed with milk. When the ligatures slacken we cut and extract them. I know a certain person who having made the dissection of the skin of the eyelid, as mentioned above, did not have recourse to sutures, but effected the cure with a healing ointment. For when the wound cicatrised, the eyelid being somewhat contracted, forced the hairs to incline outwards. In like manner, another person not practising the dissection of the eyelid, nor the two external incisions, but only making the under-incision, stretched with his fingers or by a hook the fold of the eyelid, two reeds or plates of the same length as the eyelid, and as broad as for venesection, he twisted a ligature round it at both its extremities; and thus the whole skin behind not being nourished, and on that account being deprived of life, fell off within ten, or at most fifteen days along with the reeds or plates, so as to leave scarcely any scar.

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COMMENTARY. On suture of the upper eyelid, and other methods of operating for distichiasis, see Hippocrates (de Victu acut. 66); Aëtius (vii, 71, 72); Celsus (vii, 7); Albucasis (Chir. ii, 11); Rhases (Divis. i, 30; ad Mansor. ix, 26; Contin. ii, 3); Avicenna (iii, iii, 3, 32); Avenzoar (i, 8, 6); Serapion (ii, 7); Mesue (ii, 18); Jesu Hali (ii, 10); Canamusali (vi, 26); Haly Abbas (Pract. ix, 19); Vegetius (Mulom. ii, 15.)

The description of the operation given by Aëtius from Leonidas being nearly the same as that described by our author, we shall confine ourselves to an abridged account of it, and merely make a few remarks to illustrate the description of Paulus. In order to facilitate the operation, he recommends the operator to have two assistants instead of one, as directed by our author. He also recommends him, in the first place, to mark with ink the portion of skin which requires to be cut out. He then directs him to make the under-incision, by which he seems to have meant an incision within the ciliary hairs along the tarsus, and extending from canthus to canthus. He recommends it to be made pretty deep, and even in certain cases suggests the propriety of making two under-incisions, one as above described within the ciliary hairs, in order to relax the tarsus; and the other upon the preternatural hairs. He next directs first a transverse incision to be made along the eyelid above the ciliary hairs, and then a lunated one beginning and ending like the other, after which the skin, thus separated, is to be dissected out. He recommends the edges to be united by means of five sutures, one in the middle and two at each extremity of the incisions. The other steps of the operation are exactly the same as those described by our author, and cannot be misunderstood. Hippocrates describes an operation for trichiasis, which Heister thought the same as that recommended by Aëtius, but the description is so obscure that we must confess our inability to explain it.

Celsus describes three methods of cure for trichiasis. 1. By burning the roots of the hairs. 2. The anabrochismus, which will be explained in the 13th section. 3. The anarrhaphè or suture, as described by Aëtius and our author. As the steps of the operation described by him are almost exactly the same as those of Aëtius, we need not dwell upon the explanation of them. Lest, however, there should be any misapprehension about the under-incision, we shall give his directions about it in his own language: “præter hoc, in superiore palpebrâ sub pilis ipsis incidenda linea est ut ab inferiore parte diducti pili sursum spectant; idque si levis inclinatio est, solum satis est.” Instead of five sutures, as directed by Aëtius, he recommends only three.

Albucasis states that there are four modes of curing trichiasis. 1. By the actual cautery. 2. By the potential cautery. 3. By incision and the suture, which operation he describes at great length. He directs us in the first place to evert the eyelid, either by taking hold of the ciliary hairs, or by passing a needle, armed with a hair, through the tarsus, and raising the eyelid with it. He then, like the others, directs us to make the under-incision within the ciliary hairs, from the greater canthus to the smaller, to cut out the redundant skin of the eyelid, and unite the surfaces with sutures. In short, his operation is exactly the same as our author’s. He mentions, however, another method of making the incision by elevating the redundant fold of the skin with hooks or a trident, and cutting it off with a pair of scissors. 4. The fourth method consists of making the under-incision, as in the last operation, and then twisting the redundant skin firmly about reeds or small pieces of wood until it mortifies: after which the wound is to be cured upon general principles.

Serapion’s account of the operation is defective, and need not be particularly noticed. Canamasuli directs us to cut out the hairs and burn the part with a cautery of gold.

Avicenna merely mentions, in very general terms, that the cure may be accomplished by agglutinative applications, by the cautery, or by excision.

Mesue briefly describes four modes of cure: 1. By means of agglutinants. 2. By passing a needle, armed with a hair, through the tarsus, as will be explained in the 13th section. 3. By plucking out the hairs and cauterising the part. 4. By applying medicines calculated to prevent the renewal of the hairs after they have been plucked out.

Jesu Hali’s description of these operations is very circumstantial; he speaks of cutting out the piece of skin with a fine pair of scissors.

Rhases states that the cure of trichiasis may be effected by burning the roots of the hairs with a red-hot needle, or by making the excision of the superfluous skin of the eyelid. He also makes mention of the treatment by agglutinants. In his great work, the ‘Continens,’ he briefly notices the four operations described by Albucasis. He appears to have approved very much of the burning. He also describes the operation with the reeds or pieces of wood.

Avenzoar mentions four methods of curing inversion of the ciliary hairs. 1. By everting the upper eyelid and securing it with agglutinants until the roots of the hairs have been cauterised with a rod of gold. This method he does not approve of. 2. By extirpating the offending hairs and applying the blood of a bat to the places from which they were torn. 3. By making an excision of the superfluous skin of the eyelid, and afterwards applying sutures. He alludes, we suppose, to the operation of Aëtius. 4. By twisting the skin about small reeds or tubes, in the manner described by our author and Albucasis.

Haly Abbas accurately describes the four following operations: 1. By excision and the suture. He directs the under-incision not to be made deep. 2. By twisting the hairs into the fold of a silk thread and flattening it to the forehead. 3. By the actual cautery. 4. By the potential cautery.

We will give the description of the veterinary surgeon, Vegetius, in his own words: “Non longe a pilis ab interiori parte scalpello plagam dabis in cute palpebræ, post forficibus per longum ad mensuram oculi fasciolam præcides, et impositis fibulis consucs palpebram foris versus, ut oculus sine deformitate recipiat visum et gratiam naturalem.”

It is to be remarked that Albucasis, Jesu Hali, and Vegetius speak of cutting out the superfluous skin of the eyelid with a pair of scissors, as was done by Scarpa.

All the ancient operations for trichiasis are described by Guido de Cauliaco (vi, 2.) The mode of cure by twisting the skin about small reeds until the parts slough is still generally practised in China. The Chinese surgeons grasp the fold between two slips of bamboo, which being tightly fastened at their ends perform the office of a ligature.

SECT. IX.—ON BURNING OF THE EYELIDS BY MEDICINES.

The burning of the eyelids with caustic medicines was reprobated, in a word, by all the ancients, lest the acrimony of the application should prove injurious to the eyes; and because when the burning was carried to too great an extent the affection called lagophthalmos was produced, in which case the eyelids cannot be shut, and the vision is apt to be injured by everything that comes in the way. But since many who suffer from the irritation of the ciliary hairs are not able to endure even the name of the operation by suture, we are compelled from necessity, against our will, to have recourse to burning by medicine. The following is a composition of that kind: of quicklime, p. ij; of Gallic or common soap, p. ij; and some add of aphronitrum, p. iv. These things being pounded with strained ley, or soap ley, or some other ley, as that of figs or of oaks, and being mixed with the urine of a young man not come to maturity, we apply to the eyelid, upon the knob of a specillum, the part touched having the shape of a myrtle leaf; and we burn to the extent comprehended in the operation by suture. The skin being burnt at the first application, we remove so much of it with a sponge, and apply the medicine a second time, allowing it to remain until the part blacken; and if it does not blacken we apply it a third time. When the skin is blackened and the eschar also formed, we must clean away the medicine and have recourse to bathing and washing until the eschar drop off; after which it will be proper to complete the cure by means of pledgets of charpie and emollient collyria.

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COMMENTARY. None of the other authorities describe this method of cure so minutely as our author, except Haly Abbas, who evidently copies from him. (Pract. ix, 71.) Rhases and Albucasis, however, also mention the operation. They direct us to burn the part with a preparation of quicklime and soap, with the addition of some caustic lixivia, or leys. These ancient leys, or lixivian ashes, appear to have been preparations of potass more or less pure. We need scarcely remark that these applications must have resembled the caustic paste, now used for forming issues. The method of treatment here described is, in principle, much the same as that performed by Quadri with sulphuric acid. A caustic paste very similar to that now used is described by Guy of Caulico. (vii, 1.)

The strained ley, of which mention is made by Paulus, was probably the same as the calx colata of Cælius Aurelianus. (Tard. Pass, v, 1.) It appears to have been an impure preparation of potass with the addition of some lime. It is the same, we suppose, as the πρωτόστακτον mentioned in the Third Book of this work. The calx colata would seem to have been identical with the Vienna paste now used in the treatment of varix. A composition for burning the eyelids, mentioned by Jesu Hali, contains lime, prepared beans, nitre, and sal ammoniac, formed into a paste with the water of soap and pure myrrh. Jesu, however, does not much approve of this method of treatment.

SECT. X.—ON LAGOPHTHALMOS OR HARE-EYE.

Those persons are said to have hare-eyes who have the eyelids drawn upwards. This complaint arises either naturally or from the cicatrix of a wound, and this may have occurred spontaneously, or from the operations of the suture or burning (as just mentioned) having been improperly performed; in which case even a moderate relief can only be accomplished when the eyelid is sufficiently thick. For we must divide the cicatrix, and having separated the lips with a tent, use bandages until the cure is completed, avoiding such things as are very desiccative, and having recourse to those which are fatty and relaxing, such as the juice of fenugreek poured on the part, and the ointment prepared with four ingredients called basilicon, applied on a tent.

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COMMENTARY. See Celsus (vii, 7); Aëtius (vii, 71); Albucasis (Chirurg. ii, 13); Avicenna (iii, 3, 3, 12); Haly Abbas (Pract. ix, 20); Rhases (Cont. ii, 4.)

Celsus directs us to make a lunated incision below the eyebrows, the horns of the incision being turned downwards, and care being taken not to wound the muscles. A tent or pledget of lint is to be put into this incision to prevent the edges of it from uniting. This simple operation is described in nearly the same terms by Aëtius, Albucasis, Avicenna, Haly Abbas, and Rhases.

Fabricius ab Aquapendente informs us that the operation had fallen into disuse in his time. It is now sometimes practised. See Scultet, (Arsen. de Chirurg. Tab. xxxiv, 8.)

SECT. XI.—ON THE SUTURE OF THE UNDER EYELID, AND THE BURNING OF IT BY MEDICINES.

The under eyelid is subject to the same complaints from the ciliary hairs as the upper; for, when larger than natural, it is everted; and it is subject likewise to phalangosis and distichiasis. We must, therefore, perform the operation of the suture in the same manner as for the upper eyelid, but in an inverted order, beginning with the lunated incision on account of the obstruction occasioned by the blood, and then making the veruted. But the under-incision is to be omitted altogether, because the lower eyelid, by its natural weight, is readily everted. The rest of the treatment to be completed as in the suture of the upper eyelid, except that the extremities of the ligatures are not to be glued to the forehead. If in this case the patient is averse to an operation, and prefers burning by medicines, you have already got a description of this process.

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COMMENTARY. This section requires no commentary.

SECT. XII.—ON ECTROPION, OR EVERSION OF THE LOWER EYELID.

Ectropion of the under lid is occasioned by the same causes as lagophthalmos of the upper, only that it does not occur naturally, but arises sometimes from relaxation produced by medicines possessed of this property, which have been applied for inflammation; and sometimes the eversion is occasioned by the suture or burning having been improperly performed. Taking, therefore, a needle, armed with a double thread, we perforate the fleshy mass, pushing it through from the left canthus to the right, and then by means of the thread fastened to both of its extremities, we stretch the skin with the needle, and cut down upon it with a scalpel, removing the needle at the same time. Then, if the eyelid resume its proper shape and is turned inwards, this operation will be sufficient. But if the eversion continue after the removal of the flesh, we apply the back of the specillum to the divided eyelid; and on the inside of the eyelid, having made two incisions, beginning at the two angles of the incision formerly made, and terminating in an acute point, and meeting together like the Greek Λ, we remove this substance, so that its acute point may be below at the eye, and the broad above at what is called the tarsus. Afterwards we unite the separated parts with a needle containing a woollen thread, being satisfied with two sutures. But if the ectropion be occasioned by the operation of the suture or burning we make a simple incision along the first cicatrix below the hairs of the tarsi, and having separated its lips, we fill up the wound with pledgets, using the same methods as for lagophthalmos (except fomentations) until the parts which have been stitched unite.

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COMMENTARY. See Aëtius (vii, 74); Celsus (vii, 7); Albucasis (Chirurg. ii, 14); Haly Abbas (Pract. ix, 20.)

Aëtius gives a full account of the treatment of ectropion from Demosthenes and Antyllus. When the disease is occasioned by fungous flesh on the inner membrane of the eyelid, he recommends us to burn it down with escharotics, such as misy, chalcitis, &c. (See the Third Book.) He describes the surgical operation in the following terms:—when the fleshy excrescences are very large they are to be dissected out with a scalpel, and the part touched with burnt copper or the like. When the eversion is greater, he directs us to perform an operation upon the inner part of the eyelid, making two incisions, which unite below like the Greek letter Λ, and afterwards dissecting out this lambdoid or triangular piece, and along with it the flesh below, which, he remarks, is not cartilaginous like the upper eyelid, but taking care to preserve the skin untouched. The edges of the incisions are then to be united by one suture at the eyelids. When the ectropion is occasioned by an external cicatrix, we are to operate upon the inner surface of the eyelid in the manner just now described, only avoiding to make deep incisions, and uniting the edges of the incisions as before directed. Then stretching the cicatrix with a hook, and pushing a needle armed with a double thread, under the thickened flesh from the smaller canthus to the larger, we are to cut down upon the needle and divide the thickened flesh. A pledget of lint is then to be put into the external incision, and a compress, moistened with cold water, applied with a bandage. He directs us to avoid warm fomentations until the ligatures drop out. When ectropion arises from the excrescence called encanthis, he recommends us to dissect it out. When the disease is occasioned by paralysis, or arises from too large a portion of the eyelid having been cut out in the operation for entropion, he pronounces it to be incurable. It is also said to be incurable when occasioned by the sloughing of carbuncles.

Celsus says that ectropion arises either from an operation for inversion improperly performed or from old age. In the former case he directs us to make an incision like that for lagophthalmos, only with this difference, that the horns of it are to be turned to the jaws (maxillas) and not to the eye. When it arises from old age he recommends us to burn the excrescence with a slender piece of iron, and then to anoint it with honey.

Albucasis describes the operation in nearly the same terms as Aëtius. Thus, he directs us to pass a needle armed with a double thread, below the fleshy excrescence from the left canthus to the right, and stretching it by means of the threads to cut it out with a broad scalpel. If this incision does not relieve the eyelid, he directs us to take the specillum (radius) and applying it to the incision, to evert the eyelid with it, and then to make two incisions in the inner surface of the eyelid so that they may meet at an angle below, like the Greek letter Λ. Then this triangular portion is to be dissected out, and the edges united by a suture with a woollen thread. When the disease arises from a cicatrix he directs us to divide it, and then to keep the lips of the wound separate by the application of a pledget. He concludes with the remark that, as the disease puts on various forms, a prudent surgeon will show his skill by restoring the parts to their natural state.

Haly Abbas evidently borrows his description from Aëtius or our author.

The operation here described is very similar to the one practised by the late Sir William Adams. In the days of Fabricius this operation was condemned as cruel and troublesome. It will be remarked that the V operation of modern times is a modification of the operation now described.

SECT. XIII.—ON ANABROCHISMUS AND BURNING WITH IRON.

When the hairs which irritate the eye are not numerous, but only one, two, or at most, three, close to one another, we approve of the operation called anabrochismus. Taking, therefore, a very slender needle, we pass through its ear (eye?) a woman’s hair or a fine flaxen thread, and unite the two extremities together in such a manner that the thread or hair which is passed through may have a double loop; and we pass another such thread or hair through the loop, and pushing the needle through the tarsus where the preternatural hairs appear, we introduce the hair or hairs into the loop by means of an ear-specillum, and draw it upwards. And if the hair of the eyelash be fixed in it, we draw up the loop; but if one or more, fall out, we again, by means of the one at first introduced, draw down the loop, and once more introducing a hair or hairs, draw them upwards. But if there is only one slender hair that irritates the eye we draw up another of the ciliary hairs along with it, anointing them with gum or some other glutinous substance, and bending them until they unite to the skin. Some preferring burning to the operation of anabrochismus, turn the eyelid outwards, and with a hair-forceps dragging out the offending hair, if there is but one, or two, or three; if there be as many, they apply a double-headed specillum, or an ear-specillum, or some such small instrument heated, to the place whence the hair or hairs were removed. For the skin being thus constricted, no other hair is produced.

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COMMENTARY. We will give Celsus’s description of this operation in his own words: “Quidam aiunt, acu transui juxta pilos exteriorem partem palpebræ debere, eamque transmitti duplicem capillum muliebrem ducentem, atque ubi acus transiit, in ipsius capilli sinum, qua duplicatur, pilum esse conjiciendum, et per eum in superiorem palpebræ partem attrahendum, ibique corpori agglutinandum, et imponendum medicamentum quo foramen glutinetur; sic enim fore, ut is pilus in exteriorem partem postea spectet.” However, he does not much approve of the operation. He also describes the operation of cauterising the roots of the hairs. (vii, 7.)

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

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

SECT. XIV.—ON HYDATIDS.

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

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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