Section Xxiv of the Third Book.

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

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

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

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

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

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

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

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

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

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

SECT. XXVI.—ON MAIMED PARTS.

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

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

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

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

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

SECT. XXVII.—ON EPULIS AND PARULIS.

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

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

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

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

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

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

SECT. XXVIII.—ON THE EXTRACTION OF TEETH.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

SECT. XXXI.—ON THE UVA.

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

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

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

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

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

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

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

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

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

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

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

SECT. XXXIII.—ON LARYNGOTOMY.

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

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

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

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

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

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

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

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

SECT. XXXIV.—ON ABSCESS.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

SECT. XXXVII.—ON ANEURISM.

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

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

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

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

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

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

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

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

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

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

SECT. XXXVIII.—ON BRONCHOCELE.

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

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

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

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

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

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

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

SECT. XXXIX.—ON GANGLION.

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

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

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

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

SECT. XL.—ON VENESECTION.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

SECT. XLI.—ON CUPPING.

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

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

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

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

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

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

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

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

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

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

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

SECT. XLII.—ON BURNING THE ARMPIT.

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

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

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

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

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

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

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

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

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

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COMMENTARY. Galen mentions the operation of burning the chest for phthisis. (De Morb. Vulg.)

In phthisical complaints, which do not yield to ordinary treatment, Celsus recommends the cautery to be applied in this manner: One eschar is to be burnt with a red-hot iron under the chin, another on the throat, two upon each breast, and two under the scapulæ. They are to be kept open until the cough is removed. (iii, 22.)

Aëtius directs us to burn the chest and neck much in the same manner as recommended by our author. (viii, 73.)

This operation is described by Albucasis, who gives a drawing of an instrument for performing it expeditiously. (Chirurg. i, 26.) See also Rhases (Cont. ix.)

Haly Abbas recommends such an operation as that described by Celsus and our author. He directs us to do it, not with iron, but with the root of the long birthwort smeared with oil. (Pract. ix, 74.) The use of the root of the birthwort (aristolochia) as a cautery is also mentioned by Aëtius. (xii, 3.) Cornarius, by the way, seems not to have been aware of this circumstance, which has led him into a mistake in translating the sentence where it is mentioned.

The practice of burning the chest in chronic diseases of the lungs is strongly advocated by Caillot. (Elemens de Physiologie, i.) It was tried by Dr. Mudge in his own person with great success. (See Dr. M. Good’s ‘Study of Medicine,’ ii, 786.)

Our author, it will be remarked, disapproves of paracentesis thoracis. This operation is recommended and described in one of the Hippocratic treatises. (De Morbis, i, and ii.) It is also mentioned in the ‘Isagoge’ of Galen. Rhases likewise mentions it in brief terms. (Cont. iv, 3, and x.) Rhases directs us to open the chest by a small orifice, that the matter may be slowly evacuated. He mentions that Galen recommends burning the chest, and also the operation of paracentesis in such cases.

SECT. XLV.—ON CANCER.

Cancer is an uneven swelling, rough, unseemly, darkish, painful, and sometimes without ulceration (which Hippocrates called also concealed cancer), and if operated upon, it becomes worse, and sometimes with ulceration, for it derives its origin from black bile, and spreads by erosion; forming in most parts of the body, but more especially in the female uterus and breasts. It has the veins stretched on all sides as the animal the crab (cancer) has its feet, whence it derives its name. Wherefore, the treatment of it by medicine has been sufficiently delivered by us in the Fourth Book; and cancer of the womb has been treated of in the Third. But since putrid parts and such as are simply altered from their natural state require amputation, cancers in the womb, indeed, it is neither possible nor expedient to operate upon; but of those of the external parts, and especially of the breasts, we have now to explain the surgical treatment. Some, then, have consumed the whole redundant matter by cauteries; but others first make an excision of the whole breast, and then burn the place. But Galen approves only of the excision, writing thus of the operation: “If ever you attempt to cure cancer by an operation, begin your evacuations by purging the melancholic humour, and having cut away the whole affected part, so that not a root of it be left, permit the blood to be discharged, and do not speedily restrain it, but squeeze the surrounding veins so as to force out the thick part of the blood, and then cure the wound like other ulcers.” Such are the words of Galen. And other malignant and putrid ulcers, such as phagedæna, gangrene, and the like, must be treated in the same manner.

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COMMENTARY. Hippocrates forbids the surgeon from interfering with occult cancers, that is to say, with such as have not ulcerated, remarking that if healed the patient soon dies, whereas, if let alone, he may live a long time. (Aph. vi, 38.) Upon this his commentator, Theophilus, remarks that even if the disease is eradicated by cutting or burning, many untoward symptoms follow, and the strength of the patient does not stand out. (Ed. Dietz. ii, 506.)

Celsus describes, we fear but too truly, the general result of every known method of treating cancer. He says, some use corrosive applications, some burning irons, and others cut it out with the scalpel; but medicines are of no avail, burning only exasperates the disease, and excision only removes the part affected, for the disease immediately returns, (v, 28.)

Galen’s sentiments are partly explained by our author. He states, that the disease is curable only at its commencement. When it has attained any considerable magnitude, he says, it admits of no remedy without a surgical operation; and when the tumour is cut out all around there is danger of hemorrhage, which, if restrained by ligatures, may give rise to the disease in the neighbouring parts, whereas, if cauteries be used to burn the roots of the vessels no inconsiderable danger may result from their application so near to the vital parts. (Therap. ad Glauc. ii; Meth. Med. xiv; Isagoge.)

Aëtius gives from Leonidas the following description of the operation on cancerous mammæ. Laying the patient in a supine position, he says, I make an incision into the mammæ above the cancer, and immediately apply a cautery until an eschar be produced to stop the bleeding. I then make another incision deep into the substance of the mamma, and again burn the parts, and so proceed—first cutting and then burning alternately, in order to restrain the bleeding. In this way there is no danger of hemorrhage. After the amputation is completed I again burn the parts until they are quite dry. The first burnings are for the sake of the bleedings, and the last with the intention of eradicating the disease. (xvi, 45.) This operation, described in nearly the same words, occurs in Soranus. (61.) He says, when the disease is scrofulous the burning may be omitted. (Ibid.)

Avicenna mentions that after the excision of a cancerous part the actual cautery may be required. And yet, he adds, there may be danger from the burning provided the part affected be near any vital organ. (iv, 3, 2.)

Rhases says, that they who make an incision into a cancerous part merely produce ulceration thereof, unless it be so seated that the disease can be completely removed and the parts afterwards burned. (Ad Mansor. vii, 9.) In another work he expresses himself rather favorably of excision and burning. (Contin. xiii.)

Haly Abbas approves of the operation when the cancer is seated in the mammæ or extremities. He recommends us to allow the part to bleed until all the melancholic humour is evacuated, and says nothing of the cautery or ligature. (Pract. ix, 12.)

Albucasis says that he never saw a case of cancer cured unless the tumour was small and recently formed. He directs us, when the operation is attempted, to cut out the tumour by the roots, and if the hemorrhage from any vein be profuse to stop it by the cautery. (Chirurg. ii, 53.)

Serapion expresses himself rather diffidently of excision. (v, 24.)

Soranus gives a full account of scirrhous breast distinct from the cancerous. He states that when the whole breast is scirrhous and adheres to the chest, the excision of the sound parts from the diseased ought not to be attempted; but when only the extremity of the breast, or only the half of it is hardened, he approves of amputation without burning, there being no danger of bleeding in this case as in cancer. (66.)

SECT. XLVI.—ON MALE BREASTS RESEMBLING THE FEMALE.

As at the season of puberty the breasts of females swell up, so in like manner those of the males also swell to a certain extent; but for the most part they subside again. In some cases, however, having acquired a beginning they go on increasing, owing to the formation of fat below. Wherefore, as this deformity has the reproach of effeminacy, it is proper to operate upon it. Having, therefore, made a lunated incision below the breast, and dissected away the skin, we unite the parts by sutures. But if, as in women, the breast incline downward, owing perhaps to its magnitude, we make in it two lunated incisions, meeting together at the extremities, so that the smaller may be comprehended by the larger, and dissecting away the intermediate skin, and removing the fat, we use sutures in like manner. But if, through mistake, we should cut away too little, we must again remove what is redundant, and apply the remedies for fresh wounds.

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COMMENTARY. The description given by Albucasis is so like our author’s that there can be no doubt of its being borrowed from him. When there is a great redundance of fat and flesh, he directs us to make two lunated incisions, the larger comprehending the smaller, and having dissected away the intermediate skin to unite the edges by sutures. (Chirurg. ii, 47.)

Haly Abbas repeats the same description in almost the same words. (Pract. ix, 40.)

Rhases recommends the operation upon the authority of Antyllus and our author. (Contin. xiv.)

SECT. XLVII.—ON BURNING OVER THE LIVER.

If the pain be attended with weight in those who have abscess in the liver, it is an indication that the fleshy part of the liver is affected; but if the pain be acute the matter is rather in the coats, and we must burn the part thus:—Having strongly heated slender, knobbed cauteries, we apply them a little above the loins at the extremity of the liver, making an eschar. But having burnt the whole skin and reached the coat we must evacuate the pus: after the discharge of which, having used lentils and honey, with the applications from honied water, and things of an incarnative nature, we have afterwards recourse to epulotics.

* * * * *

COMMENTARY. In cases of hepatitis, which do not yield to the usual remedies, the author of one of the Hippocratic treatises advises us to burn the side with spindles of boxwood dipped in oil, or with fungi. (De Morbis Internis.)

Aretæus directs us to open abscesses of the liver with red-hot irons. (Morb. Chron. i, 13.) Celsus mentions that some open abscesses of the liver with a scalpel, and some burn the vomica. (iv, 8.) Cælius Aurelianus, however, disapproves of this practice. (Pass. Tard. iii, 4.)

Albucasis describes the operation like our author, and gives a drawing of a spear-shaped instrument for opening the vomica. (Chirurg. ii, 30.) Haly’s description is quite similar. (Pract. ix, 75.)

SECT. XLVIII.—ON BURNING OVER THE SPLEEN.

Having stretched the skin which lies over the spleen with hooks, we burn it through by one application of a long ignited cautery so as to form two eschars; and this we do three times so that there may be six eschars formed altogether. But Marcellus by using a trident or trident-shaped cautery formed six eschars at one application.

* * * * *

COMMENTARY. In cases of diseased spleen the Coan surgeons burned eschars on the side affected. (Hippocr. de Affect. intern. and de Affect. 5.)

Aëtius directs us to burn the eschar either with the actual cautery or with caustics. (x, 12.) The ancients used an issue paste, very like the modern, prepared from potass. See above (s. 9.)

Avicenna recommends the same practice as the Greeks (iii, 15, 1); and so in like manner Haly Abbas (Pract. ix, 76); Albucasis (Chirurg. i, 32); and Rhases (Contin. xx.)

Guido de Cauliaco repeats Albucasis’s description of the process of burning the side in cases of scirrhous spleen. (ii, 2.)

SECT. XLIX.—ON BURNING OVER THE STOMACH.

In chronic defluxions of the stomach the moderns have recourse to burning,—some with knobbed cauteries, forming three eschars, one at the ensiform cartilage, and the other two below, so as to make a triangle, the depth of the burning being the thickness of the skin. Some form only one large eschar at the mouth of the stomach. But others do not burn with iron but with the substances called iscæ. The iscæ are spongy bodies forming on oaks and walnuts, being mostly in use with the barbarians. They allow the ulcers to remain for some time without cicatrizing, and rather stimulate them in order that by the great diaphoresis thereby occasioned, the mouth of the stomach may be freed from the defluxions.

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COMMENTARY. Hippocrates, Galen, and Celsus say nothing about burning over the stomach in affections of it. Aëtius’s account is similar to our author’s. He calls the iscæ the medullary part of the wood of walnuts. (vii, 91.) They are mentioned likewise by Haly Abbas, who says they are called ducanum in the Persian language. (Pract. ix, 77.) Albucasis directs us to burn with iron. (Chirurg. i, 28.)

SECT. L.—ON DROPSIES.

The formation of dropsical swellings, their varieties and causes, how they are to be distinguished from one another, and their treatment by medicine, having been explained in the Third Book, and it having been there shown that ascites alone falls under the province of surgery, we are now going to give an account of it. Wherefore we must make the patient stand erect; or if that cannot be done, we must cause him to be seated; or if he be so weak that this cannot be done, we must abandon the operation entirely. If then the man be standing erect we give orders to the assistants standing behind to press with their hands and push downwards the swelling to the pubes. Then taking a sharp-pointed knife or lancet, if the dropsy is among the intestines, in the perpendicular line of the navel, and about three fingers’ breadth distance from it we divide the hypogastrium as far as the peritoneum. But if the liver be primarily affected we must make our incision on the left side of the navel; or if the spleen, on the right, for we must not make an incision in that part on which the patient is disposed to lie. And having dissected with the point of the instrument the skin that lies over it, we divide the peritoneum a little above the first incision until the instrument comes to an empty space. After this we introduce through the incision of the abdomen and peritoneum a copper tube, having an opening like those of writing-pens, and by this we must abstract the fluid in proportion to the strength; feeling the pulse, and then removing the tube, we stop the flow of the fluid, (for it will stop immediately from the alteration of the incision,) and, for the sake of security, we introduce a twisted tent into the incision of the abdominal parietes alone; and having placed the man in a recumbent posture and recruited him, we may next day again evacuate through the tube a small quantity of fluid proportionate to his strength; and thus, in like manner, until very little be left, avoiding, by all means, a sudden evacuation. For some ignorant persons having evacuated the vital spirit with the fluid have immediately killed the patient. Some for the sake of greater security having evacuated a small quantity of the fluid by the operation so as to relieve the powers of the system from its great load, procure the discharge of the remainder by hydragogue medicines, by burying the patient in heated sand, by insolation, abstinence from liquids, giving desiccative food; and they have recourse likewise to burning over the stomach, liver, spleen, and hypogastrium; and make five eschars about the navel, some by slender cauteries of iron, and others by those substances called iscæ, or some other such like material. And many have been rather cured by this method alone, sometimes without paracentesis having been had recourse to at all.

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COMMENTARY. Hippocrates declares in one of his Aphorisms, that the sudden evacuation of the matter in empyema, or of the water in dropsy, proves fatal. He speaks of evacuating the fluid with an instrument called τρυπαντρωγλητήριον, which Camper thinks must have been a kind of trochar.

Galen, in his Commentary on the Aphorisms of Hippocrates, (vi, 7) remarks, that in his time the operation of paracentesis was in general use, instead of burning. He states, however, that he had seldom seen recovery take place after the operation. (See in particular Meth. Med. xiv.)

Aristotle alludes to paracentesis near the conclusion of his work on the ‘Generation of Animals.’

Cælius Aurelianus mentions that Erasistratus, Evenor, and Thessalus were advocates for paracentesis, but that Asclepiades, Themison, and Soranus disapproved of it. He himself approves very much of the operation, and answers all the objections which had been made to it. He says, it relieves the fulness and difficulty of breathing, and prepares the parts for the action of the remedies. He agrees, however, with the other authorities, that a sudden evacuation of the water is attended with danger. (Pass. Tard. iii, 8.)

Celsus gives a good description of the operation. Some, he says, perform it at a spot four fingers’ breadth below the navel in the left side; some do it at the navel; and some burn the skin and then perforate the abdominal parietes. He directs the operator to be careful not to wound a vessel. The size of the point of the perforator, he says, should be the third part of a finger’s breadth. After the perforation has been made, a tube (canula) of lead or copper is to be introduced and the water drawn off gradually. The whole is not to be removed at one time, but a tent is to be introduced into the opening, unless it was made with fire, to prevent it from healing too soon. He speaks favorably of the operation, unless the patient be much debilitated. (vii, 15; also ii, 10.)

Aëtius and most of the medical authors subsequent to Galen, mention the operation of paracentesis, and approve of it.

Vegetius, the veterinary surgeon, recommends paracentesis for the dropsy of cattle, when the swelling is not removed by purging. (Mulom. iii, 25.)

Avicenna expresses himself rather unfavorably of paracentesis. He says, it ought never to be attempted until every other remedy has proved ineffectual, and unless the strength of the patient be good, and he can endure exercise, abstinence from drink, and restricted diet. His description of the operation is taken from Paulus. (iii, 14; iv, 13.)

Serapion mentions the operation in very brief terms. (iv, 7.)

Albucasis’s description is very minute; but, upon the whole, little different from our author’s as to the place of the incision or the instruments with which it is to be performed. After the perforation has been made in the manner directed by our author, he recommends the introduction of a canula made of silver, copper, or brass, and having a small hole at the bottom and three in its sides; he advises us to evacuate only half the water at first. He adds, that when the canula is removed the skin will cover the opening in the abdominal muscles, and thereby stop the discharge. The remaining part of the water is to be removed afterwards, according to the strength of the patient. (Chirurg. ii, 54.)

Haly Abbas does not in general approve of the operation. He mentions, that he never saw it performed but once, and then it did not save the patient. He adds, that Galen relates that he only knew of one case in which it had proved successful. He directs the incision to be made three fingers’ breadth, straight below the navel, that is to say, in the linea alba; but if the liver is diseased he recommends it to be made in the left side, or if the spleen, in the right. (Pract. ix, 41).

Rhases gives Antyllus’s description of the operation, which, however, is scarcely at all different from that of our author. He directs us to make the assistants stand behind and compress the sides of the abdomen, and, if possible, recommends to make the patient sit on a bench. He directs us to make the incision with a large needle below the navel, when the collection is connected with disease of the intestines; but if from the liver, on the left side; or if from the spleen, on the right. Like the other authorities noticed above, he directs us to make the opening of the peritoneum higher up than that of the skin. A canula, made of copper, is then to be introduced into the opening. If the pulse sink during the operation he advises us to stop the discharge of the water. (Cont. xix.)

We have mentioned in our notes on Book Third, section 48, that Hippocrates and Aëtius approved of scarifications at the ankles. It appears that Archigenes also was an advocate for this practice in dropsical cases.

Dropsy of the womb and hydatids thereof are correctly described by Soranus. It seems to be now agreed that the dropsy in this case is a species of large hydatid. (120.)

SECT. LI.—ON EXOMPHALOS, OR PROLAPSUS OF THE NAVEL.

Protrusion of the navel takes place when the peritoneum there is ruptured and prolapsed; or from the omentum, intestine, and sometimes an inert fluid falling down upon the navel, sometimes from hypertrophy of the flesh, and sometimes from a collection of blood there, proceeding from the rupture of a vein or artery, as in aneurisms; and sometimes the collection consists not of blood, but of spirits only. If, then, the omentum be protruded, there appears a swelling at the navel, which is free from discoloration, soft to the touch, without pain, and uneven; but if it is intestine in addition to the afore-mentioned symptoms, there is greater inequality,—the tumour, when pressed by the fingers, disappears, sometimes with borborygmi; and it is increased by baths and straining. If its contents be a fluid, the tumour is equally soft, not yielding to pressure, and is neither diminished nor increased by it. If it consist of blood, in addition to the afore-mentioned symptoms, the swelling is more livid; but if it arise from hypertrophy of flesh, the tumour will be harder, elastic, and will continue of the same size. Those occasioned by flatulence are attended with softness, a certain sound when tapped, and disappearance upon pressure. We must operate then in this manner. Having placed the man in an erect posture, we order him to press down at the same time that he retains his breath; then, having marked the whole prominence of the navel with black ink, we are to lay him on his back, and dissect around the tumour with a scalpel, agreeably to the marking; then, stretching the middle with a hook, we must apply a thread or string around the part which is dissected, for thus it will be prevented from falling down, when secured with a knot. Then, at the top, having opened the constricted tumour, we must introduce the index-finger, and search carefully lest any fold of the intestine, or part of the omentum, be included in the ligature; and if intestine be included, we must loosen the fold of the thread, and push it inwards, but if it is omentum we may draw it out, and cut off what is redundant of it, securing, as is proper, with a thread, any vessel that may come in the way; and then taking two needles, containing a plain thread, we pass them through the scarified part in the form of the Greek letter Χ, and cutting the doubles of the threads, as we mentioned for aneurism, we make constriction with the four heads. After the bodies secured by the ligatures have become putrid and dropped off, we complete the cure by dressing the part with pledgets, and strive to make the cicatrix particularly hollow. Such is the operation when the part concerned is the intestine or omentum. But if flesh, or fluid, or blood occasions the complaint, having divided the middle of the tumour circularly, and then removed whatever lies external to the peritoneum at the navel, we perform the cure by incarnative applications. But exomphalos arising from aneurism, or the presence of flatus, we must abandon as hopeless, like other cases of aneurism.

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COMMENTARY. Celsus gives an interesting abstract of the ancient opinions upon this subject, but as it differs but little from our author’s description, we shall not dwell very particularly upon it. He directs us to cure the disease either by passing through the tumour a needle armed with two threads, in the manner described for staphyloma, or to produce mortification of the part by pressure between two rules. Some, he says, first make an incision in the tumour, so as to be enabled to remove with the greater facility whatever is protruded, but this he thinks unnecessary, as it will be sufficient merely to return the prolapsed substance, and apply a ligature round its base; after which the outer part is to be destroyed by medicines or the cautery. This operation, he adds, will be sufficient, whether the contents of the hernial tumour be intestine, omentum, or water. He intimates, however, that the operation is attended with some danger, and that it is only to be performed between the ages of seven and fourteen, and when the body is in a healthy state. He forbids to interfere with scirrhous tumours. (vii, 14.)

The description of the operation given by Albucasis is very minute, but is to the same effect as our author’s. (Chirurg. ii, 52.) Rhases, in like manner, recommends us to pass a needle, armed with two threads, through the tumour, and to secure it by a crucial knot. He, Avicenna, and Haly Abbas evidently copy our author’s description.

The operation with the ligature, as first described by Celsus, was revived, with very slight modifications, by the celebrated Desault, of Paris, but is now seldom practised.

SECT. LII.—ON WOUNDS OF THE PERITONEUM, AND ON FALLING DOWN OF THE INTESTINE OR OMENTUM, WHERE GASTRORAPHÉ ALSO IS DESCRIBED: FROM THE WORKS OF GALEN.

How wounds of the peritoneum are to be treated is next to be considered. If then the wound be small, so that the prolapsed intestine being distended with air, cannot be restored to its place, it will be necessary either to evacuate the flatus or enlarge the wound. The former measure is the better, provided one can accomplish it. But how may this be most probably done? By removing the cause which occasions the inflation of the intestine. But what is this? Congelation of the surrounding air; so that the cure is to be performed by heating. Wherefore, having soaked a soft sponge in hot water, and then squeezed it out, foment the intestine therewith. In the meantime let hot austere wine be prepared, for it is more heating than water, and communicates strength to the intestine. If, after having had recourse to all these things, the intestine remain inflated, we must divide as much of the peritoneum as the prolapsed intestine requires. The straight instruments called syringotoma, used for operating upon fistulæ, are very proper for this incision. A recumbent position of the patient is the best when the wound is in the lower part; and when in the right side, he may lie on the left, and when in the left, on the right; and this is common both to great and small wounds. But the replacement of the intestine into its proper place when the wound is large, requires a skilful assistant. For he must take hold of the wound externally with his hands, and contract and compress it a little, so as to expose always a small portion to the sewer, and also must compress moderately what is sewed until the whole is sewed. What is the most proper mode of performing the operation called gastroraphé, we must next explain. Since the abdomen must be united with the peritoneum, we have to begin by passing a needle through the skin from without inwards; but when it has transfixed the skin and the whole rectus muscle, passing by the adjacent peritoneum, we must push the needle from within through the other part of the peritoneum, and so hence from within outwards, through the rest of the abdomen; and when it has passed out we must push the needle again from without inwards through this part of the abdomen, and, passing by the adjacent portion of the peritoneum, and beginning again from the opposite side of this membrane, perforate it from within outwards, and at the same time all the other parts of the abdomen; then beginning again from this, sew it with the opposite membrane, and afterwards transmit it from the neighbouring skin outwards; and do this repeatedly until the whole wound be sewed up. The space between the sutures required to keep the under parts together must be very small, but the interval between those required to keep the skin from falling asunder need not be so small. Excess in either respects must be avoided, and a medium chosen between the two extremes. And a medium is likewise to be observed as to the consistence of the thread, for that which is too hard breaks the soft skin, and what is too soft is itself first broken. In the same manner, passing the needle too near the lips of the wound, occasions often a rupture of the remainder which is too narrow. But if too much is taken in, much of the skin remains ununited. These observations apply to the treatment of all ulcers, but are more especially to be observed in gastroraphé; and, as aforesaid, we must act, forming a conjecture as to the adhesion of the peritoneum with the abdomen, from the circumstance that the latter being membraneous seldom adheres; or, as some do, by bringing together the parts of the same kind; that is to say, peritoneum to peritoneum, and abdomen to abdomen. Or, it may be done thus: in the same manner as above, we must pass a needle from the side of the abdomen nearest us, from without inwards, and through it above; then passing both lips of the peritoneum, we must again turn the needle from without inwards through both lips of the peritoneum, and again turning it from within outwards, pass it through the opposite part of the abdomen. This mode differs from the common and vulgar one, inasmuch as the needle is passed through the four lips at one perforation, and exactly conceals the peritoneum within the abdomen. The proper applications are those formed of the same materials as the applications for recent wounds; but in order that no vital part may be affected sympathetically, some tender wool is to be dipped in moderately hot oil, and the whole space between the groins and armpits wrapped in it. It will be better, also, to evacuate the bowels by a clyster of warm oil. But if any of the intestines be wounded, dark austere wine, in a tepid state, should be injected, more especially if it be perforated quite through. The large intestines are easily cured, but the small ones with difficulty, and the jejunum is utterly incurable, from the multitude of its convolutions and the magnitude of its vessels, and owing to its coats being thin and nervous; besides, it receives all the bile in an undiluted state, and is nearest to the liver. The under and fleshy parts of the stomach we may attempt to cure, for we may succeed, not only because these parts are thicker, but because curative medicines are more readily applied to them, owing to their situation. The parts, however, about the mouth of the stomach and œsophagus are affected by the medicines only in passing down; and the exquisite sensibility of the mouth of the stomach is an obstacle to the cure of wounds of it. When, from a rupture of the peritoneum, the omentum is prolapsed, and either becomes livid or black, the part anterior to the black portion may be included in a ligature, for fear of hemorrhage, and then the part behind the ligature is to be cut off, and the extremities of the ligature allowed to hang from the under part of the sewed wound of the abdomen, in order that they may readily escape when cast off by the suppuration of the wound.

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COMMENTARY. The description of gastroraphé here given will be sufficiently intelligible upon an attentive perusal. It is taken from Galen. (Meth. Med. vi, 4.) By abdomen, in this place, is to be understood the abdominal parietes, namely, the skin and muscles. Galen explains that ἐπιγάστριον is used in this sense.

Celsus gives a long description of a somewhat different method of performing gastroraphé. He uses two needles. (vii, 16.)

Several modes of performing the operation are minutely described by Albucasis. He relates the history of a case in which he practised gastroraphé. (ii, 87.)

Haly Abbas recommends the warm bath, to facilitate reduction. The method of performing gastroraphé which he directs, is similar to the suture now practised upon dead bodies after dissections. (Pract. ix, 43.)

Rhases describes various modes of gastroraphé. He speaks of performing the operation with the string of a harp. (Cont. xxviii.) That the strings of the ancient harp were made of the guts of a sheep is clearly proved from the following passage in the Odyssey of Homer:

ὡς ὁτ’ ἀνὴρ φορμίγγος ἐπιστάμενος καὶ ἀοιδῆς ρηϊδίως ἐτάνυσσε νέῳ ἐπὶ κόλλοπι χορδὴν, ἄψας ἀμφοτέρωθεν ἐυστρεφὲς ἔντερον οἶὸς.

Οδυσ. φ.

The modes of gastroraphé described by Galen and Celsus are explained and commented upon by Van Swieten (Comment. cccxi), and by Fabricius ab Aquapendente. (Œuv. Chir. ii, 53.) A complete history of the operation is given by Sprengel. (Hist. de la Méd. xviii, 21.) Ambrose Paré performed the operation exactly like Galen.

SECT. LIII.—ON DEFICIENCY OF THE PREPUCE.

When there is a small deficiency in the skin of the penis, some, in order to repair the deformity, have attempted a double surgical operation; sometimes cutting the skin all round above at the commencement of the penis, in order that by this solution of continuity the skin may be drawn downwards until the glans (as it is called) be covered; and sometimes with a scalpel dissecting its inner surface from the root of the glans, and then drawing it downwards, and surrounding the glans with a soft ligature; but a piece of cloth must be interposed at the incision, in order to prevent an adhesion of the prepuce to the glans. Antyllus approves most of this method, of which he gives a full description, but we have been content with a brief outline, because it is rare that this surgical operation is required, as the complaint neither occasions any defect of the functional office, nor such deformity that one would choose to submit to the hazard of an operation on account of it.

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COMMENTARY. Celsus describes the operation as follows: “Cutis circa glandem prehenditur et extenditur, donec illam ipsam condat; ibique deligatur: deinde, juxta pubem, in orbem tergus inciditur, donec coles nudatur; magnâque curâ cavetur, ne vel urinæ iter, vel venæ quæ ibi sunt, incidantur. Eo facto, cutis ad vinculum inclinatur, nudaturque circa pubem velut circulus; eoque linamenta dantur, ut caro increscat, et id impleat: satisque velamenti supra latitudo plagæ præstat. Sed, donec cicatrix sit, cinctum esse id debet: in medio tantum relicto exiguo urinæ itinere.” (vii, 25.)

Rhases directs us to put a proper piece of lead upon the glans, then to draw the prepuce over it, and secure it with a ligature, having previously dissected it from the parts below, if necessary. (Cont. xiv.) This is much the same as our author’s operation for phimosis. See section lv.

The reader will find the ancient operation described by Fabricius ab Aquapendente. (Œuv. Chirurg. ii, 61.)

SECT. LIV.—ON HYPOSPADIÆUM, OR IMPERFORATE GLANS PENIS.

In many children the glans is not perforated at birth, but the meatus is situated under the part called canis, at the termination of the glans. Hence they can neither make water forwards unless they draw up the member to the pubes, nor procreate, as the semen cannot be injected direct into the uterus. In addition to these defects, the complaint occasions no ordinary deformity. Wherefore, the simplest and least dangerous mode of operation is that by amputation. Having then placed the patient in a supine posture, we have to stretch the glans forcibly with the fingers of the left hand, and then with the point of a scalpel we are to amputate the glans at the corona, not making the amputation obliquely, but carving it, as it were, all round, so that an eminence may appear in the middle resembling the glans. And since a hemorrhage frequently takes place, we may stop it by styptics if possible, but if not, we must have recourse to burning with slender cauteries.

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COMMENTARY. Galen makes mention of this deformity. (De usu Partium.) See also Theophilus. (De Fab. Hom. v, 22.)

Albucasis evidently transcribes our author’s description. The part named canis (κυὼν) by our author is called finis capitis virgæ in the translation of Albucasis, and finis coronæ in the translation of Haly Abbas. (Pract. ix. 44.) We do not remember to have seen the term κυὼν applied by any other medical author to a part of membrum virile. Perhaps the proper word is ἳς gent. ἱνὸς which is applied by Galen to a part of the genital member. (Meth. Med. xiv. 16.)

Guido de Cauliaco directs us to make an opening with a suitable instrument and introduce a canula of lead or wood. (iv, 2.)

SECT. LV.—ON PHIMUS, OR PHIMOSIS.

There are two causes of phimosis; for sometimes the prepuce so covers the glans that it cannot be retracted; and sometimes when drawn behind, it cannot be brought forward, which last species is properly called paraphimosis. The first variety is occasioned either from a cicatrix formed in the prepuce, or from an adhesion by flesh. But the second variety takes place in inflammations of the genital organs when the skin being brought back, the glans swells, and it cannot longer allow of being drawn forward. If it is the first species of phimosis we may operate upon it in this manner. After having placed the patient properly, and drawn the prepuce forwards, and having fastened three or four hooks into its extremity and giving them to assistants to hold, we direct them to stretch and open it; and then if the external adhesion be from a cicatrix, we divide the prepuce from the internal parts with a lancet or sharp knife in three or four places, making the divisions at the inner parts direct and equally distant from one another. The prepuce at the glans is double, wherefore we divide the mouth of the inner part; for having thus opened the contraction formed by the cicatrix, we are enabled to retract the prepuce. But if a preternatural adhesion of the flesh of the internal parts occasion the phimosis we may make scarifications in all the flesh, drawing back the prepuce and scraping away the fleshy prominences between the incisions, and afterwards apply a tube of lead to the whole glans, having wrapped it in dried paper (papyrus), the tube having its opening the same everywhere; for thus, by the application of the tube, the prepuce, when brought forwards again, is prevented from forming adhesions, being kept separate by the lead and the paper wrapped round it; for by getting swelled with the moisture it separates the skin still more. This we may do whether we operate upon a phimosis occasioned by a cicatrix, or one from a preternatural adhesion of flesh. But if the complaint called paraphimosis take place, and become chronic, adhesions take place, and the complaint is incurable, unless one choose to submit to the operation for deficiency of prepuce. But if it has not yet formed adhesions, we may make three, four, or more direct incisions circularly, and having bathed with much tepid oil, draw the prepuce outwards.

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COMMENTARY. Celsus describes the operation as follows: “Subter a summâ orâ, cutis inciditur recta linea usque ad frænum; atque ita superius tergus relaxatum, cedere retro potest. Quod si parum sic profectum est, aut propter angustias, aut propter duritiem tergoris, protinus triangula forma cutis ab inferiore parte excidenda est, sic ut vertex ejus ad frænum, basis in tergo extremo sit. Tum superdanda linamenta sunt alia que medicamenta quæ ad sanitatem perducant. Necessarium autem est, donec cicatrix sit, conquiescere: nam ambulatio, atterendo ulcus sordidum reddit.” (vii, 25.)

Our author’s description of the operation for keeping the prepuce separated from the glans, by means of a leaden tube, is mostly taken from Galen. (Meth. Med. xiv, 16.)

SECT. LVI.—ON ADHESION OF THE PREPUCE TO THE GLANS.

When there has been a previous ulceration about the glans, or prepuce, an adhesion of the one part to the other takes place. We must, therefore, dissect around, as far as may be, endeavouring to separate the adhesion with the point of a scalpel, or of a polypus knife, and more especially to free the glans completely from the prepuce, to which it adheres; but, if this be found difficult, we must rather add of the glans to the prepuce with which it is united, than contrariwise; for the prepuce, being thin, is readily perforated. After the disengagement of the adhesion, a thin cloth, dipped in cold water, is to be placed between the glans and the prepuce, that no adhesion may again take place, and the parts are to be healed with some astringent wine.

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COMMENTARY. Albucasis describes the operation in exactly the same terms. (Chirurg. ii, 56.)

SECT. LVII.—ON CIRCUMCISION.

We do not treat at present of those who are circumcised in conformity to a heathen rite, but of those in whom the prepuce has become black from some affection of the privy part. In such cases, it becomes necessary to cut off the blackened portion all around; and afterwards we must have recourse to the squama æris, with honey, or to pomegranate-rind and tare, in the form of those applications which are made upon a pledget. And if there be a hemorrhage, we must use lunated cauteries, which contribute to two good purposes: I mean the stoppage of the bleeding and of the spreading sore. But if the whole glans be consumed, having introduced a leaden tube into the urethra, we direct the patients to make water through it.

* * * * *

COMMENTARY. See a similar description in Albucasis. (Chirurg. ii, 57.) Albucasis describes the mode of performing the operation on boys, as a rite of the Jewish religion. He directs the prepuce to be cut with a pair of scissors, and the part allowed to bleed freely. From the manner in which he expresses himself respecting the operation, there can be no doubt that he was a Jew, and it is equally clear that our author was a Pagan.

Fabricius ab Aquapendente describes a similar operation. (Œuv. Chirurg. ii, 64.) Guido de Cauliaco directs us to draw the prepuce forwards, and cut it off; after which the bleeding is to be stopped with powders, or the cautery. (vi, 2.)

SECT. LVIII.—OF THYMI ON THE PENIS.

Thymi are fleshy excrescences, forming sometimes upon the glans, and sometimes upon the prepuce; and some of them are malignant, and some are not. Those which are of a mild nature it will be proper to pare away with the edge of a scalpel, and sprinkle the part with chalcitis; but when malignant, the part must be burned after they are removed. If there be thymi on both sides of the prepuce, some internal and others external, we must not attempt all at the same time, lest by mistake we should cut off the prepuce, which is thin; but we must first cut off the internal, and, when they are healed, we may next attempt the external. Some of the moderns effect a cure by cutting them off with a pair of scissors, and by binding them with a horse-hair; as, in like manner, some burn them with the cold cautery.

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COMMENTARY. Albucasis copies our author’s description. (Chirurg. ii, 56.) When the tumour is of a malignant nature, he particularly approves of using the actual cautery. These intractable tumours on the genital member are now frequently met with.

SECT. LIX.—ON CATHETERISM, AND INJECTION OF THE BLADDER.

When the urine is suppressed in the bladder, owing to some obstruction, such as a coagulum, or stones, or from any other cause, we have recourse to catheterism for the removal of it. Wherefore, taking a catheter proportionate to the age and sex we prepare the instrument for use. The mode of preparation is this: having bound a little wool round with a thread, and introduced the thread with a sharp rush into the pipe of the catheter, we adapt the wool to the opening at the head of the catheter, and having cut off the projecting parts of the wool with a pair of scissors, we put the catheter into oil. Having then placed the patient on a convenient seat, and used fomentations, if nothing prohibit, we take the catheter and introduce it at first direct down to the base of the penis, then we must draw the privy parts upwards to the umbilicus, (for at this place there is a curvature of the passage,) and thus push the instrument forwards. When in the perineum it approaches the anus, we must bend the member with the instrument in it down to its natural position, for from the perineum to the bladder the passage is upwards; and we must push the instrument forwards until it reach the cavity of the bladder. We afterwards take out the thread fastened into the opening of the catheter, in order that the urine being attracted by the wool may follow, as happens in syphons. Such is the method of introducing the catheter. But since we have often occasion to wash an ulcerated bladder, if an ear-syringe be sufficient to throw in the injection it may be used, and is to be introduced in the manner described above. But if we cannot succeed with it we may fix a skin or the bladder of an ox to the catheter, and throw in the injection through its opening.

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COMMENTARY. Although we have treated succinctly of strangury and retention of urine in the Third Book, it may be proper, before explaining the ancient methods of introducing the catheter, to give some further account of the causes of these complaints, and the opinions entertained by the physiologists with regard to the functional offices of the urinary organs. Galen states that the bladder is possessed of two faculties, a retentive and an expulsive, both of which arise from muscular power; that the retentive resides in the neck of the bladder, and is of the voluntary kind of powers; but that the expulsive belongs to the class of natural or involuntary powers, being of the same kind as the peristaltic faculty of the intestines. When a person, then, makes water voluntarily, it is by suspending the voluntary action of the sphincter vesicæ, that is to say, of the retentive faculty of the bladder, whereby the expulsive or peristaltic powers are brought into action, and the contents of the bladder are thereby evacuated. He properly adds, however, that this involuntary or expulsive faculty may be assisted by the action of the voluntary muscles which surround the bladder, especially the recti muscles of the abdomen. Retention of urine, therefore, may arise from the loss of either of these faculties. The expulsive faculty is most commonly lost, either from over-distension of the bladder, as when its contents have been allowed to accumulate too far, or from injury of the spinal marrow which supplies it with nerves. Rhases remarks that when retention of urine proceeds from debility of the expulsive faculty, the bladder may be evacuated by merely making pressure above the pubes.

According to Rhases, retention of urine arising from derangement of the retentive faculty, that is to say, from its no longer being under the control of the will, may be occasioned by inflammation, by some swelling, such as a fleshy tumour forming in the meatus urinarius, or by the presence of some foreign body, such as a stone, a clot of blood, or the like. He alludes several times to this fleshy tumour in the passage, by which he probably means either an enlargement of the prostate gland, or stricture of the urethra. He calls it a very intractable case. For a fuller exposition of the ingenious speculations and opinions stated above, see Galen (De Locis Affectis, iv, 4); Rhases (Contin. i and xxiii.)

Celsus describes very accurately the operation of catheterism. The tube or catheter, he says, should be made of copper, and the male catheter ought to be somewhat bent, smooth, and neither too large nor too small for the passage. The length of the largest male catheter should be 15 inches, of the middle-sized 12, and of the smallest 9; the largest female catheter should he 9, and the smallest 6 inches. The patient is to be laid on his back, and the surgeon standing by his right side, and holding the penis in his left hand, is to introduce with his right the catheter into the urinary passage; and when it reaches the neck of the bladder, the instrument along with the penis is to be bent downwards and introduced into the bladder. When the water is evacuated the catheter is to be extracted. The female passage, he remarks, is shorter, and is discovered by a sort of mammary protuberance above the vagina, by which he evidently means to describe the clitoris. The operation, he adds, in this case is less difficult. (vii, 26.)

The operation is mentioned by Aëtius and other of the Greek authorities, but none of them describe it fully but Paulus.

Albucasis recommends a catheter made of silver. His account of the operation is evidently borrowed from our author. He describes and gives a drawing of an instrument for throwing injections of oil and water into the bladder when inflamed. It is a tube of silver or copper having the bladder of a ram attached to it. (Chirurg. ii, 59.)

Avicenna and Serapion mention the operation but do not describe it minutely. Haly Abbas directs us to make the patient sit and to pour warm water and oil upon the penis. This is evidently recommended with a view of producing relaxation. The ordinary steps of the operation are very properly described by him. (Pract. ix, 45.)

Rhases gives a fuller account of catheterism, and all the circumstances connected therewith, than any other ancient author. He very properly forbids the catheter to be introduced when the retention arises from inflammation at the neck of the bladder. (Ad Mansor. ix, 73.) He first gives Antyllus’s description of the operation, which is very accurate, but similar to our author’s. He recommends us, before attempting the introduction of the instrument, to put the patient into a warm bath, or to apply hot fomentations to the parts. He then directs us to lubricate the instrument with oil or thick mucilage, and to introduce it into the passage until it arrives at the under extremity of the penis, when it is to be gently pushed upwards in the direction of the navel, turning it to one side or another according as it encounters obstruction. He states that it is best to have the openings of the catheter in its sides as they are less likely to be obstructed by clots than when in the extremity. He also mentions that he was sometimes in the practice of using a ductile instrument of lead which accommodated itself to the passage.

Both Serapion and Rhases mention the operation of puncturing the bladder. Rhases says that when there is retention of the urine and the bladder is inflamed, if the case be urgent, and there be reason to apprehend that the introduction of the catheter would aggravate the symptoms, it may be proper to make an incision in the perineum into the side of the bladder, and to draw off the urine with a canula. Both add, however, that there is danger of the wound not closing. (Cont. xxiii, 2.)

The ancients seem to have fancied that it was necessary to fill up the internal cavity of the catheter with wool, or some such substance, in order to produce a vacuum when drawn out, believing that the catheter in this case acted upon the principle of the syphon. See Alexander Aphrodisiensis (Prob. ii, 59.) It is singular that they should have fallen into this mistake, when Galen, as we have mentioned above, had so clearly explained that the evacuation of the bladder is accomplished by the action of its expulsive powers whenever its retentive faculty is suspended or overcome. The earlier writers on surgery likewise adopt the notion that the cavity of the instrument requires to be filled up with wool. See Guido de Cauliaco (vi, 2.) They describe stricture of the urethra under the names of hypersarcosis and caruncula in meatu urinario. See Henricus Regius (An. Med. 44.)

SECT. LX.—ON CALCULUS.

The cause of the formation of stones, and that in children they are formed most readily in the bladder, and in adults in the kidneys,—all this having been explained in another place, we now proceed to the method of performing lithotomy, but shall first give the symptoms of stones lodged in the bladder. The patients then void urine of a watery consistence with a sandy sediment; and from constant itching the member is now relaxed and again stretched in an uncommon degree, because, owing to the irritation, they are perpetually handling it, more especially in the case of children. When the stone falls into the neck of the bladder a sudden retention of urine takes place. Of those cut for the stone, children to the age of fourteen are the best subjects for the operation, on account of the softness of their bodies: old men are difficult to cure because ulcers of their bodies do not readily heal; and the intermediate ages have an intermediate chance of recovery. And again, those who have larger stones recover best because they have become habituated to the inflammation, whereas those who have smaller recover with difficulty for the opposite cause. These things being so, when we proceed to the operation, we first have recourse to shaking the patient, sometimes by means of assistants, and sometimes by making him jump from a height, in order that the stone may be forced down to the neck of the bladder. We have then to place him sitting in an erect posture, with his hands under his thighs, in order that the bladder may be forced down into a small space. If then we ascertain by feeling externally that the stone with the shaking has fallen down to the perineum, we proceed immediately to the operation; but if it has not descended, we must introduce the index finger of the left hand well oiled, or, if an adult, the middle also, into the anus, and with the fingers in a supine direction we search with them for the stone, and, bringing it down gradually to the neck of the bladder, we fix it there, pushing it out with the finger or fingers when so fixed; and having given directions to the assistant to press down the bladder with his hands, and ordering another assistant to raise the testicles in his right hand, and with the other to stretch the perineum to the other side from that upon which the incision is to be made, we take the instrument called a lithotome, and between the anus and the testicles, not, however, in the middle of the perineum, but on one side, towards the left buttock, we make an oblique incision, cutting down direct upon the stone where it protrudes, so that the external incision may be wider, but the internal not larger than just to allow the stone to fall through it. Sometimes, from the pressure of the finger or fingers at the anus, the stone starts out readily at the same time that the incision is made, without requiring extraction; but if it does not start out of itself we must extract it with the forceps called the stone-extractor. After the removal of the stone, having stopped the bleeding by manna of frankincense and aloes, comfrey, misy, and such like styptic powders, and having dipped wool or compresses in wine and oil, we apply them; and also apply the bandages for calculous diseases, namely, that having six legs. But if there be any apprehension of hemorrhage we must apply a compress which had been soaked in oxycrate, or water and rose-oil, and placing the patient in a reclining posture, bathe the parts frequently. After the third day, having loosed the bandages, and poured much water and oil into the wound, we may dress it with the ointment called tetrapharmacon (basilicon) on a pledget, removing them and dressing often on account of the acrimony of the urine. If inflammation come on, we must have recourse to the cataplasms and fomentations proper for it. And we may also inject into the bladder oil of roses, oil of camomile, or butter, unless some inflammation prevent. In like manner, if the sore become spreading, or otherwise malignant, we must suit the applications to the state of it. When the ulcer is freed from inflammation we may loose the dressings, and use diachylon plaster to the groins and bottom of the belly. During the whole time of the treatment, the thighs must be bound together, which contributes to the cure with the other remedies. If the stone, being small, fall into the penis, and cannot be voided with the urine, we may draw the prepuce strongly forwards, and bind it at the extremity of the glans. We must next apply another ligature round the penis behind the member, making the constriction at its extremity next the bladder, and then make an incision down upon the stone, and bending the penis we eject the stone, and undoing the ligatures we clear away the coagula from the wound. The posterior ligature is applied lest the calculus should retreat backwards, and the anterior, in order that, when untied, after the extraction of the stone, the skin of the prepuce may slide backwards and cover the incision.

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COMMENTARY. We will now attempt to explain all the ancient descriptions of lithotomy.

Hippocrates in his Oath binds his pupils not to perform this operation, but to leave it to those who made it their business. It appears then that in his days lithotomy was a separate branch of the profession. Celsus is the earliest author who describes lithotomy, although it is probable that he merely explained the method of operating in Alexandria, the surgeons of which city had acquired great celebrity in performing this operation. He forbids the operation, except after every other remedy had failed; and in children between the ages of nine and fourteen, and in the season of spring. The patient is to be kept upon a spare diet beforehand; and when the operation is about to be performed, he is to be directed to walk, so as to bring down the stone to the neck of the bladder, which is to be ascertained by introducing a finger into the anus. Then a strong and experienced person, sitting on a high seat, is to take the patient and hold him secure, his buttocks being placed upon the assistant’s knee, and his legs being drawn in and his hands placed on them and held there. But if the patient be strong he is to be held by two assistants, one on each side, upon two seats placed beside one another, and they are to be directed to press upon his shoulders with their breasts, so as to force down the bladder. Two other assistants are to be at hand, to prevent any risk of the former two losing their hold. The surgeon having pared his nails, is to introduce gently first the index and then the middle finger into the anus, whilst with the right he makes pressure upon the abdomen, and in this way the stone is to be secured at the neck of the bladder. The shape of the stone is to be considered, and it is to be pressed down so as to favour its exit. These matters being properly arranged, a lunated incision is to be made over the neck of the bladder near the anus down to the neck of the bladder, the horns of the incision inclining a little towards the (left?) buttock; then at that part where the incision is bent round (at the curvature of the incision?) even under the skin, another transverse incision is to be made, by which the neck is to be opened, and the urinary passage dilated, the opening being somewhat larger than the stone. When the stone is small it may be propelled and drawn out by the fingers; but if large, it is to be extracted by a hook or crotchet made for that purpose. This hook is of a semi-circular form, smooth externally, and rough on the inside. By the help of it the stone is to be taken out dexterously, attention being paid to the shape of it. He mentions that Ammonius the lithotomist was in the practice of breaking down the stone into pieces when it was so large that it could not be extracted without tearing the neck of the bladder. He states that the operation is seldom required in the case of females, but that if the stone be large it may sometimes be necessary. The fingers are to be introduced into the vagina, as they are into the rectum of males, and then, if the patient be a girl, an incision is to be made under the left edge (of the labia pudendi?); but if in an adult female, a transverse incision is to be made on both sides between the urethra and os pubis.

The above is but an abridgment of the Celsian description, which, it must be admitted, is attended with considerable difficulties. We shall give the passage in which he describes the form and place of the incisions. “Incidi super vesicæ cervicem juxta anum cutis plaga lunata usque ad cervicem vesicæ debet, cornibus ad coxas spectantibus paulum: deinde eâ parte, qua resima plaga est, etiamnum sub cute altera transversa plaga facienda est, qua cervix aperiatur; donec urinæ iter pateat, sic, ut plaga paulo major, quam calculus sit.” Sprengel renders the words “cornibus ad coxas spectantibus paulum” by “dont les angles regardant les aines;” but coxæ signifies properly not the groins, but the nates, viz., the buttocks, or perhaps the hips. (Celsus viii, 1.) In the English translation of M. Foubert’s paper on Lithotomy, in the ‘Memoirs of the French Academy of Surgery,’ these words are more correctly rendered, “the extremities of which incision must be in some measure directed towards the thighs.” Dr. Milligan, however, in his edition of Celsus, proposes to read coxam, by which he supposes that Celsus understood the coxa sinistra. He adds: “hinc liquet, cornua plagæ Celsianæ, ut hodiernæ, coxam sinistram respexisse.” We are inclined to adopt this conjecture, as it makes the Celsian description agree with that of our author and his Arabian copyists, all of whom direct the first incision to be made towards the left nates. The words “qua resima plaga est,” must signify, we suppose, the curvature in the middle of the incision where the two horns unite. M. Foubert reads “qua strictior ima plaga est,” but we suspect without any proper authority from MSS.

We may be permitted to remark that the advantages of the semi-lunar incision are pointed out by Bromfield, and the Celsian operation was generally practised by the late Baron Dupuytren of Paris.

Aëtius and other of the Greek authorities allude frequently to the operation, but none of them describe it minutely except Paulus. Our author’s statement, that there is less danger from the extraction of large than of small stones, is at variance, we believe, with modern experience. Aretæus states that small stones are most easily extracted. He was, however, no advocate for the operation at all, except in extreme cases. He speaks of cutting “the neck of the bladder.” (Morb. Acut. Curat, ii, 9.) Does he not allude to attempts at lithotrity in the following passage?—ὄυτε γὰρ (λίθος μέγας) θρύπτεται, ἢ πόσι, ἤ φαρμάκῳ, ἢ αμφιθρυπτοιτο, ὂυτε ἀσινέως τέμνεται. (Morb. Chron. ii, 4.) Which passage may be thus translated: “when the stone is large neither lithotrity, or lithotripsy, nor lithotomy, can be practised safely.” Theophilus, in his ‘Commentary on the Aphorisms of Hippocrates,’ states that in lithotomy it is not the bladder, properly speaking, but the neck of the bladder, which is muscular, that is cut.

We now proceed to the Arabians. Albucasis, after detailing the symptoms in much the same terms as our author, goes on to describe the operation as follows. Having cleared out the bowels with a clyster, the patient is to be shaken so as to make the stone descend, and he is then to be secured in the arms of an assistant, with his hands under his nates. The surgeon is then to press upon the perineum, and, if the stone be felt, the operation is to be proceeded with; but otherwise, the index finger of the left hand, if the patient be a child, and the middle if an adult, is to be introduced into the anus, and the stone is thereby to be gradually brought down to the neck of the bladder. Having pushed it outwards to the place where you mean to make your incision, an assistant is to be directed to press down the bladder from above the pubes, while another draws up the testicles with the one hand, and with the other stretches the skin under them. Then with a proper scalpel the operator is to make an incision between the anus and the testicles, not in the middle, but towards the left nates, straight upon the stone which is to be pressed out by the finger. Let the incision be transverse (oblique?), large externally, but internally of the size of the stone. If the stone does not then start out, the operator must seize upon it with a forceps, or a hook having a lunated extremity. If there be more than one stone, the largest is to be extracted first, and then the others may be easily removed. When the stone is large he directs us to break it down with a forceps. His directions respecting the treatment afterwards are similar to those of Paulus. When the stone sticks in the urethra he recommends us to cut down upon it. His description of the operation on women is likewise similar to our author’s, but more circumstantial. Having got a dexterous midwife, or some proper person to introduce her finger into the rectum or vagina, and press the stone down to the left hip, the operator is to make first a small incision over it, and afterwards, by the help of a sound or specillum, it is to be enlarged so as to allow a passage for the stone. (Chirurg. ii, 60, 61.)

Avicenna’s description is nearly the same as that of Albucasis, but not so minute. He directs the surgeon to introduce a finger into the anus, if the patient be a male, but into the vagina if a woman who is not a virgin, and to push the stone outwards, so as to make it protrude. He is then to cut down upon it, making an incision proportionate to the size of the stone; but if the stone be very large, the incision must not be made of the same size, but it is to be grasped in a forceps and broken into pieces. If inflammation come on after the operation, he recommends him to have recourse to clysters, the warm bath, and venesection, and a piece of cloth dipped in oil of roses and some vinegar is to be applied to the part. The bad symptoms after the operation are said to be violent pain in the part and under the navel, coldness of the extremities, prostration of strength, loss of appetite, and, at last, singultus and involuntary discharges from the bowels. (iii, xix, 1, 7.)

The description given by Haly Abbas being nearly the same as that of Albucasis, need not be noticed here but very briefly. He prefers performing the operation in infancy, but permits it to be done at all ages. For the reason assigned by our author he states that recovery is most likely to take place when the stone is large. Like the others, he directs the surgeon to introduce either the fore-finger alone, or it and the middle finger into the anus, behind the stone, and to push it outwards, and then the operator is to cut down upon it, making the incision between the testes and the anus, yet not in the middle, but towards the left side. When the incision is carried down to the stone it will sometimes start out from the pressure of the fingers in the anus; but otherwise, it is to be seized upon with a forceps and extracted. If inflammation come on he recommends us to apply a cataplasm, and to throw into the bladder an injection consisting of oil of roses and of camomile, or of melted butter. (Practic. ix, 46.)

Rhases gives from preceding authors several descriptions of lithotomy, but as they closely resemble our author’s, we shall treat of them only in a cursory manner. In his first description he directs the surgeon to place the patient with his hands fastened to his ankles so as to press down the bladder. When the stone does not descend properly, so as to be felt externally, he recommends him to introduce one or more fingers into the rectum and push it outwards; and then while an assistant draws up the testicles the operator is to make a transverse (oblique?) incision, larger externally, but internally only of such a size as to allow the stone to pass out. If the stone does not come out readily it is to be extracted with an instrument, and the hemorrhage checked with a composition of aloes, frankincense, and vitriol. When the patient is a child he recommends the operator to place him upon the knees of an assistant, and to make pressure on the abdomen so as to force down the bladder. He forbids the operation when the stone cannot be brought down to the neck of the bladder. When the stone is large he directs it to be broken into pieces before extraction. His next description is taken from the celebrated Antyllus, but as it scarcely differs at all from the preceding one, we shall merely select a few remarks. When the stone is smooth, round, and small, he directs the surgeon to push it down to the neck of the bladder by means of a finger introduced into the rectum, and to make an incision down upon it; after which the stone is to be forced out. When pain supervenes after the operation, he recommends him to place the patient in a bath medicated with camomile, linseed, mallows, &c.; or if it be summer, and there be any disposition to hemorrhage, to place him in a vessel filled with strong vinegar. When it is ascertained that there are clots of blood in the bladder obstructing the urine, he directs the surgeon to introduce a finger by the incision, and extract them gradually. His next description is from an author named Sarad, whom he frequently quotes in other parts of his works. He directs the operator to introduce a finger into the rectum and push the stone outwards to the left side of the perineum, removed about the size of a grain of barley from the raphe (daram), and then to make an incision into the neck of the bladder. He afterwards gives a very circumstantial account of the operation from another author called Athuriscus. He particularly directs the operator to make an incision in the left side of the perineum and to open the neck of the bladder, as a wound of the body of the bladder seldom unites. When the stone is large he recommends him to seize it with strong pincers and break it into pieces. When a stone sticks in the urethra he directs him to tie one ligature behind it and to secure the prepuce before the glans with another, and then to cut down upon the stone. He gives very minute directions about the after treatment, recommending especially the removal of any clots which obstruct the passage. (Cont. xxiii.)

The practice of lithotomy appears to have been reckoned a disreputable occupation among the Arabians, for Avenzoar mentions it as an operation which an upright and respectable man would not witness, far less perform. (ii, 2, 7.)

As there are some doubts regarding the form of the incisions in the ancient methods of performing lithotomy, we will now give the words of some of the Arabian translators. Stephanus Antiochensis, the translator of Haly Abbas, has the following words: “Inter testes anumque finde et non in mediâ viâ sed in sinistri lateris parte ab intestinis, sitque perallela fissura, et ab exterioribus larga, ab interioribus non.” The translator of Albucasis expresses himself thus: “Finde in eo quod est inter anum et testiculos et non in medio, ad latus natis sinistræ: fiat sectio transversa.” The following are the words of Avicenna’s translator: “Cave ne scindas super commissuram quum sit malum, commissura enim secundum veritatem est locus mortalis. Amplius fac super ipsum (lapidem?) scissuram tendentem ad transversum, studendo ut cadat scissura in collo vesicæ.” The translator of Rhases expresses himself in the following terms: “Scinde super lapidem cum instrumento camadan; et scissura debet fieri transversa, et sit exterior caro larga et in interiori vesicæ stricta.”

Yet notwithstanding all this we are inclined to think that the incision was oblique and not transverse; for our author, whom they all follow, directs us to make the incision oblique (λοξὸς), and it is further clear that a transverse one would not answer the purpose so well. No dependence can be put in the accuracy of these barbarous translations. The language of Stephanus Antiochensis is particularly obscure. Casiri justly characterizes the translations of the Arabian authors as being “perversiones potius quam versiones.” (Bibl. Hisp. Arab, i, 266.)

The ancient operation, with scarcely any alterations, is described by the earlier modern writers on surgery. See Brunus (Chirurg. Magna. ii, 17); and Guido de Cauliaco (Chir. vi, 2.) They direct us to introduce a finger into the rectum and push the stone outwards; then to make an incision down upon it on the left side of the raphe. Brunus recommends a longitudinal incision.

It appears that the ancient operation of lithotomy is still practised with great success by the native doctors of Hindostan. See ‘Transactions of the Medical and Physical Society of Calcutta,’ vol. iv. An interesting case in point, related in the ‘Medical Gazette’ for Feb. 7, 1845, forms a valuable commentary on the Celsian description of lithotomy. In the year 1827 Mr. Madden the traveller saw it performed in Tyre by an old pilot on a boy of thirteen years of age. The case did well.

SECT. LXI.—ON THE PARTS ABOUT THE TESTICLES.

As contributing to the understanding of the operations on herniæ, we shall premise a description of the parts about the testicles. The testicle itself is a glandular and friable substance, formed for the production of semen. The substances called parastatæ and cremasteres, are processes from the membrane of the spinal marrow, descending along with the arterial vessels in the testicles, by which the semen is injected into the pudendum; the spermatic vessels are veins from the vena cava passing to the testicles in a convoluted manner, and by them the testicles are nourished. The tunica vaginalis (erythroides or elytroides?) is of a nervous nature; at the convex and anterior part not adhering, but at the concave and posterior parts united to the testicle, deriving its origin from the peritoneal coat. This part, where it is united to the testicle, they call the posterior adhesion. The darti are membranes connecting the external skin to the tunica vaginalis, being united to it at the part where it is united behind to the testicle. But that wrinkled skin which forms an external covering to the testicles is called the scrotum.

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COMMENTARY. Celsus gives a similar description of the parts connected with the testicles. The testicles themselves, he says, consist of medullary matter and possess no sensibility of their own, but experience violent pains and inflammations from the membrane which surrounds them. They hang from the groins by nerves called cremasters by the Greeks, with each of which descend two veins and arteries. These are covered by a thin nervous white coat, without blood, called elytroides by the Greeks. (This must be the tunica vaginalis of modern anatomists.) Above it is a stronger tunic which adheres strongly to the inner at its lower part, and is called dartos by the Greeks. (This appears to be the cremaster muscle of modern anatomists.) The veins, arteries, and nerves are surrounded by many small membranes. (By these he seems to have meant the fasciæ from the aponeurosis of the external oblique muscle.) All these parts are covered by an external investment called the scrotum. (vii, 18.)

Ruffus Ephesius says that the scrotum is a loose substance in which the testicles are placed, being in particular fleshy externally; that it consists of two tunics, the external being corrugated and called dartos, and the internal being called erythroides (elytroides?). The dartos and scrotum connect the testicles to the parts above, but the erythroides (vaginalis?) is united to and surrounds the testicle itself. (De Corporis Humani partium appellationibus, ii.)

Oribasius describes the cremasters as being two muscles which descend from the groins and surround the tunica vaginalis. (Anatomica ex Galeno.) (This is very similar to Cloquet’s description of them.)

Theophilus’s description unfortunately has come down to us very incomplete. (De Fabricâ Hominis, v, ad finem.)

SECT. LXII.—ON HYDROCELE.

An inert fluid, collected about the parts which are enveloped by the scrotum, and occasioning a marked swelling there, has obtained this appellation. The fluid is, for the most part, collected in the tunica vaginalis around the testicle, at its anterior part; but the affection is sometimes, though rarely, formed externally to the tunica vaginalis. Often, however, it is collected in the proper tunic of the testicles, and surgeons call this affection hydrocele of the tunica adnata. If the complaint is formed from some preceding cause, such as weakness of the parts, the blood brought there for the purpose of nourishment is converted into an inert watery or serous substance. But if it is occasioned by a blow, a sanguineous or feculent substance constitutes its contents. The common symptom is a permanent swelling without pain about the scrotum, not disappearing under any circumstances, yet somewhat compressible when the collection is small, but not at all compressible when it is large. When the fluid is collected in the tunica vaginalis the swelling is globular, but somewhat oblong like an egg; and in these cases the testicle is not to be felt as being everywhere surrounded with the fluid. But that which is collected externally to the tunica vaginalis, is felt as through a small intervening substance. When it is formed in the adnata, being everywhere circumscribed and globular, the swelling has the appearance of another testicle. If the fluid be watery, the swelling is of one colour and transparent; but if it be feculent and bloody, it appears red or livid; and if these symptoms appear in both parts of the scrotum, you may be sure that there is a double hernia. We operate upon it in this manner. Having shaven the pubes and scrotum, unless the patient be a boy, we lay him in a supine posture upon a bench, and apply to his buttocks a cloth several times folded, and to the scrotum a sponge of considerable magnitude, and sitting at the left side of the patient, we give directions to an assistant sitting at his right side to draw the genital organs to the other side, and to draw up the skin of the scrotum to the abdomen. Then taking a scalpel we divide the scrotum longitudinally from its middle to near the pubes, making the incision straight and parallel to the raphe which divides the scrotum into two parts, and extending the incision down to the vaginalis. When the fluid is in the adnata, we make the incision where the apex of the tunica adnata makes its appearance, and separating the lips of the incision with a hook, and having dissected the darti with a knife for hydrocele and a scalpel, and laid bare the tunica vaginalis, we divide it through the middle with a lancet for bleeding, more especially in that part where it is separated from the testicle; and having discharged into some vessel the whole or most of the fluid, we cut away the vaginalis, especially its thinnest parts, with hooks. Afterwards, Antyllus uses sutures and the treatment for recent wounds; but the moderns have recourse to what is called the incarnative mode of treatment. If the testicle is found in a state of putrefaction, or otherwise diseased, the vessels which pass along with the cremaster are to be separately inclosed in a ligature, the cremaster cut, and the testicle removed. And when there are two hernias we may operate in the same manner twice, directing the incisions on both sides at the parts of the scrotum about the loins. After these things, having introduced the head of a probe through the incision below at the extremity of the scrotum, and elevating the scrotum upon it, we make an incision with a sharp-pointed scalpel in a convenient situation for the discharge of the coagulated blood and pus. By means then of the head of the probe we introduce an oblong pledget into the upper incision, and having sponged away the clotted blood, we introduce wool dipped in oil through the incision down to the testicle; and externally we may apply other pieces of wool dipped in wine and oil to the scrotum, hypogastrium, groins, perineum, and loins; and applying a compress three times folded upon them, and binding them with a six-legged bandage, and other proper bandages, we place the man in a reclining posture, putting wool under the scrotum for the sake of ease, and spreading the soft skin under him to receive the embrocations. We bathe with warm oil until the third day, after which having loosed the bandages we must use the ointment tetrapharmacon on a pledget, having changed the oblong one. Afterwards we may again apply the embrocations proper for inflammation until the seventh day, after which we have recourse to the medicine called motophylacion. After the ulcer has been cleaned and moderately incarnated, and the parts have been bathed, we must remove the oblong pledget, and have recourse to the subsequent treatment as formerly described. But if inflammation, hemorrhage, or any such disagreeable consequence come on, we must, in a word, treat each of these in a suitable manner, that I may not have occasion to make repetitions. But if we would rather have recourse to the cautery in cases of hydrocele (as is the practice of the moderns), we must follow all the directions given as to what is to be done before and after the operation, and also those given with regard to the operation itself, omitting only the incision with a scalpel, and the division for allowing the discharge of its contents. Wherefore having heated ten or twelve cauteries, shaped like the Greek letter Γ, and two sword-shaped ones, we must first burn the scrotum through the middle with the gamma-shaped, and having dissected away the membranes with a scalpel or blunt hook, we must burn with the sword-shaped as if cutting. Having laid bare the tunica vaginalis (which is easily recognized by its whiteness and density) with the extremity of a gamma-shaped cautery, we evacuate the fluid. Afterwards, when the whole is laid bare, we stretch it with hooks and remove it with a sword-shaped cautery.

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COMMENTARY. Celsus directs the surgeon, when water is contained in a hernial tumour, to make an incision in the groin, if the patient be a child, unless the largeness of the collection prevent; but in adults, and when the swelling is great, he recommends him to make it in the scrotum. Then if the incision be in the groin, the coats are to be drawn up there and the water discharged; but if in the scrotum, and if the disease be seated there, nothing more is to be done but to evacuate the fluid, and remove any membranes which may happen to contain it; after which the parts are to be washed with a solution of salt or soda. When the fluid is situated under the middle or inner coat (the tunica vaginalis and tunica albuginea?), all these tunics are to be removed without the scrotum and cut out. (vii, 21.) Celsus, as well as our author, describes the hæmatocele or bloody tumour, the existence of which is affirmed by Heister. (ii, 5, 123.)

Galen alludes incidentally to the evacuation of the fluid in hydrocele. (Meth. Med. xiv.) Sprengel and Guy de Cauliac affirm that he makes mention of the seton as a mode of cure; but if this assertion be correct we have not been able to find out the passage in which he does so.

Aëtius gives a very distinct account of the nature of hydrocele, but his description of the operation is by no means so accurate as our author’s. He trusts mostly to astringent and desiccative applications. (xiv, 22.)

Albucasis describes the operation in nearly the same terms as Paulus. His operation consisted of making an incision in the swelling and dissecting out the coats of the testicles. The dressings which he recommends are similar to those mentioned by our author. He also describes the operation by the cautery in nearly the same terms as Paulus. He adds, that if the patient be timid and do not choose to submit to these operations, the surgeon may let out the water either with a scalpel or the instrument used for tapping in dropsy. He states, however, that after this operation the water will collect again. (Chirurg. ii, 62.)

Avicenna briefly describes the operation of opening the tumour, and applying cauteries or strong medicines to the membranes. (iii, xxii, i, 6.)

Haly Abbas directs us to open the tumour, and cut out its tunics, and then to apply incarnative dressings. This treatment, he adds, the moderns prefer to the escharotic applications used by the ancients. (Pract. ix, 47.) He also describes the process of burning. (Pract. ix, 79.)

Rhases describes the operation of puncturing the scrotum for hydrocele. He also speaks of burning the part with a slender rod of iron, and of cutting out its tunics. (Cont. xxiv.)

The membrane called tunica adnata in our translation is the “ima tunica” of Celsus, and the “panniculus proprius” of the Arabian translation of Albucasis, and seems to be the same as the tunica albuginea of modern anatomists.

Sprengel gives an excellent history of the operation of hydrocele. (Hist. de la Méd. 18, 8.)

SECT. LXIII.—ON SARCOCELE AND TOPHI OF THE TESTICLES.

When flesh is formed in any part of the bodies which are connected by the scrotum, it gives rise to the disease called sarcocele. This arises either from some obscure cause, the testicle being attacked with a defluxion and becoming indurated, or from a blow, or from unskilful treatment after the operation for hernia. Its consequences are, a swelling of the same colour, with hardness; when the swelling is of a scirrhous nature, it is devoid of colour and sensibility; and when it is malignant there are sharp pains. When going to operate we place the patient as in the former case, and make the incisions in like manner; and if the complaint is occasioned by the growth of a fleshy tumour to the testicle, we divide the dartos and tunica vaginalis in like manner; then stretching the testicle and bringing it to the outside of the vaginalis, we separate the cremaster from the vessels, tie a ligature round the vessels, and cut the cremaster; then we remove the testicle affected with the fleshy tumour as a foreign body. But if the fleshy tumour be formed about any of the coats of the testicle or its vessels, having divided the scrotum and the membranes lying under the flesh, we must dissect out the whole fleshy tumour. But if the posterior process (“epididymis”?) be affected with sarcocele, having dissected all the surrounding parts, we remove the testicle along with it; for it is impossible for the testicle to continue without it. If tophi be formed about the testicle and the tunica vaginalis, they may be distinguished from sarcocele and hydrocele by their resistance, hardness, and inequality, and are to be operated upon as sarcocele.

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COMMENTARY. Celsus describes and recommends the same operations. He directs us to divide the nerve by which the testicle is suspended (the cremaster?), then to tie the veins and arteries at the groin with a thread, and cut them below the ligature. When a fleshy tumour is formed between the coats he recommends us to cut it out. (vii, 22, 23.) When the parts are indurated he forbids us to meddle with them.

Albucasis directs us to separate the cremaster from the vessels, to tie the vessels, and then remove the testicle from the surrounding parts. When the disease consists of a fleshy tumour which adheres to the testicle he directs us to cut it out. After the operation the wound is to be filled with rose-oil and wine. (Chirurg. ii, 63.) The other Arabians treat of the operation less minutely, with the exception of Haly Abbas, who describes it exactly as Albucasis. (Pract. ix, 48.)

SECT. LXIV.—ON CIRSOCELE AND PNEUMATOCELE.

When the vessels about the scrotum or darti are in a varicose condition, they are called simply varices, but if the nutrient vessels of the testicles be in a varicose state, the affection is named cirsocele. The symptoms of it are obvious. There is a collection attended with swelling, and somewhat curved, of a botryoidal shape, and accompanied with relaxation of the testicle. It also occasions certain inconveniences, especially in running, exercising, and walking. We may operate upon it thus. After putting the patient in a convenient posture, we must lay hold of the scrotum and push the cremaster to the under part; it is easily distinguished from the vessels, being more slender, firmer, and elastic, as being strong and firm; the patient also feels pain upon pressure, and moreover it is connected with the penis. Having secured the vessels in the scrotum by our own fingers and those of our assistant, and stretching them strongly, we press obliquely the point of a scalpel direct upon the vessels; then having transfixed the parts with hooks and dissected what lie under the skin, and having exposed the vessels, as mentioned in the operation of angiology and that for aneurism, and pushing through them a needle having a double thread, and cutting the loop of the thread, we tie the ligatures round the vessels where the varices arise and where they terminate, and make a straight incision in the intermediate space. Having evacuated the blood collected in the tumour, we apply the treatment for suppurations until the ligatures with the vessels themselves fall out of their own accord. Leonides says, that when a few of the vessels which nourish the testicles are in a varicose state this operation should be performed, but that when all are affected, the testicle should be cut out along with them, lest being deprived of its nutrient vessels it should decay. Pneumatocele being a species of aneurism, Leonides forbids us to operate upon it for fear of a hemorrhage, which cannot be restrained from taking place at the time; but, there being two kinds of it, the one occasioned by the four vessels which nourish the testicle, and the other by the arteries of the darti and scrotum being affected, the moderns refrain from meddling with the latter, but operate upon the former. We distinguish them from one another, inasmuch as that which arises from the arteries is easily made to disappear upon pressure with the fingers, whereas that from the nutrient vessels of the testicles, not at all or with much trouble. We operate upon it as for cirsocele, taking up each of the veins and securing it with a thread.

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COMMENTARY. Celsus thus describes the cirsocele: “Venæ intumescunt; eæque intortæ conglomeratæque a superiore parte, vel ipsum scrotum implent, vel mediam tunicam vel imam: interdum etiam sub imâ tunicâ, circa testiculum nervumque ejus, increscunt.” (vii, 18.) He describes the operation at great length afterwards. If the varicose tumour is upon the scrotum he directs us to burn it with slender and sharp irons, which are to be applied to the veins themselves, but in such a manner as to burn them alone. Then suitable dressings are to be applied for producing cicatrization. When the varicose veins are situated above the middle tunic, an incision is to be made in the groin, the tunic drawn out, and the veins separated from it with a finger or the handle of a scalpel. The veins are afterwards to be tied with a thread above and below; then they are to be cut below, and the testicle restored to its place. When the disease is situated above the third tunic (tunica albuginea?) the middle one must be cut out. Then if only two or three veins are in a varicose state they may be tied, as above directed, at the groin and where they join the testicle and cut out. When the disease is situated between the internal coat and the testicle, he says, there is no other remedy but the removal of the testicle. For this purpose he directs us to secure the arteries and veins with a thread, divide them, and then to cut the nerve by which the testicle is suspended (the cremaster?). (vii, 19 and 22.) He does not treat of pneumatocele. It must be obvious that the pneumatocele of our author was an aneurismal varix or erectile tissue. We see no good reason, therefore, for the animadversions which Heister makes upon his account of it. (See Surgery.)

This operation is briefly noticed in the ‘Isagoge’ of Galen, and ‘Meth. Med.’ (xiv.)

Albucasis considers it a dangerous operation, but says he will describe it as it was performed by the ancients. He accordingly gives our author’s account of it, directing us to dissect the congeries of vessels from the surrounding parts, to pass a needle, armed with a double thread, under them, and to tie them above and below; then to make a longitudinal incision in them, and to evacuate the feculent fluids which they contain. The wound is afterwards to be dressed with incarnants. If all the vessels are involved in the disease, he directs us to remove the testicle altogether. (Chirurg. ii, 64.) He says he never saw the operation performed for pneumatocele; but that the ancients operated for it in the same manner as for cirsocele. (66.)

Avicenna and Rhases treat of the pneumatocele, and recommend carminative applications to it; but they do not describe the surgical operation.

Haly Abbas borrows the description of Paulus. (Pract. ix, 49.)

SECT. LXV.—ON ENTEROCELE, OR INTESTINAL HERNIA.

Enterocele is a descent of the intestine into the scrotum, and is occasioned either from rupture of the peritoneum which takes place in the groin, or from stretching of the peritoneum. Both these, I mean rupture and stretching, are occasioned by previous violence, such as a blow, a leap, or loud crying, but that from stretching in particular is connected with relaxation and other weaknesses of the body. The common symptoms of both are a marked swelling in the scrotum, which is increased by exercise, heat, retention of the breath, and other exertions; and its symptoms are, that it goes up slowly upon pressure, and quickly falls down again, and that while the person affected with it lies in a recumbent posture it remains in its proper place until he stands again erect. The retention of fæces in the region of the scrotum often brings on dangerous symptoms; for it is attended with pain, and sometimes with rumbling of wind upon pressure. The peculiar symptoms of hernia from distension are, that it does not occur suddenly, but gradually; that it falls down occasionally from any ordinary causes; that the swelling appears equable and deep-seated, the protruded intestine being surrounded by the peritoneum. In those from rupture the descent at first is sudden, and happens only from violence; the swelling is very large, and appears seated superficially immediately under the skin, owing to the intestines having burst through the peritoneum. If the omentum alone falls down to the scrotum in rupture of the peritoneum the affection is called epiplocele, but if intestine descend along with it, it is named epiploenterocele; and if water be contained in the tunica vaginalis it receives an appellation compounded from all the three. But neither these nor the intestinal hernia from rupture of the peritoneum are proper subjects for surgery, but we operate upon enterocele alone from distension, in the following manner: after placing the patient in a recumbent posture, and getting the skin in the groin stretched by an assistant, we make a transverse incision, cutting as in the operation of angiology (but some make the incision not transverse but longitudinal), then having transfixed it with hooks we stretch out the incision to such a degree as to afford room for the testicle to pass through; then passing through the inner skin a number of hooks proportionate to the size of the wound, and dissecting the membranes and fat with a blind hook or scalpel we cut them across. When the peritoneum is everywhere laid bare, introducing the index-finger at the back part of the scrotum between the darti and peritoneum, we free the posterior process (epididymis?); and then with the right hand doubling its extremity to the inside of the scrotum, and at the same time stretching the peritoneum in the left hand, we bring the testicle with the vaginalis tunica to the incision, and give directions to one assistant to stretch the testicle, whilst we, having completely cleared the posterior process, ascertain by the fingers whether a fold of intestine be comprehended in the tunica vaginalis, and if so we must press it down to the belly; then we take a large-sized needle containing a doubled thread of ten pieces, and we pass it through the middle at the extremity of the peritoneum close to the incision; and cutting the double we make four pieces of them, and laying them over one another in the form of the Greek letter Χ, we bind the peritoneum securely, and again twisting round the pieces we secure it so that none of the nutrient vessels may have a free passage to it lest any inflammation be occasioned, and we apply another ligature farther out, less than two fingers’ breadth distant from the former. After making these ligatures we leave about the size of a finger of the peritoneum, and cut off the whole all round, removing at the same time the testicle, then making an incision at the lower part of the scrotum to favour the discharge, we introduce an oblong pledget, and apply embrocations of oil and bandages as for hydrocele. We must also make the other applications as there laid down. I have known some not unskilful surgeons who after the incision into the tunica vaginalis burnt the extremity of it with heated cauteries for fear of hemorrhage, as would appear. These after the operation straightway bathed their patients in a long wooden trough containing hot water, until the seventh day, repeating this as often as five times during the period of a day and a night, more especially with children; and it succeeded wonderfully, for they remained free from inflammation, and the ligatures fell out speedily along with the parts. In the intervals between the bathings the afore-mentioned embrocations were applied. Another surgeon, in addition to the means already mentioned, rubbed into their back at the time pepper triturated with oil.

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COMMENTARY. Celsus recommends us, if the patient be a child, to make an attempt, in the first place, to effect a cure with bandages. In more advanced ages, if a large portion of intestine has fallen down, and if attended with pain and vomiting, which symptoms generally arise from retention of the fæces, it is clear, he says, that the knife is not applicable, and that the case is to be remedied by other means. He recommends venesection in the arm, the tepid bath, warm cataplasms, and spare diet; but he disapproves of purgatives. This is his treatment of strangulated hernia. When an operation with the scalpel is resolved upon, an incision having been made in the groin down to the middle tunic (tunica vaginalis?), the lips of it are to be separated with the assistance of hooks, while the surgeon frees the tunic from all the small membranes (external fascia?). When this tunic is removed, an incision is to be made from the groin down to the testicle, which is to be carefully cut out. This process, however, is only applicable when the patient is of a tender age, and the mischief is moderate. When the patient is a strong man and the disease greater, the testicle is not to be removed, but is to be allowed to remain in its place. It is accomplished in this manner: the groin being opened with a scalpel, in the same manner, down to the middle tunic, it is to be seized with two hooks, so that an assistant may prevent the testicle from falling out at the wound; then that tunic is to be cut downwards with a scalpel, and under it the index-finger of the left hand is to be pushed down to the bottom of the testicle so as to force it up to the wound: then the thumb and index-finger of the right hand separate the vein, artery, nerve, and their tunic, from the upper tunic. But if any small membranes (fasciæ?) come in the way, they are to be cut out with a scalpel, until the whole tunic be exposed. Having cut out what is proper, and replaced the testicle, a somewhat broader thong of skin is to be removed from the lips of the wound in the groin, in order to enlarge the wound, and thereby occasion a greater formation of new flesh. The object of this operation, it will be remarked, is to produce a firm cicatrix at the external abdominal ring. In cases of epiplocele, he recommends us either to replace the omentum, or to cause the death of it by septic medicines, cauteries, or the ligature; or to cut it out with a pair of scissors, but of this proceeding he does not much approve, as it may occasion dangerous hemorrhage. (vii, 20, 21.)

Galen briefly states that intestinal and omental herniæ are to be cured by pressing up the intestine or omentum, removing as much as possible of the spermatic vessels; or otherwise drawing out the peritoneum, fomenting it, and then cutting it off. (Isagoge.) He mentions that it was customary to bleed the patient before the operation when he was plethoric. (De Opt. sec.)

Aëtius speaks of the operation as being highly dangerous. He forbids attempts at reduction while the prolapsed parts are affected with inflammation, tormina, and flatus. (xiv, 23.)

Albucasis’s account of the treatment is quite similar to our author’s. He states that the disease is occasioned by the descent of a portion of intestine to the testicle, owing to rupture or distension of the peritoneum. Sometimes, he says, fæces get into the prolapsed bowels, and being retained give rise to violent and sometimes fatal symptoms. When going to operate he directs us, in the first place, to make the patient reduce the intestine if reducible. Then an incision is to be made along the whole skin of the testicle, and hooks are to be fixed in the lips of the wound so as to enlarge it, and allow a passage for the testicle. The membranes, then, below the skin, are to be dissected, so as to expose completely the tunica vaginalis (sifac album.) The index-finger is then to be introduced between the tunica vaginalis and the second coat (tunica albuginea?) so as to free the adhesions at the back part of the testicle. The operator is afterwards to separate the testicle from all its adhesions and raise it up to the external wound. He must now examine whether any portion of intestine remain protruded, and if so, it must be replaced. The operator is then to take a large needle armed with a cord of ten threads, and having introduced it behind the tunic under the skin of the testicle (tunica vaginalis?) its extremities are to be cut, and the threads arranged into four pieces. With them the peritoneum is to be tightly bound in a crucial form, so as that the nutrient vessels may not be able to reach it, which will obviate inflammation. Another ligature is to be applied afterwards at the distance of less than two fingers’ breadth from the former. After applying these two ligatures, about a finger’s breadth of the peritoneum is to be left, and the rest is then to be cut all around, and the testicle removed along with it. An incision is then to be made at the lower part so as to allow an outlet for the blood and matter. Wool dipped in oil is to be applied afterwards, and bound as formerly described. Sometimes, he adds, the cautery is applied to the tunica vaginalis after the incision for fear of hemorrhage. (Chirurg. ii, 65.) He describes minutely the treatment by burning in another place. (i, 47.)

Avicenna recommends the cautery, but does not describe the other operation. Haly’s description is evidently taken from our author. (Pract. ix, 50.)

Rhases states correctly that hernia generally arises from dilatation of the passage which leads from the cavity of the abdomen to the testicle. In ordinary cases, he says, there is no rupture of the peritoneum. He states that the contents of the hernial tumour are either intestines or omentum. The omentum, he adds, is the intestine most commonly found in ruptures. He says the peritoneum (sifac) lines the whole intestines and surrounds the testicles. Antyllus, from whom he gives a subsequent extract, states in like manner that the peritoneum descends to the testicles and forms the tunica elytroides, i. e. vaginalis. Antyllus also affirms that hernia arises from relaxation of the passage between the cavity of the abdomen and the testicles. This opinion regarding ruptures is maintained by several of the authorities quoted by Rhases. (Contin. xxiv.)

Sprengel says of Rhases: “Sa théorie des hernies proprement dites est infiniment préférable à celle des Grecs.” (Hist. de la Méd.) The account which Rhases gives of ruptures is, no doubt, very correct; but there is every reason to suppose that it was entirely taken from the works of the Greek surgeons.

The operations practised by the ancients for the radical cure of hernia cannot but appear to us extremely cruel and hazardous; and yet the danger attending them must have been less than is generally supposed, otherwise they could not have been so frequently performed as they were about two centuries ago. Fabricius ab Aquapendente mentions that a celebrated rupture doctor of his time informed him that he used to operate upon 200 patients at an average every year. Fabricius, however, prudently recommends us not to perform the operation except in extreme cases, and to be content in general with supporting the parts by means of a truss.

The ancients never operated to relieve strangulated hernia.

SECT. LXVI.—ON BUBONOCELE, OR INGUINAL HERNIA.

Enterocele arising from distension commences as bubonocele; for at first the peritoneum being stretched the relaxed intestine is protruded as far as the groin, and forms this disease, which the ancients operated upon in this manner. After making the incision to the extent of three fingers’ breadth transversely across the tumour in the groin, and removing the membranes and fat, and the peritoneum being exposed in the middle where it is raised up to a point, let the knob of a probe be applied, by which the intestines will be pressed deep down. The prominences, then, of the peritoneum formed on each side of the knob of the probe are to be united to one another by sutures, and then we extract the probe, neither cutting the peritoneum nor removing the testicle, nor anything else, but curing it with the applications for fresh wounds. But since burning in cases of bubonocele is preferred by most of the moderns it will be right for us to give an account of this operation. After the man has undergone moderate exercise, let him cough violently and strain to keep in his breath; and when the swelling appears at the groin we mark with black ink or collyrium the place that is to be burned in a triangular figure, making its transverse line above in the situation of the groin, and we also make a mark in the middle of the triangle. Having laid the patient in a recumbent posture we first apply to the mark in the middle nail-shaped cauteries heated in the fire, afterwards burn the sides of the triangle with gamma-shaped (Γ) cauteries, and afterward level the triangle with cauteries shaped like tiles or lentils, an assistant during the whole process of burning wiping away the ichorous discharges with a rag; and in those who are of a moderate habit of body the burning should be carried to such a depth as to touch the fat. But in those who are lean we must not attend to this mark lest by mistake we should burn the peritoneum; nor again in those who are grosser and fatter, for in them the fat appears before a sufficient burning has taken place. We must, therefore, be rather guided as to its extent by a skilful conjecture. After the burning, having triturated salts with leeks we apply them to the eschar, and use the inguinal bandage shaped like the Greek letter Χ. On the following days we complete the cure with the dressings fitting for eschars, such as lentils with honey, and the like.

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COMMENTARY. Celsus directs us, when the inguinal tumour is moderate in size, to make one incision; but if larger, he recommends two lines to be made, so that the middle may be cut out; then, without extracting the testicle, as advised in certain cases of prolapsed intestines, the veins are to be bound together and tied where they adhere to the tunics, and afterwards cut below the knots. (vii, 24.)

Avicenna speaks of astringent applications and the actual cautery, but disapproves of the incision and suture. (iii, 22, 1.)

The operations of the suture and burning are described by Albucasis (Chirurg. ii, 67, and i, 47); by Rhases (Cont. xxiv); and by Haly Abbas (Pract. ix, 52, and ix, 80.) They all evidently copy from our author.

Garengoit affirms that Paulus has made mention of crural hernia, but we agree with Heister that this is a mistake.

SECT. LXVII.—ON RHACOSIS, OR RELAXATION OF THE SCROTUM.

When the skin about the scrotum is relaxed without the bodies within being affected, rhacosis is formed, being a most unseemly complaint. Wherefore Leonides, having placed the man in a recumbent posture, cut off the redundant skin with a scalpel direct upon some board or some hard skin, and united the lips of the wound with sutures. But Antyllus, having first transfixed the redundant skin with three or four ligatures, cut off what was external to them with a sharp-pointed pair of scissors or scalpel, and having secured the parts with sutures, effected the cure by the treatment for recent wounds.

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COMMENTARY. Our author’s description of the two modes of performing the operation is copied by Albucasis. (Chirurg. ii, 68); and by Haly Abbas (Pract. ix, 53.)

SECT. LXVIII.—ON CASTRATION.

The object of our art being to restore those parts which are in a preternatural state to their natural, the operation of castration professes just the reverse. But since we are sometimes compelled against our will by persons of high rank to perform the operation, we shall briefly describe the mode of doing it. There are two ways of performing it, the one by compression, and the other by excision. That by compression is thus performed: children, still of a tender age, are placed in a vessel of hot water, and then when the parts are softened in the bath, the testicles are to be squeezed with the fingers until they disappear, and, being dissolved, can no longer be felt. The method by excision is as follows: let the person to be castrated be placed upon a bench, and the scrotum with the testicles grasped by the fingers of the left hand, and stretched; two straight incisions are then to be made with a scalpel, one in each testicle; and when the testicles start up they are to be dissected around and cut out, having merely left the very thin bond of connexion between the vessels in their natural state. This method is preferred to that by compression; for those who have had them squeezed sometimes have venereal desires, a certain part, as it would appear, of the testicles having escaped the compression.

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COMMENTARY. We have given Celsus’s description of the operation in the 64th section of this Book. Albucasis describes the operations by compression and by excision. In the former the testicle is squeezed by the operator while the patient is seated in hot water. In the other the spermatic cord is to be first secured with a ligature and then the testicle cut out. (Chirurg. ii, 69.)

They are likewise described in nearly the same terms by Haly Abbas. (Pract. ix, 54.) The castration of the inferior animals is mentioned by Aristotle (Hist. Animal. ix, 50); by Varro (De Re Rustica, iii, 9); by Columella (De R. R. vi, 26); and by Palladius (De R. R. vi, 7.) Varro informs us that it was customary to make capons by burning the testicles of cocks with a red-hot iron. It appears from Juvenal that the surgeons in his time were often called upon to perform castration. (Sat. vi, l. 370.) Abulpharagius likewise mentions that the performance of this operation constituted at one time an important part of the surgical practice in Bagdad. (Dynast. ix.) But the Emperor Justinian condemned the operation as being dangerous and often fatal.

Sprengel gives an interesting history of castration. One of the most important points in this operation is the mode of tying the cord. Some modern authorities affirm that no bad effects result from putting a ligature round the whole cord, but others condemn this practice as bringing on convulsions and tetanus. All admit the difficulty of securing the artery separately.

SECT. LXIX.—ON HERMAPHRODITES.

This affection derives its name from a combination of the names Hermes and Aphrodite (Mercury and Venus,) and occasions great deformity to both sexes. There being four varieties of it, according to Leonides; three of them occur in men and one in women. In men, sometimes about the perineum and sometimes about the middle of the scrotum, there is the appearance of a female pudendum with hair; and in addition to these there is a third variety, in which the discharge of urine takes place at the scrotum as from a female pudendum. In women there is often found above the pudendum and in the situation of the pubes the appearance of a man’s privy parts, there being three bodies projecting there, one like a penis, and two like testicles. The third of the male varieties in which the urine is voided through the scrotum is incurable; but the other three may be cured by removing the supernumerary bodies and treating the part like sores.

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COMMENTARY. This section of our author is copied by Albucasis (Chirurg. ii, 70); and by Haly Abbas (Pract. ix, 55.) Avicenna briefly mentions this monstrosity. (iii, 20, 2, 43.)

Guy of Cauliac and Brunus describe it in the same terms as the Arabians.

SECT. LXX.—ON EXTIRPATION OF THE NYMPHA AND CAUDA PUDENDI.

In certain women the nympha (clitoris?) is excessively large and presents a shameful deformity, insomuch that, as has been related, some women have had erections of this part like men, and also venereal desires of a like kind. Wherefore, having placed the woman in a supine posture, and seizing the redundant portion of the nympha in a forceps we cut it out with a scalpel, taking care not to cut too deep lest we occasion the complaint called rhœas. The cauda is a fleshy excrescence arising from the mouth of the womb, and filling the female pudendum, sometimes even projecting externally like a tail; and it may be removed in the same manner as the nympha.

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COMMENTARY. That the nympha and clitoris were used anciently as synonymous terms is evident from Ruffus Ephesius (De Partibus Hominis); Soranus (c. 6); and Pollux (Onomasticon, ii.) Martial, in more than one place, makes allusion to unnatural practices connected with an enlarged clitoris. Aëtius says that it is a small muscular substance situated at the commissure of the alæ pudendi above the meatus urinarius. He adds, that when preternaturally enlarged it is to be amputated. Like our author, he directs us to take hold of the tumour with a forceps and cut off the protuberance, taking care not to carry the excision too far. He recommends us to apply a sponge squeezed out of an astringent wine or cold water, with suitable dressings. He gives the same account of the cauda as our author. (xvi, 103 and 104.) It was a tumour arising from the uterus itself. Albucasis merely transcribes our author’s account of these operations. (Chirurg. ii, 71.) Avicenna briefly recommends us to remove the enlarged nympha by medicines or the knife. (iii, 22; i, 24.) It would appear that this operation, like circumcision, is still often practised in the East.

The chapters of Soranus, in which these operations were treated of, are unfortunately wanting.

On extirpation of the enlarged clitoris see Heister’s Surgery (ii, 5, 147). The cauda pudendi was probably the cauliflower excrescence of the os uteri described by late authorities on midwifery.

SECT. LXXI.—ON THYMI, CONDYLOMATA, AND HEMORRHOIDS ABOUT THE FEMALE PARTS OF GENERATION.

The thymus is an excrescence sometimes red, but sometimes white, for the most part without pain, and resembling the clusters of thyme. The condylomata are rugose protuberances; and the hemorrhoids resemble those about the anus, and, like them, sometimes pour forth blood. Such excrescences in women, when brought into view and exposed, are to be seized with a forceps and cut out with the point of a half-spatula. And we are then to use pounded galls, or fissile alum. For the more distinguished surgeons do not approve of ligatures in these cases.

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COMMENTARY. Aëtius gives a fuller account of these tubercles. He recommends us to seize them with a forceps and cut them out by the roots. He directs us not to interfere with such hemorrhoids of the womb as are varicose and malignant. Those which are hard and do not bleed are to be cut out at once, but such as are disposed to bleed are to be seized with a forceps and a ligature put round them before they are cut. Moschion, however, condemns this practice as being highly dangerous.

Albucasis evidently copies from our author. (Chirurg. ii, 73.)

Haly Abbas briefly directs us to seize these tubercles with a forceps and cut them out with a pair of scissors. (Pract. ix, 65.)

Rhases, treating of diseases of the uterus, says, “if there be a red piece of flesh in the mouth of the womb, if situated at its anterior part, and if it be round, or long, and not attended with pain, some surgeons cut it off, but I prefer tying it.” (Cont. xxii.) This description seems to apply to polypus of the womb.

See a full account of the condylomata and hemorrhoids of the womb, by Lodovicus Mercatus (in the Gynæcia, p. 962.) He remarks that Celsus and Aëtius call any tubercle arising from inflammation by the name of condyloma, whereas Paulus applies the term only to callous tubercles of the uterus. He approves of seizing them with a forceps and cutting them out.

SECT. LXXII.—ON IMPERFORATE PUDENDUM AND PHIMUS.

Some women have the genital parts imperforate, sometimes naturally, and sometimes owing to some previous disease. And sometimes it is deep-seated, sometimes in the alæ pudendi, or in the intermediate places, and is sometimes occasioned by an adhesion of the parts, and sometimes by obstruction. The obstructing substance is either flesh or membrane. The disease occasions great impediment sometimes in coition, sometimes in conception, or in parturition, and occasionally during the menstrual purgation, provided the membrane or flesh occasion a complete obstruction; for in certain cases there is a perforation in the middle. Having ascertained the cause, either from its being obvious to the sight, or by introducing the speculum, if it be a simple adhesion only, it may be separated by a straight incision, made with a scalpel, for operating upon fistulæ. But if it is an obstruction, having transfixed the connecting body, whether it be membrane or flesh, with hooks, we stretch it and divide with a scalpel for fistulæ; and having stopped the hemorrhage with such applications as are desiccative without being stimulant, we have then recourse to such medicines as promote cicatrization, applying a priapus-shaped tent covered with some epulotic medicine, in those cases especially in which the operation is performed upon a part not very deep-seated, in order that the parts may not unite again. And the phimus which is formed at the mouth of the uterus is operated upon in the same manner.

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COMMENTARY. Aristotle makes mention of imperforate vagina. (De Generat. Animal. iv, 4.) Aëtius treats of these diseases at considerably greater length than our author, but his practice is nearly the same. Upon the whole the amount of his directions respecting the treatment is, that when the obstruction is occasioned by a membrane, it is to be divided and the lips of the incision prevented from adhering by the introduction of suitable tents; or, if it is a fleshy body, it is to be dissected out, and the parts separated by a piece of sponge or tents. (xvi, 96.) The same operation is described by Soranus. (219.)

The same method of treatment, however, had been previously recommended by Celsus. Thus, when the obstruction is occasioned by a simple membrane, he recommends us to divide it by two transverse incisions like the letter Χ, taking great care not to wound the urinary passage, and then the membrane is to be cut out. When the obstruction is produced by a fleshy tumour, he directs us to expose it by making a straight incision; then, having seized it with a forceps or hook, to dissect it out, and introduce an oblong tent (λημνίσκος) soaked in vinegar, and apply externally wool moistened with vinegar. The dressings are to be removed on the third day, and the sore treated upon general principles. When the wound is healing, he advises us to introduce a leaden tube smeared with some suitable ointment to prevent adhesion. (vii, 28.)

Albucasis makes mention of a singular substitute for the leaden tube recommended by Celsus: “Coeat mulier omni die ut non consolidetur locus vice alia!!” The same advice is gravely given by Rhases (Cont. xxii), and by Alsaharavius, who, as we have formerly stated, was probably the same person as Albucasis. (Pract. xxv, 2, 19.) But when the obstruction arises from a fleshy tumour, Albucasis recommends us to make use of the leaden tube. (Chirurg. ii, 72.) Alsaharavius directs us to remove the obstruction by corrosive medicines or with the knife.

Rhases briefly describes the phimus, and directs us to perforate it with an instrument of iron, and then to introduce a tent moistened in some styptic wine.

Haly Abbas states that obstruction of the uterus may arise either from a natural, that is to say, a congenital impediment, or from the effects of ulceration. He recommends us to make the midwife clear away the obstruction with a scalpel or any other convenient instrument. The Arabians were very delicate in allowing male practitioners to perform surgical operations about the genital organs of women. (Pract. ix, 66.)

SECT. LXXIII.—ON ABSCESS OF THE WOMB.

When the abscess is situated at the mouth of the womb, so as that it can be operated upon, we must not be in haste in having recourse to incision, nor until the disease be ripened, and the inflammation has increased to its utmost, and the vascular bodies which surround it have become attenuated, owing to the importance of the uterus in the system. In operating, the woman should be placed on a seat in a supine posture, having her legs drawn up to the belly, and her thighs separated from one another. Let her arms likewise be brought down to her legs and secured by proper ligatures about the neck. The operator, sitting on her right side, is to make an examination with a speculum proportionate to her age. The person using the speculum should measure with a probe the depth of the woman’s vagina, lest the stalk (fistula) of the speculum being too long it should happen that the uterus should be pressed upon. If it be ascertained that the stalk is larger than the vagina, folded compresses are to be laid upon the alæ pudendi, in order that the speculum may be placed upon them. The stalk (fistula) is to be introduced, having a screw at the upper part, and the speculum is to be held by the operator, but the screw is to be turned by the assistant, so that the laminæ of the stalk being separated the vagina may be distended. When the abscess is exposed, if it be soft and thin (which may be ascertained by touching it with the finger), it is to be divided at the top by a scalpel or needle, and after the discharge of the pus, a soft oblong tent well smeared with rose-oil is to be introduced into the incision, or rather external to the opening into the woman’s vagina, so as not to produce compression. And externally to the alæ pudendi and the region of the pubes and loins unwashed wool, or clean wool dipped in oil, is to be applied. On the third day she is to be placed in a hip-bath of warm oil or water, or of a decoction of mallows; and having wiped the parts, we introduce the tent gently into the opening, spread with the ointment tetrapharmacon, either alone or with clarified honey; its strength, however, ought to be reduced with butter or oil of roses. The external parts are to be covered with cataplasms until the inflammation subside and the sore become clean. If it is got cleansed with difficulty, an injection of the decoction of iris, of birthwort, or of honey, may be thrown up with an ear-syringe. The healing process may be promoted by the calamine ointment diluted with wine and applied upon a pledget. But if the abscess be within the mouth of the uterus, we must decline operating.

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COMMENTARY. A similar description of the method of opening abscesses in the vagina is given by Aëtius. (xvi, 85.) The only difficulty in comprehending his description or our author’s arises from our unacquaintance with the construction of the ancient dioptræ or specula. Drawings of several sorts of them are given in the surgery of Albucasis and by Scultet. (Arsenal de Chirurg. tab. 18.) One of the simplest of them consists of two laminæ or plates so united that by turning a vice or screw they separated to the proper distance. Albucasis evidently copies our author’s description. (Chirurg. ii, 71.) The account given by Haly Abbas is quite similar. (Pract. ix, 57.)

SECT. LXXIV.—ON EMBRYULCIA AND EMBRYOTOMY.

We have described the treatment of difficult labours in the Third Book. If the process of parturition be not rectified by the means there laid down, we must proceed to the surgical operation, after having formed a probable conjecture whether the woman will survive or not; and if she may be saved, then we are to operate; but if not, we must decline attempting the operation. Those in a dying state are affected with coma, lethargy, and loss of muscular motion; they are difficult to rouse, or if roused by loud cries, they return a feeble answer, and again sink into a comatose state. Some have convulsive contractions, or subsultus tendinum, or insensibility to food. The pulse is found to be greatly inflated, but obscure and feeble. Those who are to recover have none of these symptoms. Having placed the woman in a supine posture, with her head rather depressed, her thighs are to be kept elevated by women on each side, or by certain assistants; or if they are not at hand, her chest is to be first fastened to the bed by ligatures, so that when the fœtus is pulled the woman’s body may not follow, and diminish the force of the pulling. Then the alæ pudendi being separated by an assistant, we must introduce the left hand lubricated with some unctuous substance, the fingers being contracted, to the mouth of the uterus, and dilate it, and having got it relaxed by lubricating it with oil, we seek for the most convenient place for fastening the hook (embryulcus). The most convenient places in presentations of the head are—the eyes, the occiput, the roof of the mouth, the chin, the clavicles, and the parts about the sides and hypochondrium; and in feet presentations, the bones of the pubes, the middle of the ribs, or, again, the clavicles. The hook is to be held in the right hand, and its curvature grasped with the fingers, and it is to be gently introduced with the left hand, and fixed on some of the afore-mentioned places, being pushed to the cavity of the uterus. And another is to be applied opposite to it in order that the pulling may be straight down and not to one side. Then we are to pull gently, not only straight-forward but also from side to side, as in the extraction of teeth; and there ought to be no relaxation of the pulling in the intervals. Then introducing the index-finger or more fingers besmeared with fat between the mouth of the womb and the impacted body, we must lubricate it all around. When the hook comes down properly it must be changed to a part above, and so on until the fœtus is completely extracted. When a hand presents, and is so impacted that it cannot be returned, we must wrap a cloth round it so that it may not slip, and pull it so far, and when it is properly fallen down it should be cut off at the shoulder. The same thing is to be done when two hands fall down into the vagina; and in like manner, when the feet come down, and the rest of the body does not come along, we must amputate at the groins, and then endeavour to turn the rest of the body. If the impaction take place owing to the head being larger than natural, if it be a hydrocephalous fœtus, we must open its skull with a polypus-scalpel, or a needle, or a sharp-pointed knife concealed between the fingers, in order that it may collapse when evacuated; but if it be a naturally large head, we must open the skull in like manner, and break down its bones with a tooth-forceps or a bone-forceps, and if the bones project they ought to be extracted. If, after the head has been delivered, an impediment should take place at the chest, the parts about the clavicles should be divided down to the cavity of the thorax with the same instrument, so that the thorax may collapse when its fluid contents are discharged; but if it do not collapse we may divide the clavicles and extract them, when the thorax will collapse. If the belly be inflated, owing to the death of the child, or its being dropsical, we must evacuate its contents with the intestines in the same way. In presentations by the feet the wrong direction may be easily rectified at the mouth of the womb. But if the fœtus stick at the chest or belly, we must wrap a cloth about it and draw it down, and making a division in the same manner, evacuate its contents. If, after the other parts are cut off, the head retreat backwards and is retained, we must introduce the left hand, and if the mouth of the womb be open, push up the hand to the cavity of the womb, and having found the head, bring it down with the fingers fixed in the mouth, and extract by one or two hooks fixed in it; but when there is inflammation at the mouth of the womb we must use no violence, but lubricate the parts with unctuous and fatty applications, and have recourse to hip-baths, embrocations, and cataplasms, in order that when the mouth is dilated extraction may be accomplished in the manner described above. Cross presentations, if they can be rectified, may be treated according to the afore-mentioned methods; but if not, the whole fœtus must be cut asunder within, and extracted in pieces, taking care that none of the parts of it be left behind. After the operation we must have recourse to the treatment for inflammations of the uterus. If hemorrhage come on, you have already had the management of it described.

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COMMENTARY. There is a curious treatise commonly published along with the works of Hippocrates on the extraction of the fœtus; but, as it is not mentioned by Erotian and Galen, it is now generally admitted not to be genuine. The author of it directs us, when the arm presents, to pull it down and amputate at the shoulder-joint; after which the head is to be brought to the proper position and delivery accomplished accordingly. This is not now the general rule of practice, and yet we were once compelled by necessity to deliver in this way, after we and an intelligent assistant had been foiled in all our attempts to turn the child. We have known of similar cases happening in the practice of other surgeons; and, in fact, this method of procedure was advocated lately by a sensible writer in the ‘Edinburgh Medical and Surgical Journal.’ The author of the ancient treatise in question recommends us to bring down the head in its natural state, if possible, but if this be found impracticable, to break it down. He directs us to give for drink a white, sweet, undiluted wine.

Celsus gives an interesting account of this subject, and his practice is deserving of much consideration. He recommends us, when the position is unnatural, to turn the child either to the head or the feet; adding, afterwards, that delivery may generally be accomplished easily enough by the feet. In arm presentations, he approves of turning to the head, that is to say, in cases when it is ascertained that the fœtus is dead. If the head is at hand, a smooth hook with a small point is to be fastened at the eye, the ear, the mouth, or the forehead, and its body is to be thus dragged down. This, however, must not be attempted when the mouth of the womb is not properly dilated. The right hand is to be employed in dragging down the fœtus, and the left in directing the instrument and the fœtus. When the body of the fœtus is distended with a fluid, it is to be let out, and the body brought down with a hook. If the child lie across and the position cannot be got rectified, the hook is to be inserted at the armpit, and extraction gradually performed. In extreme cases he recommends us to cut the neck asunder, and extract the parts separately, beginning with the head, for fear of its being left in the uterus. Should such an accident occur, however, he directs us to get the belly compressed so as to force the head down to the os uteri; after which it may be extracted with a hook in the manner described above. (Smellie relates histories of such cases.) When one foot presents, and the breech sticks at the os uteri, he recommends us, when the other foot cannot be found, to separate the one which protrudes; after which the body of the child may be pushed up, and the other leg found and brought down. It is to be recollected that this practice is only recommended when the child is dead. He adds, that other difficulties may give rise to the necessity of performing embryotomy. (vii, 29.)

Aëtius has an interesting chapter on the Extraction of the Dead Fœtus, copied from the works of Philumenus. His description of embryotomy is similar to our author’s. He directs us to apply two hooks to certain parts of the head, such as the eye, mouth, and chin, and thus to drag down the body. If the head is large or hydrocephalic, he advises us to open it and evacuate its contents; and if even then it is found to be too large for the passage, he recommends us to break down the bones of the skull and remove them with a forceps, after which the instrument is to be fixed and the fœtus dragged down. If obstruction to the delivery take place at the chest or the belly, he directs us to evacuate their contents in like manner. When an arm or both present, he recommends us to amputate at the shoulder-joint. If the child come down doubled, and the position cannot be got rectified, he advises us, if the head can be reached, to break down its bones, and then extract the other parts accordingly; but if the legs are got at most easily and cannot be brought down, they are to be amputated at the hip-joint, and then the head will be got delivered. When the body is so impacted in a doubled state that it cannot be moved, he directs us to separate the vertebra at the neck, and then to drag down the lower part of the body; after which the head is to be sought for by the hand introduced into the uterus, and brought along with two hooks. (xvi, 23.)

No ancient author has described the operation of embryotomy so accurately as Soranus; but as his account of the process is lengthy and does not differ essentially from that of Aëtius, (indeed the latter evidently copies from Soranus,) we need not seek to give any outline of it. (Op. 51, 52, 53.)

Avicenna takes his chapter on the extraction of the dead fœtus from our author. (iii, 21, 2, 24.) We have mentioned in the Third Book that he was acquainted with the forceps.

Albucasis, in like manner, takes his account of embryotomy from Paulus. He relates a singular case that came under his own knowledge of an extra-uterine conception; the most remarkable circumstance about which was, that the bones of the fœtus after a time were discharged at the umbilicus. The work of Albucasis contains drawings of the instruments used in his time for obstetrical operations. There are several forcipes among them, but as they all have teeth, it is to be presumed that they were used only for delivering the fœtus when dead. It is to be regretted that he has entirely omitted the forceps mentioned by Avicenna. (See Chirurg. ii, 76 and 77.)

Rhases directs us when the child’s head is large and cannot be brought down with fillets, to open it and deliver with hooks. When it is ascertained that the child is dead, he recommends us to break down the bones of the head and evacuate the brain. In preternatural presentations he recommends us to deliver, if possible, by the head or feet, but if this cannot be got accomplished, he directs us to cut off the protruding part. Upon the whole his rules of practice are much the same as our author’s. (Cont. xxii.)

Haly Abbas gives ample directions for the management of these cases. When the head presents (the child being dead and delivery found otherwise impracticable), he directs us to fix hooks in the hollows of the eyes, neck, or jaw-bone; or if the feet present, at the tops of the thighs. The body of the child is then to be dragged along. When a hand presents, he recommends us to pull down the arm and amputate at the shoulder; and in like manner he directs us to amputate at the hip-joint when in footling presentations the delivery cannot be otherwise accomplished. When the head is preternaturally large, he directs us to open it and evacuate its contents; and to do so in like manner with the chest when any obstruction takes place at it. He makes no mention of any instrument resembling the modern forceps. (Pract. ix, 57.)

SECT. LXXV.—ON RETENTION OF THE SECUNDINES.

Often, after the removal of the fœtus, the placenta (which is also called the secundines) is retained in the uterus. When the mouth of the uterus is dilated and the placenta separated, and rolled into a ball in some part of the uterus, the extraction is most easy. The left hand warmed and anointed is to be introduced into its cavity, and the secundines extracted as they present. But if they adhere to the fundus uteri we must introduce the hand in like manner, and grasp them and pull them along, not straight down for fear of prolapsus, nor with great violence, but they are to be moved gently, at first from this side to that, and afterwards somewhat more strongly, for thus they will yield and be freed from their adhesion. If the mouth of the uterus be found shut we must have recourse to the same treatment. If the strength is not sunk, sternutatories and fumigations with aromatics in a pot may be used; and if the mouth of the womb dilate, the hand is to be introduced and an attempt made to extract the placenta, as aforesaid. If even in this way it cannot be extracted, one need not be alarmed, for after a few days it will putrefy, dissolve into sanies and drop off. But since the fetid smell affects the head and disorders the stomach, we must use suitable fumigations, among which cardamom and dried figs are much approved.

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COMMENTARY. We have mentioned in another place that Hippocrates’ practice in retention of the placenta consisted in suspending weights from the end of the umbilical cord.

Celsus directs us, when the placenta is not cast off soon after the delivery of the child, to draw down the umbilical cord gently with the left hand, taking care not to break it. The right hand is then to follow it up to the secundines, and their veins and membranes being separated from the womb, the whole are to be extracted along with whatever coagulated blood may be in the uterus. (vii, 29.)

Our author merely abridges a fuller account of the subject given by Aëtius from the works of Philumenus. (xvi, 24.)

Moschion reprobates the ancient practice of using sternutatories, pessaries, and fumigations, and of suspending scales or weights from the cord, because these means sometimes occasion hemorrhage. He recommends the midwife, if the mouth of the womb be still open, to introduce her left hand, and to take hold of whatever part of the placenta presents: then, if it does not adhere to the fundus uteri it is to be extracted; but if it is not separated it is to be moved gently hither and thither without violence. When the mouth of the uterus is contracted, he advises her to use those liquors and injections which are applicable for inflammations of the womb. (Section liv.) His method of securing the umbilical cord after delivery is nearly the same as that now adopted. After the child has been allowed to lie on the ground for a few minutes, two ligatures are to be applied round the cord, the nearest being four fingers from the belly; it is then to be cut with a scalpel or any sharp knife. He disapproves of using instruments of wood, glass, or reeds, and hard crusts of bread, as practised by the ancients. (lxv.) He directs lacerations of the perineum to be treated by applying ointments composed of wax, oil of roses, litharge, ceruse, and alum, with suitable bandages. (lvii.)

The practice of Soranus in these cases is most judicious, and such as can scarcely be improved upon at the present day. He disapproves of all violent attempts at extraction, but when the placenta cannot be got otherwise removed from the womb, he approves of introducing the hand well lubricated to extract the secundines gently. He directs us when the mouth of the womb is shut to open it if possible with the fingers in a gentle manner. This is the case now incorrectly called the hour-glass contraction.

Avicenna repeats the directions given by Paulus and Aëtius, but seems to have considered the introduction of the hand into the uterus as a painful, and, in general, an unnecessary operation. (iii, 21, 2, 16.)

Albucasis follows our author’s practice. (Chirurg. ii, 78.)

Haly Abbas directs us to introduce the hand well lubricated with oil of violets, or the like, into the uterus, and extract the placenta if it be separated; but if it still adhere it is to be moved from side to side, and not pulled straight downwards. He adds, that when not extracted, it becomes putrid. (Pract. ix, 59.)

Rhases directs us when the secundines do not come away after delivery to make the woman sneeze, and if they are still retained, to pare the nails, and having introduced the hand into the uterus to pull cautiously so as not to give pain. When they cannot be removed in this way, he recommends us to throw injections into the womb so as to promote putrefaction of the placenta. In another place he mentions, that when long retained, the placenta putrefies and comes off in pieces. (Cont. xxii.)

SECT. LXXVI.—ON BURNING THE HIPS.

As in the case of the shoulder, so also the hip-joint getting dislocated from a collection of humours requires burning. Wherefore Hippocrates says: “When dislocation at the hip-joint takes place from long-continued ischiatic disease, the leg wastes, and the patients are lame unless burnt.” Burning, therefore, is to be performed more particularly at the place where the joint is dislocated, for thus the redundant humour will be dried up, and the part being condensed by the cicatrix will no longer be able to receive the bone, wherefore the burning should be carried to a considerable depth. The moderns form three eschars by burning; one behind in the hollow of the buttocks, another a little above the knee on the outside, and a third on the outside of the ankle in the fleshy part.

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COMMENTARY. Hippocrates recommends us to burn the parts over the hip-joint with crude flax. (De Affectionibus.) The author of another of the Hippocratic treatises directs us to burn the bony parts with fungi and the flesh with a red-hot iron. (De Affect. Int.)

Aëtius, upon the authority of Archigenes, recommends burning in this case with irons, the roots of fuller’s herb and birthwort, or with goat’s dung. (xii, 3.)

Cælius Aurelianus, in cases of ischiatic disease, speaks of forming issues over the hip-joint by the actual and potential cauteries. His potential cauteries, with which he mentions that eschars were burnt, appear to have been the ashes of herbs, that is to say, impure preparations of the caustic alkali, to which quicklime was sometimes added. They must, therefore, have been nearly the same as the calx cum kali of modern use. He states, that some burned the part with the root of fuller’s herb; others with pieces of iron shaped like the letter Γ; that some raised the skin in a fold and transfixed it with heated irons; that some burned it with fungi, and others with a piece of linen cloth folded and laid on the part. (Pass. Tard. v, 1.)

But the fullest account which we have of the ancient modes of burning the hips for diseases of the joint is that which is given in the book ‘Euporistôn,’ ascribed to Dioscorides. Mention is there made of the methods of burning with goat’s dung, and with wool smeared with oil. Some, it is said, form a ball of clay, and, having laid it on the place, apply to it a burning staff as long as it can be borne. Others, having stretched the skin over the affected joint, transfix it with a heated style or writing pen. The Libyans performed the operation with shavings of the lote tree, sulphur, and elaterium. The Marmaridæ are said to have done it with green pieces of the wood of olive trees. The Parthians used a leaden tube, the extremity of which they smeared with dough, in order to prevent the oil in the inside from escaping; then hot cauteries, to the number of forty or fifty, were introduced, and the burning continued as long as it could be well endured. Care in the meantime was taken to cool the face with cold water; and it was attended to, that the tube was not over-filled with oil, lest it should run over. (Euporist. i, 242.)

Albucasis describes minutely the process of burning with red-hot irons. (Chirurg. i, 43.) Haly Abbas in like manner directs us to burn an eschar over the joint, and to keep it open for a considerable time. (Pract. ix, 81.)

Asclepiades (apud Nicetæ Collect.) mentions that he had seen two cases in which dislocation had taken place at the hip-joint without any accident. The editor of this work, Anthony Cocchi, states that he had met with only one such case in the whole course of his practice. We need scarcely remark that such cases, however, are by no means of rare occurrence.

SECT. LXXVII.—ON FISTULÆ AND FAVI.

The present occasion requiring us to treat of fistula in ano, it will not be improper to give an account in the first place of fistulæ in general. A fistula then is a callous sinus, attended with little or no pain, and forming in most parts of the body. It generally originates in abscesses not properly healed. The callus is compact and white, the flesh dry, and therefore insensible, neither vein nor nerve passing to it. Sometimes the sinus is dry and sometimes filled with a discharge. The discharge is sometimes constant, and sometimes at intervals, the mouth of it being at one time shut up, and at another time open. Sometimes the fistula terminates on a bone, sometimes on a nerve, or some other important part; and it is either straight or crooked; has either one orifice or many. Those therefore that terminate upon large arteries, or nerves, or tendons of considerable size, or the pleura, or any important part, are either not to be meddled with at all, or with great and skilful caution; but the others may be operated upon in this manner. We first examine them if they be straight with a sound (specillum), or if crooked with a double-headed specillum of a very flexible nature, such as those made of tin, and the smallest of those made of copper. When there are two or more orifices, we must not trust to the examination with a specillum, but injecting the sinus by one of its openings we ascertain from the manner in which the injection comes out whether it be one fistula with many orifices, or if there be several fistulæ. After the examination, if the sinus be superficial and narrow, it is to be distended by the introduction of a specillum, and the callus is to be cut off with a properly-shaped scalpel, or pared with the nails or the point of a scalpel. If it is also broad the redundant parts are to be dissected away. If it is not superficial, but deep and straight, we must cut off the callus all around as far as we can make incisions, and if any part remain, destroy it with a caustic medicine; or if the callus be large, and do not yield to medicine, we must form a slough by burning it with hot irons. If the fistula terminate with a bone, and if it is not diseased, we need only scrape it, but if it is carious, or otherwise corrupted, the whole diseased portion is to be cut out with counter perforators, and if necessary we may bore a hole with a wimble (trephine?) whether the bone be diseased only to the diploe or as far as the marrow. If a bone project, as after a transverse fracture, we must saw it off. Taking, therefore, two bandages, we apply the middle of the one to the projecting bone itself, and get it kept stretched by an assistant; the other being thicker, or formed of wool, we are to take in like manner, and apply the middle of it to the flesh under the bone, and taking its ends below, we give directions that the flesh below be retracted by this band lest it be torn by the teeth of the saw, and in this manner we accomplish the sawing. When any vital part is situated below, such as the pleura, spinal marrow, or the like, in cutting or sawing the bone, we must use the instrument called meningophylax for protecting them. If the bone is not diseased, but is denuded of flesh all around, it is to be sawn in the same manner, for bones which are disengaged from the other parts all around cannot possibly incarnate. In like manner, the extremity of a bone near a joint, if diseased, is to be sawn off; and often, if the whole of a bone, such as the ulna, radius, tibia, or the like, be diseased, it is to be taken out entire. But if the head of the thigh-bone, or pelvis, or a vertebra of the spine be diseased, we must not attempt to operate upon them for fear of the adjoining arteries. We must proceed in this manner in every particular case, attention being paid to the situation, proximity, and connexions of the affected parts, the extent of the disease, the strength and powers of the patient. The favus being a fistulous sinus with a milky discharge must be subjected to the same operation and treatment as fistula.

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COMMENTARY. For an account of the practice of Hippocrates we refer to our notes on the 49th section of the Fourth Book.

Celsus states that if fistulæ spread deep, are crooked, or are numerous, they are to be cured by an operation rather than by medicines. Wherefore, if it spread transversely, he recommends us to introduce a specillum, or sound, and cut down upon it. But if it is crooked, its bendings are to be followed out and cut open in the same manner. When the operator has reached the end of the fistula, all the callus is to be cut out, and the lips of the wound secured by clasps and agglutinative applications. When the fistula terminates with a rib he directs us to saw out a piece of it lest it affect the adjoining parts. Fistulous sores about the abdomen he pronounces to be highly dangerous. He recommends us, however, to attempt a cure by making an incision, and uniting the edges of the wound by sutures. (vii, 4.)

Aëtius lays down nearly the same rules for the treatment of fistulæ as our author. When the sinus runs transversely along the skin, he directs us to lay it open. When it penetrates downwards he advises us to cut off the callus; and when the ulcer terminates with a bone to remove the diseased lamina of it. (xiv, 55.)

Albucasis delivers the surgical treatment of fistulæ at great length. He is very particular in inculcating the necessity of making free incisions, and of removing any pieces of diseased bone which may happen to be found at the bottom of the sore. He relates a case of fistulous ulcer in the thigh, to cure which he removed large pieces of bone, sawing it down as far as the marrow. Some of his saws are very ingeniously constructed, and one of them is not unlike the saw introduced into the practice of surgery by the late Mr. Hey, of Leeds. He enumerates nine causes which prevent sores from healing; and as they appear to be of some practical utility we shall briefly mention what they are: 1, a deficiency of blood in the body; 2, cachexy, or bad condition thereof; 3, fungous flesh, which prevents the union of the edges of the sore; 4, much sordes in the ulcer; 5, putridity, or any other bad quality of the fluids; 6, improper applications; 7 and 8, the pestilential state of the atmosphere and the insalubrity of the place where the patient resides; 9, a diseased bone. When none of these causes are present, the restorative principle of nature will of itself effect the cure of any solution of continuity. (Chirurg. ii, 88.)

Rhases gives extracts from Antyllus, and many other authors, on this subject, but as their principles of treatment are much the same as those delivered by Paulus, we need not occupy much room with an abstract of them. Antyllus forbids us to use the knife when the fistula is situated in the groin or fundament. When it is not judged expedient to have recourse to an operation, one of his Arabian authorities, Aaron, recommends a powder composed of equal parts of quicklime, cantharides, arsenic, sandarach, sal ammoniac, and ginger. (Cont. xxviii.)

SECT. LXXVIII.—ON FISTULÆ IN ANO.

Fistulæ in ano are discovered, if they are blind, from their being attended with pain, although no orifice appears; from there being a purulent moisture about the anus, and in most cases from their being preceded by symptoms of abscess; or, if they are open, by the introduction of a sound or swine’s bristle; for the instrument will pass down into a cavity and meet the index-finger introduced into the anus if the fistula has penetrated to the inside; but if it has not penetrated, the instrument does not come in contact with the finger but the intermediate substance between them remains imperforated. The fistula is known to be crooked and winding from the instrument’s passing down but a short way, while a great quantity of pus is discharged in proportion. Those near the intestines are known by an abdominal worm or fæces sometimes passing through the mouth of them. In almost all cases some callus appears about the orifice of the fistula. A fistula is incurable that perforates the neck of the bladder, or extends to the joint of the thigh, or to the rectum. A fistula is difficult to cure when it has no orifice, is blind, ends with a bone, and has many windings. All the rest are, in general, easily cured. We proceed with them thus: having placed the patient in a supine posture, with the legs elevated, so that the thighs may be bent upon the belly, as when an injection of the bowels is administered, if the fistula terminate superficially, having introduced a sound or ear-specillum through the orifice of it, we cut the skin which covers it at one incision. But if the fistula terminate deeply in the anus, having introduced a specillum into the mouth of it, and if we find that it has perforated the gut, by introducing the finger into the anus opposite the affected buttock, we take hold of the head of the specillum, and bending it, bring it to the outside, and with one simple division cut asunder the parts which lie over the sound. If the fistula is found not to have as yet perforated the gut, and to have terminated only deeply in the fundament, and if upon examination we find that a scaly or membranous substance intervenes between the index-finger and the extremity of the sound, we must perforate it violently with the head of the sound, and forcing the sound through the rectum, we must again, as formerly described, cut asunder the intervening parts with a scalpel; or, having perforated the bottom of the fistula in ano with the sharp part of a falciform instrument for operating upon fistulæ, we bring the instrument out at the anus, and so divide all the intermediate space with the edge of the instrument; and after the incision, having taken hold of the surrounding parts, which mostly consist of callus, with a common forceps, or one called staphylagra, we cut them out all around, avoiding the sphincter muscle; for some cutting deep in an unskilful manner, have wounded it, from which the patient has had an involuntary discharge of fæces. Those who from timidity, avoid a surgical operation may be treated with the ligature, as recommended by Hippocrates. For Hippocrates directs us to pass a raw thread, consisting of five pieces, through the fistula by means of a probe having a perforation, or a double-headed specillum, and to tie the ends of the thread and tighten it every day until the whole intermediate substance between the orifice be divided and the ligature fall out. If it remain long, the thread may be sprinkled with the detergent powder called psarum, or some such powder, and drawn in. Some insert a thread into the opening of the falciform instrument for operations on fistulæ, and pass it through in the manner described, which I think ought not to be done. For by avoiding an operation, in addition they incur the inconvenience of a slow recovery. With regard to blind fistulæ, Leonides says: “When the fistula is deep, and penetrates the sphincter, whether beginning in the fundament, or arising from a distance and terminating in the sphincter, after the examination which has been described, we dilate the anus as we do the female vagina, with the instrument for that purpose, or the small specillum. When the orifice of the fistula is discovered, the end of an ear-specillum is to be passed through it, and pushed deep into it, and cutting down upon it where it presents, the whole fistula is to be divided with a semispathula or a spathula for operating upon fistulæ.” We having met with this state of the disease, have found it impossible to practise this mode of operating, because we could not discover the cavity of the fistula. For it was situated between the anus and sphincter towards the right side, and the dilator rather obscured the operation. But having dilated the wrinkles about the anus a certain fissure appeared among them, being as it were the defluxion of the fistula, for the pus passed out by it we saw to pass the head of the specillum into the fistula by it, which served as a director; and having passed the index-finger of the right hand to the sphincter, and having found a certain thin substance intervening between the finger and the sound, by pressing the sound violently to the finger, we perforated the bottom of the fistula, which was turned upwards; and passing with the finger the head of the instrument outwards, the whole of the substance between the mouths of the fistula, (I mean the one so situated as to favour the defluxion, and that now made by us,) we divided with a scalpel and cut out the sound.

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COMMENTARY. Hippocrates describes minutely the apolinose, or the cure with the ligature, in his work ‘De Fistulis.’ We must mention, however, that Kühn and Sprengel do not admit this among the genuine treatises of Hippocrates, although they allow that it is ancient. Littré also, though with some hesitation, has rejected it from his list of the genuine works of Hippocrates. And yet, considering that it was received as such by Galen and Erotian, it seems bold in any modern critic to refuse its claims.

Celsus likewise describes distinctly the method of applying the ligature. The process, he says, is slow but free from pain. It may be expedited by smearing the thread with some escharotic ointment. The same thing, he adds, may be accomplished by means of a scalpel guided upon a specillum (sound). When many sinuses open by one mouth, he directs us to cut open a straight fistula with a scalpel, and then the others being thereby exposed are to be tied with a thread. The diet is to be of a diluent nature, with a liberal allowance of water for drink. (vii, 4.)

Aëtius gives, from Leonides, a full account of fistulæ in ano, as we have explained in another place. He recommends us to introduce a specillum, and having cut open the fistula upon it, to pare away the callous parts of it. (xiv, 11.)

Actuarius approves of the same practice as the others. He cautions against making large incisions lest the sphincter ani be wounded. (Meth. Med. iv, 6.)

Albucasis delivers nearly the same rules of treatment as our author. According to circumstances he approves of the knife, the cautery, or the apolinose. (Chir. ii, 80.)

Haly Abbas describes only the operation by the incision. He also states that if the sphincter ani be wounded, it will occasion irretention of the fæces. (Pr. ix, 60.) See also Rhases (Ad Mansor. ix, 80; Cont. xxviii); and Avicenna (iii, 18, 1, 18.) Avicenna prefers twisted hairs or bristles of a hog, as they will not putrefy.

Upon the whole no other of the ancient authorities has treated so efficiently of fistulæ in ano as Paulus.

See an excellent account of the operation in Sprengel’s ‘History of Medicine.’ John de Vigo trusted to septics, such as arsenic and the ægyptiacum. Ambrose Paré approved of the apolinose and incision. Severinus was an advocate for the cautery. Foubert and Camper likewise practised the apolinose—the one with a leaden thread, the other with a silk one. Guido de Cauliaco and Rogerius approve of the ligature. Brunus and Theodoricus prefer the actual cautery, but describe the others. The surgeons of this country have now generally rejected the methods with the ligature and the cautery.

The following account of the ancient specillum by the learned Harduin will serve to illustrate our author’s description of the operation. We overlooked it in the commentary on the fifteenth section. “Quid sit specillum Varro explicat (Lib. 5 de Lingua Lat.) Quo oculos inunguimus quibus specimus (hoc est, aspicimus), specillum est. Græcis μηλὴ dicitur. Aëtius Serm. 8, 14, cum specillo instrumento, quod melam Græci appellant. Instrumentum parvum ac teres, quo utuntur ad vulnerum aut fistularum viam aut profunditatem pernoscendam. Une sonde de chirurgien.” (Ad Plin. H. N. vii, 54.) If the κοπάριον, however, was the same as the μηλὴ or the specillum, it was evidently used for cutting with as well as for cutting upon.

SECT. LXXIX.—ON HEMORRHOIDS OR PILES.

The existence of hemorrhoids is rendered manifest to us by the discharge from them. Before proceeding to the operation we must use frequent clysters with the view of evacuating at the same time the contents of the intestine, and, by irritating the anus, of rendering it more disposed to eversion and protrusion of the gut. Having, therefore, laid the patient on his back in a clear light, if we are to use the ligature we pass a very thick thread round the lips and secure each of the hemorrhoids with this ligature, leaving one as an outlet to the superfluous blood (for so Hippocrates directs.) After the application of the ligature, using a compress that has been dipped in oil and the bandage adapted for the anus, we order the patient to remain quiet, and treat the bowels with tepid oil and honied water, and afterwards we use a cataplasm made of crumbs of bread and saffron; and after the falling off of the hemorrhoids the cicatrization is to be promoted by wine. Leonides has not recourse to the ligature, but having seized the hemorrhoids and held them for some time with the forceps used for operations on the uvula he cuts them off with a scalpel. After the operation we must use manna and starch with chalcitis, or the plaster of burnt sponge with pitch, and the trochisk called faustinum, in order to burn it completely. Others by filling the cavity of the instrument called staphylocaustes, with caustic medicines, have burnt hemorrhoids like a scirrhous uvula.

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COMMENTARY. Hippocrates directs us to pass a needle armed with a very thick thread through the hemorrhoids, and tie them with it. Septic applications are afterwards to be made to them. (De Victu Acut. 67.) The author of another of the Hippocratic treatises recommends us to cure them by burning with red-hot irons. (De Hæmorr.)

Celsus directs us when the base of a hemorrhoid is narrow to tie it with a thread where it joins the anus, and to apply over it a sponge squeezed out of hot water until it become livid, when it is to be scraped off with the nail or a scalpel. Sometimes, however, he says, the ligature occasions great pain and retention of urine. If the hemorrhoid be large and its base broad, he directs us to seize it with a hook, and dissect it out a little above its base: the part is to be secured with a thread. When there are many hemorrhoids he advises us not to operate upon them all at one time. When there is a discharge of blood it is to be stopped by the application of a sponge. The day after the operation he recommends us to use the tepid bath and catalapsms. (vii, 30.)

Aëtius approves of cutting off hemorrhoids, and describes the operation minutely. He directs us to seize the pile with a hook, grasp it firmly, and bind it with a thread, after which it is to be raised and cut off. To stop the bleeding a piece of sponge bound round with a thread is to be introduced into the anus. Suitable dressings and bandages are then to be applied, (xiv, 6.)

In the ‘Isagoge’ ascribed to Galen, the method of treating hemorrhoids by the ligature is particularly commended.

Albucasis prefers excision and burning, but if the patient will not submit to these methods of cure he approves of having recourse to the ligature. Excision is performed by seizing the hemorrhoid with a hook and cutting it at its base, after which some styptic application is to be made. The ligature is applied by transfixing the base of the hemorrhoid with a needle armed with a thread. (Chirurg. ii, 81.) He gives particular directions about the process of burning. (p. i, 37.)

When the hemorrhoid is internal Rhases directs us to evert the anus, and having laid hold of the tumour to cut it out. He also describes the process of tying them in the same terms as the other authorities. (Contin. xxiv.) The directions given by Avicenna are quite similar.

Haly Abbas recommends excision or the ligature. (Pract. ix, 61.)

Fabricius makes mention of all these methods of treatment, but speaks of the application of the cautery as being dangerous. Upon the whole he appears to have entertained great apprehensions from stopping the discharge of piles. (Œuv. Ch. ii, 94.)

Theodoricus and Brunus recommend excision, the cautery, and the ligature, according to circumstances. Theodoricus also makes mention of applications for consuming and drying them up.

SECT. LXXX.—ON CONDYLOMATA OR EXCRESCENCES, AND FISSURES.

Condyloma on the fundament differs in situation alone from that on the female parts of generation, being a wrinkled excrescence of the anus, either from a preceding inflammation or fissure. At first, then, it is called an excrescence, but when it becomes callous, condyloma. These also, like the former, are to be taken hold of with a forceps and cut out, and the cure completed with escharotics. Fissures are occasioned principally by hard fæces, and being slow of granulating owing to their callosity, must be converted into recent ulcers by paring them with the nails or a scalpel, when they may be made to granulate by proper applications.

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COMMENTARY. Celsus briefly directs us to seize the condyloma with a forceps and cut it out by the roots. Should any fungous flesh arise it is to be kept down with the squama æris. (vii, 30.)

Aëtius gives a fuller account of these affections than our author. The condyloma, he says, is a tubercle which forms in the soft wrinkled skin about the anus. When it becomes hard and callous he recommends us to take hold of it with a forceps and cut it out by the roots. Old fissures he directs us to treat by paring their edges and applying suitable dressings. (xiv, 3.)

The same treatment is recommended by the Arabians. See Haly Abbas (Chirurg. ix, 62); Albucasis (Chirurg. ii, 81, 82); Rhases (Contin. xxiv.)

SECT. LXXXI.—ON IMPERFORATE ANUS.

In new-born children the anus is sometimes found imperforate, being blocked up by a membrane. If possible, then, the membrane is to be ruptured with the fingers, but if not, we must cut it with the point of a scalpel, and accomplish the cure with wine. And since often in adults, owing to an ulcer not properly cured, a stricture takes place at the anus, we must break it with a convenient instrument, and treat it properly with a pipe of lead, or some wedge-shaped tent introduced into the anus until the cure be completed, lest contraction should again take place. The wedge-shaped tent is to be anointed with some healing ointment.

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COMMENTARY. Soranus describes this operation in very distinct terms. (p. 164.)

Albucasis evidently copies our author’s account, recommending us to break or divide the membrane, and introduce a canula of lead into the opening to prevent adhesion. (Chirurg. ii, 79.)

Haly Abbas, in like manner, directs us to make an opening and introduce a leaden tube or a piece of sponge. (Pract. ix, 63.)

SECT. LXXXII.—ON THE EXCISION OF VARICES.

The varix is a dilatation of a vein occurring sometimes in the temples, sometimes in the hypogastric region below the navel, sometimes in the testicles, but more especially in the legs. For the most part it derives its origin from a melancholic humour. The operation for those of the testicle we have already described when treating of cirsocele, and those in the leg may be operated upon in a similar manner, making the attempt upon those in the inner parts of the thighs, where they generally arise; for below this, as they are divided into many ramifications, they are more difficult to succeed with. Wherefore, having washed the man, and applied a ligature round the upper part of the thigh, we are to direct him to walk about, and when the vein becomes distended we are to mark its situation with writing ink or collyrium, to the extent of three fingers’ breadth or a little more, and having placed the man in a reclining posture with his leg extended, we apply another ligature above the knee; and where the vein is distended we make an incision upon the mark with a scalpel, but not to a greater depth than the thickness of the skin, lest we divide the vein; and having separated the lips of the wound with hooks, and dissected away the membranes with crooked specilla, like those used in the operation for hydrocele, and laid bare the vein, and freed it all around, we loose the ligatures from the thigh, and having raised the vessel with a blind hook, and introduced under it a needle having a double thread we cut the double of it, and opening the vein in the middle with a lancet, evacuate as much blood as may be required. Then having tied the upper part of the vessel with one of the ligatures, and stretched the leg, we evacuate the blood in the limb by compression with the hands. Then having tied the lower part of the vein, we may either cut out the portion intermediate between the ligatures, or suffer it to remain until it drop out of its own accord with the ligatures; then we have to put a dry pledget into the wound, and apply over it an oblong compress soaked in wine and oil, and secure them with a bandage, and accomplish the cure by the treatment applicable in cases of suppuration. I am aware that some of the ancients do not use ligatures, but cut out the vessel immediately after it is laid bare, whilst others stretch it from below and tear it out by force. But the mode of operating now described is of all others the safest. Varices on the hypogastrium may be treated in like manner, and those on the temples as described in the operation of angiology.

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COMMENTARY. Hippocrates directs us to make small punctures in varices of the leg, but forbids to open them freely. (De Ulceribus, 16.) In the Hippocratic treatise entitled ‘Hippiatrica,’ it is recommended to burn varices in the legs of horses.

Celsus treats ingeniously of varices on the head (aneurism by anastamosis) on the belly (cirsocele?), and on the leg. With regard to the treatment, he says, in a word, that they are all either to be burnt or cut out. If the varix be straight, or if, although transverse, it consist of a single vein of moderate size, it will be better, he says, to burn it. If crooked and convoluted, and if it consist of a multitude of veins, it will be more useful to cut them out. He directs us, in burning them, to make an incision in the skin, and having laid bare the vein to touch it with a slender blunt piece of iron red-hot, taking care not to burn the edges of the wound which are to be drawn aside with hooks. This is to be done at intervals of about four fingers along the whole extent of the varix, and then the dressings for burns are to be applied. The varix is cut out in this way. The vein is to be exposed as above directed, and dissected with a scalpel from the surrounding parts (care being taken not to hurt it); a blunt hook is then to be introduced below it; and the same thing is to be done at the same interval as mentioned above. When this has been performed wherever there are varices, the vein is to be cut asunder at one of the hooks, and drawn towards the next hook, and then torn out. The leg being in this way cleared of the varices, the lips of the wound are to be united, and an agglutinative plaster applied above. (vii, 31.) It will be remarked that our author makes mention of this method of treatment but disapproves of it.

Aëtius describes the excision of varices in exactly the same terms as our author. He also makes mention of the treatment by the actual cautery. (xiv, 84.)

The operation of extracting varicose veins is briefly described in the ‘Isagoge’ of Galen. Albucasis describes accurately the different modes of operating upon varices. He says there are two methods of performing the operation with the knife, that is to say, by incision or by extraction. The former method is done by applying a piece of fillet round the upper part of the thigh, and at the inferior part near the knee, and then opening the vein in one, two, or three places, and evacuating the blood in it: the limb is then to be bound up. In performing extraction, the veins are first to be made to swell by putting the limb into hot water, applying fomentations, and taking strong exercise; and then a longitudinal incision is to be made in it, either at the knee or the ankle. The vein is afterwards to be dissected from the neighbouring parts and suspended with a blunt hook. The vein is to be laid bare in like manner at the distance of three fingers’ breadth, and in more places if required. At last, it is to be cut asunder at the ankle and drawn out. Afterwards wool dipped in wine and rose-oil is to be applied. When the varix consists of a congeries of tortuous vessels he recommends us to dissect it out entire. (Chirurg. ii, 92.)

Haly Abbas briefly inculcates the same treatment as Albucasis. (Pract. ix, 64.) Avenzoar considers the complaint nearly incurable.

Rhases directs us, in the first place, to bleed and purge, and then to expose the vessel or cut it out. He also approves of compression. (Cont. xxviii.)

It is related that the operation here described was performed upon the celebrated Caius Marius. See Cicero (Tusc. Disput. ii.) Pliny (H. N. xi, 104); and Plutarchus (in Mario.) It seems to have been a very painful operation, since it is mentioned as a proof of his fortitude that he submitted to it without being bound. It would appear that the learned and ingenious Aurelius Severinus used to perform it. (V. Mangeti Bib. Chir. xvi.)

SECT. LXXXIII.—ON THE DRACUNCULI OR GUINEA-WORMS.

The treatment of dracunculi being principally accomplished by medicines, we have given an account of it in the Fourth Book.

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COMMENTARY. We have treated fully of this subject at the end of the Fourth Book.

SECT. LXXXIV.—ON AMPUTATION OF THE EXTREMITIES.

Sometimes the extremities, such as a hand or a foot, having mortified, so that the bones themselves are corrupted, either from having been fractured by some external means, or from having become putrid owing to some internal cause, it is necessary to saw them off; before doing which the parts surrounding the bones must be divided. But since, when this is done first, as a considerable time is required for the sawing, there is danger of a hemorrhage taking place, Leonides properly directs us not to divide all the parts at once unless they are completely mortified, but first to cut the part where not many nor very large veins or arteries are known to be situated, down to the bone quickly; then to saw the bone as expeditiously as possible, applying a linen rag to the parts which have been cut lest they be torn by the sawing and occasion pain, and then having cut through what remains, to apply red-hot irons to the vessels and stop the hemorrhage thereby with compresses of lint, and to apply proper bandages with the dressings suitable to suppurations.

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COMMENTARY. Hippocrates and Galen recommend amputation to be performed in general at a joint. (De Articulis, Galeni Comment. t. v, p. 650, ed. Basil.) Hippocrates says complete excision may be performed at the joints of the hand and foot, and at those of the wrist and ankle, and generally with safety, unless the patient be cut off by fainting, or continual fever supervene on the fourth day. When gangrene attacks a fractured limb, his rule of practice is to let the parts drop off, and he remarks, many persons thus recover, even when the fracture is seated in the femur. When gangrene comes on without being preceded by fracture, he directs the soft parts, as soon as they have lost all sensibility, to be removed at the nearest joint below, and the surgeon is to wait until the bone also separates. He says he had seen the bone of the thigh thus separate on the eightieth day; in that case the limb below had been removed at the knee on the twentieth day. In a similar case of gangrene of the leg, the bones separated on the sixtieth day. He pronounces gangrene of the extremities to be more formidable in appearance than in reality. He recommends a mild and anti-inflammatory treatment, and that the limb should be laid in an elevated position as long as there is any fear of hemorrhage. Violent attacks of dysentery are apt to come on, but do not generally prove obstinate. (De Artic. 69.) It would appear from Thucydides and Lucretius that it was not uncommon to amputate in cases of gangrene in the days of Hippocrates. (See their Descriptions of the Plague of Athens.)

In cases of gangrene Celsus directs us to make an incision of the flesh, between the sound and corrupted part, down to the bone, which is to be sawed across, and after the asperities have been removed from the end of the bone, the skin is to be brought over the stump. (vii, 33.) He gives us no particular description, however, of amputation of the extremities. We turn, therefore, to the celebrated fragments of the works of Archigenes and Heliodorus, preserved in the collection of Nicetas, published by Cocchius. (Chirurgici Græci, Florent. 1756.)

Archigenes begins by stating the circumstances which require recourse to be had to amputation. They are, the presence of some intractable disease, such as gangrene, necrosis, putrefaction, cancer, certain callous tumours, and sometimes wounds inflicted by weapons, and the like. Before attempting the operation he recommends us to consider well if the patient’s strength will enable him to endure it. The operator must then tie or sew the vessels which pass to the parts; in certain cases a ligature is to be applied round the whole limb, cold water is to be poured upon it, and some are to be bled. Amputation near the joints is not to be attempted. In such as are of a full habit of body, a circular band is to be put round the limb, to draw up the skin with, and to direct the incision. After cutting down to the bone, the tendons are to be retracted, and the bone scraped and sawn. When much blood is discharged, red-hot irons are to be applied, and a double compress laid on the part from which the blood proceeds. Having loosened the band, a cataplasm of leeks, bread, and salt is to be applied to the stump; and the parts about the jaw-bone are to be anointed with cerate of iris and old oil, doubtless in order to obviate the danger from tetanus.

Heliodorus states that a limb may require to be amputated owing to gangrene or any other cause that occasions the death of it. In the extremities, then, he remarks, amputation may be performed with less danger; but above the knee or elbow the danger of hemorrhage from the great vessels being wounded is very considerable. Some, he says, from too great anxiety for despatch, cut through all the bodies (the soft parts?) at one incision, and then saw the bones. But this method of removing the limb is not unattended with danger, as many vessels pour forth blood at the same time. “Wherefore,” he adds, “it appears to me better first to divide those parts of the limb where there is least flesh, as on the anterior part of the leg, and then to saw the bone; and I myself am in the practice of first applying a ligature above the part of the limb which is to be sawn across, and then of operating in the manner described. In sawing the bone the plate of the saw ought to be applied even, in order that the sawing of the bones may be even. When the bones are sawed the other parts which remain undivided are straightway to be cut through with a scalpel, and large pledgets applied along with suitable compresses. External to these, sponges with suitable bandages are to be put on. After the third or fourth day, when all fear of hemorrhage is over, suppuration is to be promoted by suitable dressings.”

In no other of the Greek medical works which have come down to us is there any description of amputation of the extremities.

Avicenna mentions the operation of sawing off the bones of the extremities, but in such general terms as gives us no information in what manner it was performed. (iv, 4, 4, 10, 11, 12.)

The description given by Haly Abbas is more complete. A limb, he says, is amputated thus. The operation is to commence with first cutting the skin, and then when the bone of a limb is to be sawn, you must not cut through the whole flesh at once, lest an immoderate discharge of blood take place from the veins and arteries so as to occasion the death of the patient and interrupt the process of sawing the bone; except the flesh of the limb be wasted or putrid. But you ought first to divide that part of the flesh where no great arteries and veins are situated, cutting them down to the bone, which is to be sawn across as quickly as possible, the fleshy parts in the mean time being retracted with a piece of linen, lest the saw should tear them and occasion bleeding and pain; when the bone is sawn across, whatever portion of the flesh remains undivided is to be cut, and then the veins and arteries are to be burned. When the bleeding is stopped a pledget with suitable bandages is to be applied. (Pract. ix, 65.)

Albucasis represents amputation as necessary in cases of mortification, as indicated by the smell and discoloration. When the disease is seated in the hand, he recommends us to amputate at the fore-arm; when in the forearm, at the elbow; and if the arm itself be affected, he pronounces the case to be hopeless. In like manner, with regard to the lower extremities, he pronounces all cases incurable in which the disease is seated above the knee. In performing the operation he directs us to apply two bandages around the limb, the one above and the other below the place at which it is to be cut off. These bandages are to be pulled, the former upwards and the latter downwards, by two assistants, so as to put the skin upon the stretch; the fleshy parts are then to be divided with a large scalpel down to the bone, which is afterwards to be cut out, or sawed across, and during this part of the process a piece of linen is to be applied around all the fleshy parts, to prevent them from being injured by the sawing. Should any hemorrhage occur during the operation, he directs us to apply the cautery, or a styptic powder; and after the operation he recommends us to bandage the limb in a suitable manner, until the stump is healed. He relates a case, from which the timidity of his own practice is rendered very apparent. A person who had a spreading mortification in the foot, cut it off at the ankle-joint himself, and was cured for the time. The disease next attacked the hand, upon which he applied to Albucasis, requesting that he would cut it off in the same manner, but this he refused to do, for fear that the man’s strength might not be able to endure the operation. He afterwards learned that the man had cut off his whole hand, and had recovered. (Chirurg. ii, 89.) The history of this case proves decidedly that the operative surgery of the Arabians, in the days of Albucasis, must have been very defective; this he himself frankly confesses, for he declares that all knowledge of this art had been lost, except what vestiges of it had been preserved in the works of the ancient authors, whose descriptions, he complains, had been mutilated and corrupted. (Prefatio.) We mention this, in order that the ignorance which prevailed in his time may not be imputed to all preceding ages, nor may be used as an argument against the genuineness of the extracts from the works of Heliodorus and Archigenes, given above.

Rhases makes some interesting remarks on the sawing of bones. He directs us to stretch the flesh upwards and downwards, with a piece of cloth, so that it may not come in the way of the teeth of the saw. When it is necessary to saw a rib or a bone, near any important membrane or organ, he recommends us to use a plate (tabella), to protect the soft parts from the saw. When the bone connected with a joint is diseased, he directs us to extract it at the joint. When the os brachii, or tibia, is diseased, he recommends us to extract it entire, but forbids to meddle with the head of the femur or the vertebræ. In another place he declares it as his opinion that when a joint is swelled, and the bone diseased, (in cases of white swelling?) it will be impossible to effect a cure unless the whole diseased portion of the bone be cut out. (Cont. xxix.) From these passages it is quite obvious that the ancients practised excision of the bones of joints. See also what our author says on this subject in the seventy-seventh section of this book. A Cooper or a Liston could not recommend a bolder plan of treatment in such cases.

Theodoricus, Guy of Cauliac, and the other surgical writers of that age, follow closely in the footsteps of the ancients, especially of the Arabians. When the mortified part is near to a joint, they recommend amputation at it. In other cases they direct us to make an incision between the sound and the dead parts, to saw the bone with a fine saw, and to stop the bleeding with a heated iron. Theodoricus recommends stupifying medicines, such as opium, hyoscyamus, mandragora, or cicuta, before the operation. Ambrose Paré has undoubtedly the merit of introducing the use of the ligature into modern practice in amputations, and, in fact, Archigenes seems to be the only ancient authority who mentions it in such cases. We have shown, however, in another place, that the ligature was freely used by the ancients for stopping bleeding from wounds.

SECT. LXXXV.—ON PTERYGIA ABOUT THE NAILS.

The pterygium is a fleshy excrescence about the nails, covering part of the nail, and being commonly formed in the large fingers and toes. But those in the feet arise most commonly from an accident, whereas, those in the hands arise from whitlow, the inflammation being neglected and turning to pus. For, the pus being allowed to remain, corrodes and corrupts the root of the nail, and often destroys the whole of it, but generally the one half, while a portion of it uncorroded is left at the root of the nail, and sometimes the whole root is left uncorroded. Sometimes, too, it corrupts the bone, when a disagreeable smell arises from it, and the extremity of the finger becomes swelled and appears livid. They are to be treated, then, by cutting and removing all the remaining part of the nail with the point of a scalpel, and then burning both the ulcerated and cut part with cauteries. For, the pterygium is a spreading disease, and does not stop unless burnt, so that, if neglected, it affects the whole finger. If, while the nail and bone remain sound, the inner angle of the nail sink down and pierce the adjacent flesh, it occasions inflammation; and in this case the irritating portion is to be raised upon a thin probe, or some such thing put under it, and removed with the point of a scalpel, and the excrescence eaten down with an escharotic medicine. And most cases are cured by being treated in this way. But if larger, it is first to be cut out with a scalpel, and then the medicine is to be used.

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COMMENTARY. We have given an account of the ancient treatment of pterygia by medicines towards the end of the Third Book.

Celsus recommends excision with the knife and the application of cauteries or strong caustics afterwards. (vi, 19.)

Aëtius and Oribasius trust to septic and caustic applications without an operation. Antyllus (apud Rhasis Cont. xxxvi,) recommended excision and burning when the discharge from the ulcer is fetid.

Albucasis, like our author, recommends us to cut off the piece of nail that is attached, and then to apply a burning iron to the part. The burning, he adds, is of great consequence. When the bone is diseased he directs us to take it out, which generally may be done at the joint. (Chirurg. ii, 9.)

Haly Abbas likewise directs us to cut off the piece of nail and apply the cautery. He says, if this be neglected the bone is apt to become diseased. When pus is seated below the nail, he recommends us to introduce the head of a probe under it, and cut upon it with a knife; after which a caustic medicine is to be applied to the flesh. (Pract. ix, 66.)

SECT. LXXXVI.—ON A BRUISED NAIL.

Since, owing to nails having been bruised by accidents, pains supervene, which compel us to operate upon them, it will be sufficient to give you Galen’s account of the matter. He says, then: “When the nails are contused we have found the evacuation of the blood a palpable remedy for soothing the pain, when it and the throbbings are very violent. But we must make an oblique incision, not straight from above downwards, with a sharp scalpel, so that when the blood is evacuated the divided part of the nail may serve as a cover to the parts under it. But if you make a straight incision from above down to the fleshy excrescence, as it is called, another body is formed from the flesh below the nail shooting out through the division of the nail, whence pains again invade, as in the complaint we call paronychia, owing to the flesh under the nail being compressed by it. Wherefore, one may see the patients immediately relieved from pain by this section. On the following days we may gently raise the divided part of the nail, and press the sanies from under the nail, and then again, as I said, apply the nail as a cover to the flesh below. The rest of the treatment of the finger should be soothing and discutient.”

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COMMENTARY. Avicenna and Rhases approve of the plan of treatment here recommended, upon the authority of Galen. Rhases, in fact, gives the very words of Galen. (Cont. xxxvi.)

Albucasis directs us, in the case of a bruised nail, first to have recourse to venesection, and then to make a transverse (oblique?) incision through it. (Chirurg. ii, 91.)

See our remarks in the sixtieth section of this Book on the confusion of the terms transverse and oblique by the translators of the Arabians.

The same treatment is recommended by Haly Abbas. (Pract. ix, 67.)

SECT. LXXXVII.—ON CLAVI, MYRMECIA, AND ACROCHORDONES.

The clavus is a round callus, white, resembling the head of a nail, and occurring in all parts of the body, but more especially on the soles of the feet and the toes, occasioning pain and lameness in walking. Wherefore, having scarified around the clavus or corn, and taken hold of it with a forceps, we cut it out by the roots with a sharp-pointed scalpel or lancet for bleeding. Some, in order that they may not grow again, use heated cauteries. The myrmecia is a prominence of the skin, small, callous, round, thick, spreading deep at the base, and, if rubbed, occasioning a sensation like the bites of ants, and being formed in all parts of the body, but more especially in the hands. Wherefore, some, among whom is Galen, advise us to scarify around the myrmecia with the stalk of a hard feather, such as those of old fowls, of geese, and of eagles, and to push it down so as to remove the myrmecia from the root. Others do the same thing with a copper or iron tube. The moderns are satisfied to scarify around it, and, having seized it with a forceps, to cut it out like corns with a scalpel. The acrochordon is a small rising of the surface, free of pain, callous, for the most part round, and having a narrow base so as to appear to hang. It is so called from its resemblance to the end of a cord. Having stretched out the protuberance then we may cut it out; or, otherwise, we may tie a thread or a hair round it. I have known many who consumed this and all the afore-mentioned protuberances with what is called the cold cautery.

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COMMENTARY. We have already treated fully of these diseases towards the end of the Third Book and in the Fourth, to which we refer the reader for further information on this head.

Celsus recommends us merely to shave the clavus or corn. The others he directs us to remove by caustics, such as the lees of wine (potass?), or a mixture of alum and sandarach. The acrochordon, he says, when cut out leaves no roots behind. (v, 28.)

Albucasis particularly recommends burning for the cure of clavus and myrmecia. This may be accomplished either with fire or hot water. If the former method is preferred, an iron proportionate to the size of the corn is to be heated red-hot and applied to it, and the burning carried to such an extent as to occasion suppuration. In the other method a funnel of copper or iron, or else the quill of a vulture is to be applied to the corn, and then filled with boiling water. By these means, he says, the corn may be eradicated. (Chirurg. i, 55.)

See also Haly Abbas (Pract. ix, 12) and Rhases (Cont. xxxvi.) Rhases does not state very distinctly the difference between the myrmecia and acrochordon. He speaks of scraping them out with a hard pen, and of tying them at the base; but upon the whole he approves most of taking hold of them with a forceps and dissecting them out.

Avicenna recommends us to cut out the clavus and then apply a caustic medicine to the part. (iv, 7, 4, 14.)

SECT. LXXXVIII.—ON THE EXTRACTION OF WEAPONS.

That the extraction of weapons is a most important department of surgery is declared by the Poet Homer, when he says:

“The man of medicine can in worth with many warriors vie, Who knows the weapons to excise, and soothing salves apply.”

We must first describe the different kinds of weapons. Warlike instruments, then, differ from one another in material, figure, size, number, mode, and power. In material, then, as the shafts are made of wood or of reeds; and the heads themselves are either made of iron, copper, tin, lead, horn, glass, bones, and of reeds, too, or of wood: and such differences are found especially among the Egyptians. In figure, inasmuch as some are round, some angled (as triangular), some pointed and lance-shaped, as some have three points; some are barbed and some are without barbs; and of the barbed, some have the barbs turned backwards, so that in attempting to extract them they may fasten in the parts; and some forwards, so that when pushed they may do the same thing: some have them diverging in opposite directions like the forked lightning, in order that whether pulled or pushed they may fasten in the parts. Some missiles have their barbs united by a hinge, which being expanded in the extraction, prevent the weapon from being drawn out. They differ in size, inasmuch as some are three fingers’ breadth in size, and some are as small as one finger, which are called micca in Egypt, and some are intermediate between them. In number, inasmuch as some are simple and some compounded. For certain small pieces of iron are inserted in them, which, in the extraction of the weapon, remain concealed in deep-seated parts. In mode, as some have the sharp extremity fixed to a tail and some to a shaft; and some have it carefully inserted in the shaft, and some carelessly, so that in the extraction they may separate and leave the head behind. In power, as some are not poisoned and some are poisoned. Such are the differences of weapons. We now proceed to treat of the extraction, both in cases of those who have been wounded in war and those not in war, whether voluntarily and involuntarily, under whatever circumstances, and of whatever materials they may be composed. There are two modes of extracting weapons from fleshy parts; either by pulling them backwards, or pushing them forwards. When the weapon is fixed superficially the extraction is made by pulling it back, and in like manner when it is lodged deep, but the opposite parts, if wounded, would occasion danger from hemorrhage or sympathy. It is to be pushed forwards when lodged deep, and the intervening substances between it and the opposite side are of small size, and neither nerve, bone, nor any such thing is an obstacle to the division. When a bone is wounded, the mode of extraction is by pulling; if, therefore, the head of the weapon be in sight, we make the extraction immediately; but, if it is hid, we must, says Hippocrates, get the wounded person to put himself in the same posture as when he received the wound, and thus make the examination; or, if this cannot be done, he is to be placed in the nearest possible to it, and thus it is to be examined with a sound. If the head of the weapon has fixed in the flesh, it is to be drawn out with the hands, or by laying hold of the appendage, which is called the shaft, if it has not fallen off. This part is mostly made of wood. When it has fallen off, we make the extraction by means of a tooth-extractor, or a root-extractor, or an instrument for extracting weapons, or any other convenient instrument. And sometimes we make an incision in the flesh around it in the first place, if the wound do not admit the instrument. And if the head of the weapon has passed to the opposite side, and it is found impossible to extract it by the way in which it entered, having divided the parts opposite we extract it through them, either drawing it out in the manner mentioned, or we make a hole with the weapon itself, pushing it either by the shaft, or, if it has come away, by an impellent instrument, taking care not to divide a nerve, vein, artery, or any important part, for it would be disgraceful if, in extracting the weapon, we should do more mischief than the weapon itself had done. If the weapon has a tail, which is ascertained by examination with the probe, having introduced the female part of the impellent instrument and fixing it, we push the weapon forwards, but if it has a shaft, the male part. And if the head when extracted appear to have notches, so that other small pieces of iron might be inserted in them, we make an examination again with the probe, if we find them we extract them in the same manner. And if the weapon has barbs in opposite directions, which do not yield to our pulling, we must make an incision in the adjacent parts, if no important vessel or the like lie there, and when the weapon is laid bare, we extract it without trouble. Some apply a tube about the barbs, so that when they draw out the weapon the flesh may not be torn by the barbs. If the wound does not become inflamed, we may use sutures, and heal it up like a bloody wound; but if it inflame we may remove the inflammation by embrocations, cataplasms, and the like. If the weapon be poisoned we must, if possible, cut off all the flesh which has imbibed the poison, which is known by its being altered from the sound flesh, for it appears pale, livid, and as it were dead. They say that the Dacians and Dalmatians touch the points of their weapons with elecampane, called also ninum, and that when it thus becomes mixed with the blood of the wounded animal it proves fatal, although it is eaten by them with impunity. If, again, the weapon fix in a bone, we make trial with the instrument, and, if flesh prevent the extraction, we cut it off, or separate it; but if it be lodged deep in the bone (which we know by its being so firm that it cannot be shaken with a considerable force) we first remove the remaining part of the bone with a cutting instrument, or bore it with trephines if it has considerable thickness, and thus disengage the weapon. If a weapon be lodged in any important part, such as the brain, heart, throat, lungs, liver, stomach, intestines, kidneys, womb, or bladder, and fatal symptoms have already shown themselves, as the extraction would occasion much laceration we must decline the attempt, lest while we do no good we expose ourselves to the reprobation of ignorant people. But if the result be dubious, we must make the attempt, having first given warning of the danger. For in many cases, when an abscess has formed in some vital part, recovery has unexpectedly taken place; and the lobe of the liver, part of the omentum and peritoneum, and the whole uterus are said to have been taken away, and yet death was not the consequence. And we often open the windpipe intentionally, in cases of angina, as we mentioned under the head of Laryngotomy. To leave the weapon then as it is, occasions certain death, and exhibits the art in an inhumane light, whereas by extracting it we might possibly save a life. It is not difficult to ascertain when an important part is wounded, this being discovered by the peculiarity of the symptoms, the discharges, and situation of the parts. When, therefore, the membranes of the brain are wounded, there is intense pain of the head, the eyes are fiery, the tongue red, and there is aberration of intellect; but if it is attended with a wound of the brain, there is prostration of strength, with loss of speech, distortion of the countenance, vomiting of bile, a discharge of blood from the nostrils, an evacuation of a white and pultaceous fluid by the auditory foramen, and of ichor, if it can find a passage by the wound. If the weapon has penetrated to the cavity of the chest, and sufficient room is left for it, the breath passes out. When the heart is wounded, the weapon appears at the left breast, and feels not as if in a cavity, but as fixed in another body, and sometimes there is a throbbing motion; there is a discharge of black blood if it can find vent, with coldness, sweats, and deliquium animi, and death follows in a short time. When the lungs are wounded, if the opening be sufficiently large, a frothy blood passes out at it; but if not, it is rather vomited up, the vessels of the neck are swelled, the tongue changes colour, and there is an urgent desire of cold things. When the diaphragm is wounded the weapon appears lodged about the false ribs, there are large inspirations with pain, sighs, and heavings of the parts about the shoulder-joints. If the viscera of the abdomen are wounded, the nature of the injury will be apparent from the discharge, if the wound be sufficiently large, or if the weapon be extracted, or if the shaft be broken internally; for chyle is evacuated from the stomach, and fæces from the intestines; sometimes the omentum or an intestine protrudes. When the bladder is wounded urine is discharged. When the membranes of the brain or the cerebrum itself is wounded, we extract the weapon by trepanning the skull, as will be described presently in fractures of the bones of the head. If the weapon is lodged in the chest, and does not come out readily, it is to be extracted by means of a moderate incision in the intercostal space, or by cutting out a rib with the assistance of the instrument called meningophylax. In like manner, when the stomach, bladder, and other deep-seated parts are wounded, if the weapon come out readily it is to be extracted without more ado; but if not, we must enlarge the wound, and afterwards use the dressings for fresh wounds. In wounds of the abdomen, gastroraphé as formerly described may be had recourse to, if necessary. But if the weapon has lodged in any of the larger vessels, such as the internal jugulars or carotids, and the large arteries in the armpits or groins, and if the extraction threaten a great hemorrhage, they are first to be secured with ligatures on both sides, and then the extraction is to be made. If parts have been fastened to one another, such as the arm to the chest, or the fore-arm to the other parts of the body, or the feet to one another, if the weapon (as a spear) do not penetrate through both parts, we are to take hold of the weapon externally and extract as if only one part were affected, but if it has passed through both, having sawed the wood through the middle, we extract each part singly, in the most convenient direction. But since often stones or the sharp points of rocks, or pieces of lead, or the like, are lodged in the body, either being impelled with force from a sling, or happening to be acuminated, they are to be known by the swelling being hard and irregular, and by the solution not being everywhere straight, but larger than common, and having the skin bruised and livid, and the pain being attended with a sense of weight. They are, therefore, to be dislodged by means of suitable instruments, or scraped out with the concave part of a specillum or of an ear-specillum adapted for wounds; or, if they can be applied, a tooth-extractor or a root-extractor may be used for pulling them out. In many instances weapons lodged in the body lie concealed, and a long time after, when the wounds are healed up, the part having suppurated bursts, and the weapon drops out.

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COMMENTARY. Hippocrates considered the extraction of weapons to be one of the most important departments of surgery. It is to be fully learned, he says, only by attaching oneself to a foreign army. (De Medico.) He makes some interesting remarks on the subject in his treatise ‘De Capitis Vulneribus.’

We must now attempt to give an abstract of Celsus’s very interesting chapter on the Extraction of Weapons. Every weapon is to be extracted either by the part at which it enters or by that to which it tends. If it is not deep-seated, or if it has not passed any great vessels or nerves, there is no better plan than to draw it out as it entered. But if there is a greater space through which it must return than there would be to push it out, and if it has already passed the vessels and nerves, it will be better to open what remains undivided, and extract it in this direction. If the weapon is to be drawn backwards, the opening is to be enlarged by a scalpel, which will occasion less inflammation and obstruction of the parts than if they are torn by the weapon itself. In whichever way it be extracted great care ought to be taken that no nerve, large vein, or artery be divided. If any of these parts be detected in the wound they are to be drawn aside with a blunt hook. These are his general directions. He then subjoins instructions for extracting particular kinds of weapons. An arrow being a slender body, and generally impelled with great force, is often lodged deep, and is to be extracted for the most part rather by the opposite side to which it entered, especially as it has barbs, which tear most if drawn backwards. The flesh about the weapon is to be separated by means of a suitable instrument, and then if the head (mucro) appear with the shaft (arundo) fixed to it, the weapon is to be propelled until it can be laid hold of at the opposite side and extracted; or if the shaft has fallen out and only the iron remain lodged within, the head is to be seized with the fingers or a forceps, and removed, and it is to be extracted by the opening at which it entered, upon the same principles; for the wound being enlarged, the weapon is to be drawn back by the shaft if it remain, or otherwise by the iron itself. If there appear to be barbs upon the arrow, and if short and small, they are to be broken off with a pair of pincers; or, if larger and stronger, they are to be covered with split writing-pens (fissis scriptoriis calamis) to prevent them from tearing the flesh during extraction. And here we may mention, that the common calamus scriptorius of the ancients was made from an Egyptian reed. See Montfauçon (Palæographia Græca, p. 3.) When the weapon which is lodged in the body is large it must not be extracted by the opposite side, as it would make the wound too large. He directs us to draw it back by means of an instrument invented by Diocles, of which he gives a description. Another class of weapons which must sometimes be extracted are leaden balls, stones, or any such thing which breaks the skin, and is buried within. In all such cases the wound, he says, must be enlarged and the body extracted with a forceps. A complication which increases the difficulty of extraction arises from the weapon being lodged in a bone, or between two bones at a joint. When lodged in a bone it is to be moved about until loosened, when it is to be grasped with a forceps and extracted in the same way that a tooth is pulled out. It rarely happens that the weapon cannot be removed in this way; but if it remain fixed in the bone, it is to be struck with some iron instrument until it be shaken from the place where it is lodged. When other means do not succeed, the bone is to be perforated with a trephine. When the body is lodged in a joint between two bones, the two members about the wound are to be wrapped round with strips of cloth, or leathern thongs, and thereby separated by pulling in opposite directions, by which means the space between them will be slackened, and then the weapon may be removed without difficulty. When the weapon had been poisoned, these things must be done with all possible despatch, and the remedies applied which are used when a poison has been swallowed, or a person has been stung by a serpent. The wound from which a weapon has been extracted requires no other treatment than what is applicable for ordinary injuries. (vii, 5.)

Albucasis borrows mostly from our author the account which he gives of the construction of weapons and the symptoms occasioned by the wounds which they inflict. He also relates some interesting cases of recovery from very severe wounds. An arrow entered at the root of a man’s nose and was extracted by Albucasis behind his ear; and the man recovered without having sustained any injury to the eye. He extracted another large arrow which had lodged deep below the eye of a Jew; and in this case also the sight was not impaired. He extracted a barbed arrow which had lodged in the throat of a Christian, by enlarging the wound, and the man recovered. An arrow had lodged in a man’s belly, so that, at first sight, Albucasis considered the case as hopeless; but, after thirty days, as no mortal symptoms had supervened, he enlarged the wound and extracted the weapon. He saw a man who had got an arrow lodged in his back; the wound healed, but after an interval of seven years the weapon came out below his buttocks. He knew a woman who had an arrow lodged in her belly, and the wound healed, and the weapon never afterwards occasioned her any inconvenience. He knew a man who had an arrow lodged in his face, and the wound healed up, and never gave him much trouble. He relates that he extracted an arrow which had been buried in the nose of a prince, after making various fruitless attempts for the space of four months. He then delivers general directions for the extraction of weapons, borrowing, as usual, very freely from our author. When a weapon cannot readily be got extracted at the time, he recommends us to let it alone until it become loosened by the putrefaction of the surrounding parts. When impacted in a bone, he directs us either to move it about until it is loosened, or to perforate the bone with a trephine. When lodged in the cranium, it is to be removed in like manner with a trephine, provided the dura mater is not injured, for if it is wounded the case must not be interfered with. When a weapon is lodged deep in any part of the body where there are no large nerves, veins, or bones, he directs us to enlarge the wound and extract the weapon; but if it has barbs, the fleshy parts about it must first be carefully separated to prevent them from being torn. When a weapon passes through a limb, or attaches one part of the body to another, he directs us to cut off the part which projects, and then extraction may easily be accomplished. If fastened in a bone, he advises us to turn it round so as to loosen it; and if that does not suffice, he recommends us to leave it for a few days, when it may be extracted without difficulty. If the shaft or wooden part of a weapon be broken off, he directs us to apply to the head an impellent instrument with a concave extremity, so as to adapt itself to the form of the body which is to be extracted. When the weapon is poisoned, he recommends us, if possible, to cut out the flesh around it. When a weapon lodges in the breast, belly, bladder, or side, and can be felt with a probe, he directs us to cut cautiously upon it, taking care not to wound a vein or nerve. He concludes with giving drawings of forcipes and impellents. (Chirurg. ii, 96.)

Rhases gives sensible directions for the management of these cases, but they are so similar to those of our author that we need not dwell upon them. If the size of the wound permit, he directs us to introduce a forceps to the iron head and draw it out. If the opening be too small, he recommends us to enlarge it. When the weapon has nearly passed through the limb, he advises us to push it out at the opposite side. Thorns and such like sharp things are to be removed by the application of extractive plasters. (Ad Mans. vii, 25.)

Avicenna gives a literal translation of the present chapter of Paulus, and supplies nothing additional of much interest. (iv, 4, 2, 10.)

The account given by Haly Abbas is full, but like that of Albucasis. He mentions that he had seen cases in which an arrow had been lodged in the intestines, and although fæces were discharged by the wound, the patient recovered. He adds that others relate cases in which recovery took place although the liver or omentum had been wounded. (Pract. ix, 15.)

The rules for the extraction of weapons laid down by Theodoricus and all the earlier authorities are mostly copied from the ancient authors. (i, 22.)

It would be naturally expected that we should give some account in this place of the surgery in the heroic ages, as far as it can be learned from the poems of Homer and the Commentary of Eustathius. The Commentator remarks that three methods of extracting weapons are mentioned by Homer: 1. By evulsion or pulling the weapon backwards, as in the case of Menelaus. (Iliad, iv, 214.) 2. By protrusion or pushing it forwards, as in the case of Diomedes. (Iliad, v, 112.) 3. By enlarging the wound and cutting out the weapon, as practised by Patroclus in the case of Eurypylus. (Iliad, xi, 218.) He further remarks that it appears to have been a common practice to suck a wound with the mouth; and, he adds, that this method was still in use among a barbarous people in his days. (Iliad, iv, 219.) The weapons used in the Trojan war were swords, spears or javelins, stones flung by the hand or by a sling, hatchets or axes, as used by the Trojans on certain occasions (Iliad, xii, 590), and arrows. Eustathius remarks, however, that there would appear to have been very few bowmen. In his Commentary on the Odyssey he states that poisoned arrows were never employed in war, but only for killing wild beasts. (Odyss. i, 260.) We believe that no weapons of iron were used in the war of Troy, and that they were all made of copper. (See Jameson’s Mineralogy, iii.) Little transpires from Homer with regard to the internal treatment. In one place (Iliad, xi, 638) mention is made of a mixture of wine and cheese having been given to a wounded warrior, which practice, Eustathius says, had given rise to a variety of conjectures. Some supposed that the wound in the case referred to was so slight as not to render the administration of stimulants improper; others rather believed that the loss of blood had been so great as to call for the use of wine to support the strength. But many, he adds, were of opinion that men in the heroic ages lived so temperately that their constitutions readily bore things on extraordinary occasions, which in after ages were reckoned to be of too inflammatory a nature. This explanation is advocated by Athenæus. (Deipnos, i.) In the Odyssey, mention is made of a hemorrhage being stopped by incantation, which shows, as Eustathius remarks, that amulets and incantations were as ancient as the heroic ages.

SECT. LXXXIX.—ON FRACTURES AND THEIR DIFFERENCES.

Having described the surgical operations on the fleshy parts, we have next to give an account of those which relate to the bones, I mean the treatment of fractures and dislocations; for these also fall under the department of surgery. And first, of fractures, beginning with fractures of the bones of the head, because they hold an intermediate place between the operations on the fleshy parts and the bones, and because the cranium overtops all the other parts. In general terms, then, a fracture is a division of a bone, or rupture, or excision of it, produced by external violence. The differences of fractures are many. A bone, then, is said to be fractured raphanatim, scandulatim, in unguem, polentatim, and per defractionem. A fracture raphanatim is a transverse one through the thickness of the bone, and is called also cucumeratim and caulatim, because cucumbers and cabbages break in this way. Scandulatim is a longitudinal fracture of a bone. In unguem is a fracture at one part straight, and at its extremity lunated, and it is also called arundatim. Polentatim is a fracture of a bone into small pieces; and it is also called nucatim by some: Defractio or præcisio is when part of a bone is taken away with tearing of the skin, so that part is removed and is wanting. These are the differences of fractures.

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COMMENTARY. The following is a list of the ancient authors who have treated of fractures and dislocations: Hippocrates (de Fracturis; de Articulis; de Vulner. Capit.; Officina Medici); Galen (Comment. in eosdem, Meth. Med. vi.); Celsus (viii); Oribasius (de Machinamentis, &c.); Nicetæ Collectio ex Chirurg. Græc.; Apollonius Citiensis (Scholia in Hippocrat. ed. Dietz); Avicenna (iv, 5, 23); Rhases (ad Mansor. vii, 26; Divis i, 140; Cont. xxix); Averrhoes (Collig. vii, 36); Avenzoar (ii, 6, 1); Haly Abbas (Pract. ix, ad finem.)

Hippocrates does not make use of the technical terms explained by our author in this section, and Galen hints that he thinks his Master did better in confining himself to words generally understood. Galen defines only a few of these terms. He calls that kind of fracture in which the end of a bone at an articulation is entirely taken away, âbruptio (ἄπαγμα.) A transverse fracture with a complete separation of the broken portions is called a fracture caulatim (καυληδὸν.) A longitudinal division not attended with an entire separation of the parts is called scandulatim (σχιδακηδὸν.) He thinks the later writers on the subject who had introduced the use of such terms as raphanatim (ῥαφανηδὸν) and polentatim (ἀλφιτηδὸν) had refined too much.

All the terms mentioned by our author occur in a fragment of Soranus, preserved in the collection of Nicetas. They are also treated of very elaborately in the fragments of Heliodorus, contained in the same collection.

Celsus, who was studious of perspicuity and elegance, avoids all technical terms as much as possible. He thus defines the varieties of fractures. A bone, he says, may be split longitudinally like a piece of wood, or it may be broken transversely or obliquely, and its ends may be blunt or sharp, which last variety is the worst of all, as they cannot be easily made to unite with the other parts, and are apt to wound the muscles and nerves. Sometimes the bone is broken into fragments, and in certain bones a fragment is occasionally separated entirely from the broken bone.

The Arabians, especially Avicenna, Haly Abbas, and Albucasis, adopt the terms used by our author. Albucasis remarks, that the fracture of a bone is recognised by the derangement of the broken pieces, by their projection, and the crepitus produced upon pressure. He says, however, that there may be a fissure without derangement or crepitus.

SECT. XC.—ON FRACTURES OF THE BONES OF THE HEAD.

In particular, then, a fracture in the head is a division of the cranium, sometimes simple and sometimes complex, occasioned by some external violence. The differences of fractures of the head are these: a fissure, an incision, an expression, a depression, an arched fracture, and, in infants, a dent. A fissure, then, is a division of the skull, either superficial or deep, when the inward bone is not removed out of its place. An incision, or slash, (ἐγκοπὴ) is a division of the skull with refraction of the fractured bone (if the injured bone be broken off some call the affection deasciatio, i. e. as if done by a hatchet). An expression is a division of a bone into many parts, with a sinking down of the fractured pieces upon the membrane of the brain. A depression (ἐγγίσωμα) is a division of a bone with a sinking downwards of the fractured bone from its natural position towards the meninx. An arched fracture (καμάρωσις), as Galen says, is a division of the skull attended with elevation of the fractured pieces in the middle, and depression around the edges of the sound parts, like as in expression. Such is his opinion. Some enumerate also the capillary fracture, but it is a very narrow fissure which eludes the senses, and therefore, being often overlooked owing to the symptoms of it not being obvious, it occasions death. An indentation is not a division of a bone, and, therefore, such an injury is not properly called a fracture, but is, as it were, a protrusion and bending of the skull inwardly, forming a hollow without a solution of continuity, as when vessels made of copper, or the raw hide of an ox, are struck on the outside. There are two different kinds of indentation, for either the bone is depressed through its whole thickness, so that often a separation of the membrane of the brain takes place, or it is pressed upon by the skull throughout; or sometimes the indentation does not affect the skull through its whole thickness but only its outer plate down to the diploe. To these differences some also add that by repercussion, which happens, say they, when a fracture of the cranium takes place opposite to the part which received the blow. But they are in a mistake, for what happens to glass vessels does not, as they say, happen here; for, this happens to them from their being empty, but the skull is full and otherwise strong. But when many other parts of the head have been struck, as in a fall, and a fissure of the skull takes place without a solution of continuity of the skin, an abscess afterwards forms in it, and being opened, this fissure is discovered, which appears to them to have been occasioned by the blow on the opposite side; and this is to be cured like the fissure first mentioned. If a fracture, then, occur in the head, it is discovered by the sharpness, weight, hardness, or violent force of the body which struck it, and by the symptoms which supervene upon the person who has been struck, such as vertigo, loss of speech, and sudden prostration, more particularly if it be a fracture with depression, or contusion, or expression, or the internally-arched fracture, owing to the compression of the brain. It is also discovered by its appearances to the senses; for if there be a considerable division of the skin we ascertain the occurrence readily thereby; but if there be no division, or a very narrow one, and we suspect a fracture, we make an incision in the skin and ascertain it by the sight, or by probing it with an instrument. If then it be any of the other kinds of fracture it will readily be apparent, but if it is only a narrow capillary fissure which eludes the sense, having poured on the part some black liquid medicine, or the common writing ink, we scrape the bone, for the fissure appears black, and we must go on scraping until the symptoms of the fissure disappear; but if it extend to the membrane we must desist from the scraping, and endeavour to ascertain whether the membrane has separated from the bone or remains fixed. For if it remain, the inflammation of the wound continues moderate, the patient gets gradually freed from the fever, and the pus appears concocted. But if the membrane has separated, the pains increase and the fever in like manner, the bone changes colour, and then unconcocted pus is discharged; and if the person who has the charge of it neglect the case, and has not recourse to perforation, still more grievous symptoms will come on, vomiting of bile, convulsions, disorder of intellect, and acute fever, under which circumstances one must decline operating. But if these are not present, and the membrane has not separated, and if the fracture be a mere fissure, it may be cured by scraping alone, although it be of considerable depth. If it extend to the diploe only it is to be scraped down to it, or the broken bone removed, as will be described. If broken into small pieces, these also are to be extracted with a convenient instrument. And if the membrane separate, and you have treated the patient from the commencement, and if it be winter, endeavour by all means to effect the removal of the bone before the fourteenth day; but, if in summer, before the seventh, while the afore-mentioned symptoms have not come on you may operate in this way:

The Operation.—Having first shaved the head about the wound, we make two incisions intersecting one another at right angles like the Greek letter Χ, one of them being the wound already existing; then dissecting the four angles at the top, so that the bone about to be perforated may be wholly laid bare, if there be bleeding we apply pledgets moistened in oxycrate, but if not dry ones; and then applying a compress out of wine and oil, we use a proper bandage; and next day, if no new symptom supervene, we proceed to perforate the affected bone. Wherefore, having placed the patient on a seat, or in a reclining posture suitable to the wound, and stuffed his ears with wool in order to avoid the noise of the perforation, we loosen the bandage from the wound, and having removed all the dressings and sponged it, we direct two assistants with small twisted bands to retract the four angles of the parts lying over the fracture, and if the bone be weak, either naturally or from the fracture, we cut it out with counter-perforators, beginning first with the broader ones and changing to the narrower, and then using those which are of the form of a specillum, striking gently with the mallet to avoid shaking the head. But if the bone be strong it is to be first perforated with that kind of perforators called abaptistæ, which have certain eminences projecting a little above the point that prevent them from sinking down to the membrane, and then, by using the chisels, we remove the fractured bone not at once, but by pieces, if possible with the fingers, or otherwise with a tooth forceps, or bone forceps, or hair-nippers, or some such instrument. The space between the perforations should be as great as the breadth of the largest head of a specillum, and its depth should be until it is near the inner surface of the bone, taking care that the perforator (trepan?) do not touch the membrane. Therefore, in order to suit the thickness of the bone with the size of the perforator, several ought to be previously prepared for the purpose. But if the fracture extend only to the diploe the perforation should be carried no farther. After the removal of the bone, having cleared away any asperity that remained after the cutting of the bone with a carving instrument, or the extremity of a perforator, using the meningo-phylax as a protector, and bringing away carefully the small bones and spiculæ which remain, we proceed to the application of the dressings. This is the more common, and at the same time the easiest and least dangerous mode of operating; but the method of performing it with a sort of incisor called lenticular is greatly praised by Galen, being performed without perforation after the part has been scraped all round with hollow chisels (κυκλίσκοι). Wherefore he says thus: “If you have once laid bare the place, then applying the incisor, which has a projection at the extremity like a lenticular, blunt and smooth, but sharp longitudinally, when you apply the broad part of the lenticular to the meninx, divide the cranium by striking with the small hammer. For we have all that we require in such operations; for the membrane, even if the operator were half asleep, could not be wounded being in contact only with the broad part of the lenticular, and if anything adhere to the cranium, the round part of the lenticular removes its adhesion without trouble. And behind it follows the incisor, or knife itself, dividing the skull; so that is impossible to discover another mode of operating more free from danger or more expeditious.” But the mode of operating with saws and the instruments called chœnicides or modioli (trepans?) is condemned by the moderns as a bad one, and the operation may be done as we described for fissure. The same mode of removing bones will be applicable in the other fractures of the cranium. But regarding the amount of bones requiring extraction Galen informs us, writing thus plainly: “What parts of a fractured bone are to be removed I will now explain to you in order. When it is greatly bruised it is to be taken out entire, but if certain fissures extend from it farther, as sometimes they appear to do, we must not pursue them to their termination, well knowing that no harm will result from them if everything else be properly done.” After the operation, having dipped a simple linen rag of the size of the wound in oil of roses, we lay it over the membrane as a cover, and in like manner, having dipped a small ball of wool in oil of roses, we put it over the aforesaid rag, and then having moistened a doubled compress in wine and oil, or in the same oil of roses, we apply it to the whole wound, taking care that they be not too heavy for the meninx. We then have recourse to a broad bandage, which also must not be made tight, but so as merely to preserve the pledgets. And the regimen is to be what is called anti-inflammatory and such as is applicable for fevers, frequently bathing the membrane with oil of roses. After the third day loosing them and sponging the part we pursue the treatment applicable for recent wounds and the anti-inflammatory; sprinkling upon the meninx some of the powders called cephalics until it incarnate, and sometimes scraping the bone, if it require it, on account of certain projecting spiculæ, or for the sake of incarnation itself. And we may apply medicines of the ingredients recommended for wounds.

On inflammation of the membrane of the brain. Often after the operation the membrane is inflamed, so as not only to rise above the skull but likewise above the skin, and is attended with hardness, and obstructs the natural pulsatory motion of the brain, in which case convulsions and other severe symptoms, or death, for the most part supervene. It becomes inflamed either from the irritation of some sharp projecting piece of bone, or from the weight of the dressings, or from cold, or from eating too much, or from drinking wine, or some other cause not apparent. If then the cause be obvious it is to be speedily removed, or, if it is not, it will be proper to contend strenuously against it, either by having recourse to venesection, if nothing prohibit it, or to a diet suitable for inflammation. We must also use topical remedies, such as warm embrocations with hot rose-oil, and bathing the part with the decoction of marshmallows, or of fenugreek, of linseed, of camomile, and such like, and cataplasms of raw barley flour, or of linseed with the aforementioned decoction and the grease of a fowl; and irrigations with wool to be poured upon the head and occiput, and some anti-inflammatory oil is also to be poured into the meatus auditorius. The viscera also are not to be neglected, but suitable cataplasms are to be applied to them. And care is to be taken of the whole body, putting the patients into warm baths and anointing them. If the inflammation continues and nothing else prohibit, Hippocrates directs us to purge them with cholagogue medicines.

On blackness of the meninx. When the meninx turns black, if the blackness be superficial, and has been brought on by medicines which have that property, we may remove it by applying three parts of honey with rose-oil upon pledgets, along with the other suitable treatment. But if the blackness has come on spontaneously, more particularly if deep-seated, and be attended with other dangerous symptoms, then we must refrain from using them, for these appearances indicate a dissolution of the natural heat. I knew a person who had his skull trephined a year after the accident, and recovered. The fracture was from a weapon, and was situated on the bregma, and the discharge having an outlet, the meninx was thereby preserved free from injury.

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COMMENTARY. Hippocrates very properly lays it down as a rule that no injuries of the head are to be considered as trifling, since wounds affecting only the integuments will sometimes prove dangerous if neglected. He treats distinctly of fissures, contusions, and fractures of the cranium, which is an excellent arrangement of these accidents. Our limits, however, will not allow of our entering minutely into an explanation of his modes of treatment. In fractures of the head he forbids liquid applications, especially wine. He calls the trephine by the name of τρύπανον; and makes mention of a raspatory (ξυστὴρ). It would appear that his object in applying the trepan was altogether preventive; that is to say, that he had recourse to the operation in order to prevent inflammation and swelling of the brain, and not to remove the effects of them. He holds that severe contusions without fracture and fissures are more dangerous than injuries attended with depression and considerable separation of the fractured portions, and it is in the former class of cases that he recommends trepanning. When the bone is broken into several pieces, he says it stands in no need of the trephine. One of the varieties of fracture, which he describes with surprising accuracy, is the separation of the bones at a suture. It, he adds, seldom requires the use of the trephine. He remarks, that convulsions often occur in consequence of injuries of the head, and that the convulsions are in the opposite side to that in which the injury of the brain is seated. He gives an excellent account of erysipelas of the face supervening upon injury of the head, and recommends it to be treated with cholagogues. Altogether, his work ‘On Injuries of the Head’ bespeaks extensive acquaintance with the subject, and we need have little hesitation in pronouncing it to be one of the most valuable relics of antiquity. In one of his aphorisms, he states that concussion of the brain occasions loss of speech; that is to say, as Galen explains his meaning, superinduces apoplectic symptoms.

Galen mentions three sorts of instruments for operating upon the cranium, namely the cyclisci, the lenticulars, and the narrow raspatories. Fractures are classed by him into those which extend only to the diploe, and those which penetrate to the inner surface of the bone. He likewise divides them into simple fissures, contusions, and depressions inflicted by the body, which occasioned the injury. When the fissure extends down only to the diploe, he directs us to scrape down the bone with raspatories, and then to apply the medicines called cephalics, consisting of Illyrian iris, the farina of tares, manna, birthwort, and panacea. Of the fractures which extend to the meninx, if a simple fissure, it may be treated in the same manner by raspatories; but if attended with contusion, by perforating it all round with an auger (trepan?), and then using the scalpel, or by means of the cyclisci at once. Some, he says, instead of these instruments, use the abaptista, which had a circular border projecting a little above the sharp extremity of the perforator. Some, he says, from timidity, use only the instrument called chœnix (modiolus). Of all modes, however, he prefers that by the lenticular, as stated by our author. He then defines the engeisoma and camerosis, which we have translated the depressed and the arched fractures, the former being attended with depression, and the latter with elevation in the middle of the fracture. These are to be taken out entire by means of a lenticular or bone forceps. This, by the way, was the practice of the celebrated Heliodorus, of whose opinions on this subject we will give a short abstract below. (Nicetæ Collectio.) Such is Galen’s general treatment of fractures of the skull. In a word, he lays it down as a rule, that parts which are greatly comminuted, must be entirely removed; but that fragments, which extend far, must not be followed to their extremities. He forbids the use of bandages. He mentions having trepanned the head occasionally, but states that he generally left this task to the Roman surgeons. Sprengel remarks, that Galen was averse to the use of the trepan, and preferred the two instruments called by him φακωτὸς and κυκλίσκος. The latter, he remarks, was, properly speaking, a hollow chisel (un ciseau creux), which he drove in with a hammer. The former was a true lenticular-knife, resembling that described by Petit and Bell (Hist. de la Méd., 18.)

We will now attempt an abstract of Celsus’s lengthy account of these accidents. When the skull has been struck, he recommends us in the first place to inquire whether the person has vomited bile, has experienced dimness of vision, with loss of speech, or a discharge of blood from the nose and ears; whether he fell down at the time, and if he lay in a comatose and senseless state. These symptoms, he says, indicate a fracture of the bone, and the accident is to be looked upon as serious. But if torpor has come on, with mental aberration, paralysis, or contraction of the tendons, it is probable that the membrane of the brain has been injured, and little hopes of recovery need be entertained. In order to ascertain whether or not the bone be fractured, nothing answers better, he says, than making an examination with a specillum (sound), that is neither too sharp nor too blunt. If the bone is felt to be everywhere smooth, we are certain that it is sound; but if roughness is detected, we know that it is occasioned by a fracture. He warns us, however, not to mistake a suture for a fissure, as was once done by Hippocrates, upon whom he bestows a merited eulogium for this frank confession of his own blunder. When this method of inspection does not succeed, he advises us to pour writing ink on the part and to scrape the bone, which will appear black when there is a fissure. Sometimes, however, he adds, the blow has been sustained on one part of the skull, and the fissure occurs in another. This is the case of fracture by repercussion, of which we will make further mention afterwards. Celsus says, we ought to suspect the existence of it when symptoms of fracture have occurred without our being able to detect one in the part which received the blow. He also recommends us, if softness and swelling be detected in any part, to examine it, as it is likely that a fissure of the bone may be found there. (By the softness and swelling, of which he speaks, he probably meant the puffy tumour, described by Mr. Pott, in his work on ‘Injuries of the Head.’) Sometimes, he adds, but rarely, although the skull be safe, a vessel in the membrane of the brain bursts and pours forth much blood, which, becoming coagulated, occasions great pain and dimness of sight. In such a case, he says, the pain will point out the seat of the extravasation, and if an incision be made in the skin, the bone will be found to be pale—“eo loco cute incisâ, pallidum os reperitur.” (Heliodorus, in like manner, states that when extravasation has taken place within the cranium, the bone will be found to be pale—Nicetæ Collectio.) The fact that in cases of extravasation below the skull the bone is pale, that is to say, does not bleed, is pointed out by Mr. Abernethy as an unerring guide to practice in such cases. He says, “unless one of the large vessels of the dura mater be wounded, the quantity of blood poured out will probably be inconsiderable; I believe that a bone so circumstanced will not be found to bleed.” Celsus then proceeds to the description of the operation. If the injured portion of the bone is not sufficiently exposed, he directs us in the first place to enlarge the wound of the integuments. The periosteum is then to be scraped away with a raspatory. The form of the incision, if made solely by the operator, is to consist of two cross lines intersecting one another like the letter Χ, from the extremities of which the skin is to be dissected away. If there be a discharge of blood it is to be stopped by a sponge dipped in vinegar, or by compresses, while the head is elevated. In cases of fracture and fissure of the cranium, the ancient surgeons, he says, had immediate recourse to instruments for cutting out the part; but he recommends the surgeon, in the first place, to try the effect of applications for allaying the irritation, such as suitable plasters, with wool soaked in vinegar, proper bandages, and the like. This treatment is to be continued for five days, and on the sixth the part is to be fomented with a sponge soaked in warm water. If the skin begin to heal, and the fever to abate, and if the appetite return, with sound sleep, he recommends perseverance in the use of these applications. In this manner, he adds, fissures will often be filled with callus; thus, also, bones more extensively fractured may become united with callus, which forms a much better cover to the brain than the common integuments after a piece of bone has been cut out. But if, on the other hand, fever set in at the first with disturbed sleep, a copious discharge from the wound which shows no appearance of healing; if the glands of the neck swell, or if violent pain comes on, with loathing of food, the surgeon must proceed forthwith to the operation. Dangerous consequences, he adds, may arise either from a fissure or a depression. A fissure may allow fluids to descend to the membrane of the brain, and thereby give rise to pain and inflammation. A depression in like manner may occasion irritation, and spiculæ of bones by wounding the brain may prove particularly troublesome. As a general rule, he recommends as little of the bone as possible to be removed. If the one edge overtop the other, it will be sufficient to remove with a raspatory the prominent part; for when it is taken away there will be a sufficient opening for the cure. If the edges are firmly compressed together, a hole is to be bored with a wimble (terebra) on its side, at the distance of a finger’s breath, and from it two lines are to be cut to the fissure with a raspatory (scalpel), in the form of the letter V, so that its vertex may be at the hole, and its base at the fissure. If the fracture be long, more of these holes must be cut out. In cases of depression the whole depressed portion must be removed. In whatever way the pieces of bone are cut they are all to be removed by means of a suitable forceps. But we will not occupy more space in explaining his method of operating, as we have been already more than usually prolix. Enough has been said to show that the practice of Celsus was sensible, and in many respects not very different from that which is now followed in such cases. It will be seen that he was not forward to perforate the skull, and that many of the rules of treatment lately laid down as new discoveries are distinctly mentioned by him. For a description of the instruments used by him, namely, the modiolus, terebræ, and scalper excisorius, we must refer the reader to the original work. (viii, 3.)

The different kinds of fracture to which the skull is subject, and the treatment of them, are given very minutely in the Fragments of Heliodorus, published by Cocchi (Ch. Vet. 100, &c.); but as the views of the subject there laid down are nearly the same as our author’s, we shall only give a few specimens of the doctrines he inculcates. He describes very distinctly the species of fracture called diastasis, namely, the separation of two bones of the head at a suture. He directs that the head should be moulded into its former shape, and secured with compresses and tight bandaging. When matter forms he recommends it to be cut down upon. When depression of the bone without fracture occurs in children, it is not to be much interfered with, if no untoward symptoms come on. But if any collection take place, it is to be evacuated, even if trepanning should be required for this purpose. He says, in the treatment of simple injuries of the scalp, that the cure by the first intention is the quickest, but the suppurative the safest. In the same Collection there are a few fragments of Archigenes, containing some curious and important matter. He describes diastasis of the bones with more minuteness than any other ancient author, but does not touch upon the treatment. He appears to treat of hernia cerebri under the name of hypersarcosis, and recommends the excrescence to be removed, with septic medicines or the scalpel, down to the membrane (dura mater); after which a light dressing dipped in rose-oil is to be applied, and the part surrounded with a circular bandage. (Chirurg. Vet. p. 119.) Effusion of blood within the cranium is indicated by fevers coming on with chills, inordinate heat, disturbed sleep, eyes glossy, muddy, and red, loss of flesh, &c. In such cases, he remarks, if operated upon speedily, they exhibit promises of recovery, but generally soon die. (Ibid. 117.)

Albucasis enumerates the same varieties of fracture as our author, and his description of the operation is little different. The drawings which he gives of the surgical instruments used by the ancients in operations on the head are interesting, as they tend to illustrate the descriptions of Paulus and the other authorities. We may remark, by the way, that his abaptista, which he calls terebra non profundantia, are a sort of spear-shaped instruments, having a globular ball a short way above their extremity. They, therefore, had no resemblance to a modern trephine with a conical crown.

Avicenna gives a very full account of injuries of the head, but it is taken almost word for word from Galen and our author. Nearly the same may be said of Haly Abbas.

Avenzoar states that trepanning the skull will be proper when there is fracture with depression; but laments that in his time it would be difficult to find a surgeon capable of performing the operation. Averrhoes likewise intimates that he did not know a surgeon who could trepan the skull. This is an additional proof to what we have mentioned in the section on amputation that the Arabians in general were very timid operators.

Rhases strongly inculcates the propriety of having recourse promptly to the operation, when the bone is fractured and depressed, before dangerous symptoms have come on. Unless there be pressure on the brain, however, he does not approve of having immediate recourse to the operation.

It will be remarked that Celsus affirms, and our author denies, the occurrence of fracture by repercussion. It is the same as la fracture par contre-coup of the French medical authors, or the counter-fissure, namely, the fractura per resonitum of the earlier authorities. Soranus, who, like Celsus, believes in its occurrence, defines it to be a fissure which takes place in the part of the cranium opposite to that which received the blow. (Nicetæ Collectio.) Hippocrates himself makes mention of the counter-fissure, and pronounces it to be incurable, as the surgeon has no certain data to discover its existence. (Vul. Cap. viii.) Tulpius, Paré, and Van Sweiten have related cases of the counter-fissure. (See Comment. in Boerhaav. Aph. 254.) Heister also believed in its occurrence. (Chirurg. i, 1, 14.) For cases of it he refers to D. Wagnerus, (Dissert. de contra-fissura,) and Le Maire (De resonitu.) He is mistaken, however, when he quotes Ægineta as an authority for it. Sabatier relates a case of fracture par contre-coup in the sternum occasioned by a fall on the back. (Mémoires de l’Institut Natural, ii, 120.) See also Sprengel (Hist. de la Méd. 17.) Garengoit further relates various cases of the contre fissure. Bertaphalia defines it in much the same terms as Soranus. (v, 5.) Mr. Guthrie treats learnedly of this subject; but although he quotes many instances from the earlier authorities of fracture on one side of the head from a blow on the other, he states that in later years there is little proof of such an occurrence taking place. He admits, however, as indisputable the occurrence of fracture at the base of the skull from a blow on the vertex or back of the head. (Injuries of the Head, 65.) He also states that the term ἀπήχημα of our author, and that of ‘resonitus,’ as used by Latin authors, was applied to that species of fracture when the inner plate of the skull is knocked in or fractured, without the outer one being injured. (Ibid.) It does not appear, however, that the ancients applied the term in this sense. Thus Soranus, as stated above, defined it to be a fissure produced in the parts of the skull opposite to those which have received the blow. See the learned note of Cocchi. (Ap. Chirurg. Vet. 47.) Galen’s definition is to the same effect. (Ibid. 107.)

The treatment here recommended for inflammation of the membranes of the brain is so judicious, that even at the present day scarcely any improvement could be made on it. Our late authorities have shown the utility of cholagogue purgatives in such cases, and it will be remarked that they are recommended by our author and Hippocrates. (De Cap. Vuln. 27.)

Celsus directs us, when the dura mater gets inflamed and swelled, to pour tepid rose-oil upon it; and if it rise above the bone to apply lentil or vine leaves pounded with fresh butter or the grease of geese. He enjoins us to avoid all kinds of food requiring mastication, also smoke and sternutatories. When the brain projects beyond the bone (a case called hernia cerebri by modern surgeons), he advises us to sprinkle it with squama æris, and to use cicatrizing applications. A person who has sustained a fracture of the skull is advised to avoid the sun, wind, frequent baths, and the free use of wine until the wound is healed.

Aëtius recommends bleeding and laxative clysters. (vi, 47.)

Heliodorus recommends abstinence at first, and afterwards spare diet, water for drink, bleeding, when the inflammation is violent and the patient full, light dressings, cataplasms of melilot, linseed, and oil, and fomentations with decoctions of fenugreek or mallows. Archigenes directs us when there is a fungous tumour projecting above the bone, to remove it with septics or the scalpel, and then to apply pledgets. (Nicetæ Collect.)

Avicenna and Albucasis repeat our author’s directions. Haly Abbas follows in the same strain, recommending us to remove any cause of irritation, to pour refrigerant oils on the place, and to have recourse to venesection. (Pract. ix, 85.)

Our author having alluded to the pulsatory motion of the brain, we will state briefly the opinions of the principal ancient and modern authorities on this matter. Besides our author, Hippocrates, Galen, Oribasius, and Aëtius, among the ancients, mention a certain movement of the brain, namely, a swelling up during expiration, and a falling down during inspiration. Fallopius, Vesalius, Voltherus, Coiter, and Boerhaave maintained that this opinion is unfounded. But Columbo, Piccolomini, Dulaurens, Riolan, Littré, and more recently, Schliting, Lamure, Haller, Lorri, Vic d’Azyr, and Dumas, have reproduced this ancient truth. We once had an opportunity of observing the pulsatory motion of the brain in the case of a poor boy who had lost a considerable piece of the skull by exfoliation.

This would appear to be the most suitable occasion which we shall have to introduce an account of the osseous tumour, nearly all the information regarding which is derived from a fragment of Heliodorus. He describes it as a hard resistent tumour, immoveable, without pain, or change of colour. He says it occurs on all parts of the body, but more especially on the head, about the temples, when if one is formed on each side they are called horns. He directs that the tumour should be cut out from the very base, and the bone scraped with a raspatory. The wound is to be healed by glueing (the first intention?), if possible, but otherwise by suppurative applications. (Ch. Vet. 124.)

SECT. XCI.—ON FRACTURE AND CONTUSION OF THE NOSE.

The under part of the nose being cartilaginous does not admit of fracture, but it is liable to be crushed, flattened, and distorted; but the upper part being of a bony substance is sometimes fractured. In such cases Hippocrates prohibits bandaging, which only increases the flatness and distortion, unless when from a blow the parts about the middle of the nose protrude. For in these cases he applies a suitable bandage with medicines, in order to give the nose its proper shape. When, therefore, the nose is fractured in its under parts, having introduced the index or little finger into the nostril, push the parts outwards to their proper position. When the fracture is of the inner parts this is to be done with the head of a probe immediately, during the course of the first day, or not long afterwards, because the bones of the nose get consolidated about the tenth day. But they are to be put into the proper position with the index-finger and thumb externally. In order to prevent the bones from changing their position, two wedge-like tents, formed of a twisted linen rag, are to be applied, one to each nostril, even if but one part of the nose be deranged, and these are to be allowed to remain until the bone or cartilage gets consolidated. And some sew the quills of the feathers of a goose into the rags, and thus introduce them into the nose, in order that they may preserve the parts in position without obstructing the respiration; but this is unnecessary, as respiration is carried on by the mouth. If the nose become inflamed we may use some anti-inflammatory application to it, such as that from juices (diachylon), the one from vinegar and oil, and such like; or a cataplasm of fine wheaten flour boiled with manna or gum may be applied, both for the sake of the inflammation and in order to keep the nose in position. When the nose is distorted to either side, Hippocrates directs us, after it has been restored to its proper position, to take a piece of leather of a finger’s breadth, and having spread one of its ends with taurocolla or gum, to fasten one extremity of it on that side of the nose to which it inclines, and after it dries to bring the thong by the opposite ear to the occiput and forehead, and to fix the other end of the thong firmly there, so that the nose being drawn sideways may take the proper position in the middle. This practice, however, is not much approved of by the moderns. If the bones of the nose are broken into small pieces we must make an incision or enlarge the wound, and having removed the small bones with a hair forceps, unite the divided parts with sutures, and use the applications for recent wounds and those of an agglutinative nature. If there be a sore within the nose it is to be cured with the pledgets called lemnisci, spread with suitable ointments. Some also use leaden tubes until it cicatrize, lest a fleshy excrescence should arise from the ulcer.

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COMMENTARY. Some account of Hippocrates’s practice is given by our author. As here mentioned, he strongly disapproves of bandages which, he says, never fail to disappoint the expectations of both surgeon and patient. He directs us to replace the broken parts, either with the fore-finger or a specillum. He also describes the application of the piece of thong; a distinct account of which is given by our author. (De Articulis, 30.)

Galen, in his ‘Commentary,’ explains the obscurities in the text, but supplies no additional facts or views of practice. He greatly disapproved of agglutinative applications and bandages. (Fragmentum ap. Nicetæ Collect.)

Celsus gives a full account of fractures of the nose, but as he follows the plan of treatment recommended by Hippocrates, it will be unnecessary to dwell long upon it. When the cartilages are fractured, the pieces are to be replaced with a specillum, or with two fingers pressing on both sides; then oblong tents sewed round with a thin soft skin are to be introduced into the nostrils; or a large quill smeared with gum, or artificers’ glue may be applied in like manner. He speaks of the leathern thong, but uses it under somewhat different circumstances than those for which our author recommends it. He directs us to fasten the middle of it to the nose, and the extremities to the temples on either side. When any fragment of a bone does not coalesce properly with the rest, he recommends us to extract it with a forceps. The case, he properly states, is more dangerous when there is an external wound; but in this case he recommends us to apply one of the plasters adapted for recent wounds; like the others he disapproves of bandages.

Rhases, Avicenna, Haly Abbas, and Albucasis lay down exactly the same rules of practice as Hippocrates and our author.

The recent authorities consider the introduction of the tents into the nostrils unnecessary, and even prejudicial. (See Bell’s Operative Surgery; Cooper’s Surgical Dictionary.) But the earlier modern writers adopt exactly the practice of the ancients. Theodoricus recommends us to turn the nose to its proper shape when distorted, by means of a strip of linen fastened to its extremity with ichthyocolla, or the gluten of hides, as directed by the ancients. (ii, 29.)

SECT. XCII.—ON FRACTURE OF THE LOWER JAW, AND CONTUSION OF THE EAR.

We have treated of contusion of the ear in the Third Book, as this affection is not of the nature of a fracture. But the lower jaw is fractured from many causes. If, then, it be only fractured externally, and is not divided into two, as it occasions a curvature inwardly, the symptoms of it are obvious. Wherefore, having introduced the index and middle fingers of one hand—of the right, if the right jaw be fractured, and of the left, if it is the left—we push outwards the internal curvature of the fracture, which is to be secured with the other hand externally. The bones of the jaw are ascertained to be set straight by the equality of the teeth. When the jaw is fractured completely across, (that is to say, caulatim,) it is to be set by making extension and counter-extension, with the aid of an assistant; and the teeth, separated at the broken part, are to be fastened together, as Hippocrates says, and bound with gold, namely, with a ligature or thread of gold. But since this is not readily procured by everybody, a strong flaxen thread, a piece of fine linen, horse-hairs, or the like, may be substituted. If the fracture be attended with an external wound, we must examine with a probe and ascertain whether a piece of bone be broken off, and if this be found to be the case, and the wound is small, it is to be enlarged and the broken piece or pieces removed with some suitable instrument, and the lips of the wound united with sutures; then dressings suitable to recent wounds with bandages are to be applied. If there be no wound, a simple cerate is to be applied to the jaw along with suitable bandages. In applying the bandage, the middle of it is to be placed on the occiput, and the fold of it brought along by the ears on both sides to the chin, and then from the chin to the occiput again, and then again to the chin, and thence by the cheeks to the bregma, and then again to below the occiput, where the bandage must terminate. Upon these again a cover, that is to say, another bandage, is to be applied to the forehead and fastened behind the head, in order to secure the aforementioned bandages. Some, also, apply a light splint, or a piece of leather of proper size, to the jaw, and bandage it as we have described. Others use the bandage called a muzzle. If both sides of the jaws are separated at the symphysis, having removed them a little asunder with both the hands, adapt them again to one another, and having fastened the teeth together as aforesaid with a ligature, and applied the proper bandages, order the patient to be nourished with thin soups, because mastication is hurtful in this case. And, if you suspect that it has been deranged from its position, loose the bandages on the third day, and apply them again, and do in like manner until the callus be formed. The callus of the jaw-bone is generally formed within three weeks at most, because it is spongy and full of marrow. If any inflammation come on, we must not neglect the embrocations and cataplasms suitable to it; which practice is to be observed in all cases.

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COMMENTARY. Our author’s account of fractures of the lower jaw is taken almost word for word from Hippocrates. (De Articulis.) He divides them into external fractures, and fractures caulatim (or cauledon), which, agreeably to the explanation of this term, given in the 89th section, Galen interprets to be a complete separation of the fractured portions. He directs us to fasten the teeth with a gold thread; and in other respects also his practice is exactly the same as our author’s. His account of fracture at the symphysis is very correct.

Soranus gives a very sensible account of this subject. A transverse fracture, he says, often takes place, but a longitudinal one seldom, and in certain cases it is not attended with any distortion. It is to be recognized by examination with the fingers, when any displacement of the parts and crepitus will be recognized. Fracture in the ramus may be distinguished from dislocation, by there being mobility in the former case, whereas there is none in the latter. (Chirurg. Vet. p. 49.)

Celsus says, that in fractures of the jaw-bone the separated portions are never completely disjoined. When the bone is fairly broken transverse, the tooth at the fractured part protrudes, and is therefore to be secured to the adjoining one with a hair. He then recommends us to apply a double compress, moistened in wine and oil, with agglutinants; and afterwards a bandage or soft piece of leather is to be put on with its middle at the chin, and its extremities fastened above the head. In this, as in every other species of fracture, he recommends at first abstinence, and afterwards, liquid food; not allowing a full diet until the inflammation has subsided. He says, a fractured jaw-bone gets consolidated between the 14th and the 21st day.

Albucasis evidently copies from our author; and Avicenna and Rhases do so avowedly.

Haly Abbas gives a similar account, recommending us to secure the teeth with a thread; and then to apply bandages, and occasionally a compress, as directed by our author.

By the first variety, described by all the ancient authorities, was meant, we suppose, a fracture of the condyle.

SECT. XCIII.—ON FRACTURE OF THE CLAVICLE.

The clavicle in its natural position is united to the sternum at its inner extremity, and at its outer it is articulated with the acromion; and, therefore, as it supports the shoulder and the arm itself, if it undergo a fracture in any part whatever, the portion of it united to the shoulder sinks down, being dragged along with the arm. It is better, then, that the fracture be transverse, and not longitudinal, or partly straight with a lunated extremity, according to the opinion of most surgeons. For that which is fractured transversely, can, by extension and compression with the fingers, be readily restored to its proper position; but the other kinds of fracture have prominences not easily arranged. If, therefore, it be broken in any way through its whole thickness, let one assistant take hold of the arm connected with the fractured clavicle, pulling it at the same time outwards and upwards; and let another pull the opposite shoulder, or at least the neck, and let them make counter-extension. The surgeon then, with his fingers, is to set the fracture, pushing down what is prominent, and drawing outwards what is situated too deep. If more counter-extension be required, a ball of rags, wool, or something such, may be applied below the armpit, and the elbow brought to the rib adjoining to it; and the other things may be done as described already. But if it is found impossible to raise up the end of the clavicle connected with the shoulder that is lodged down below, having laid the man on his back, and placed a moderate cushion under his back, let an assistant push the shoulders downwards, so that the bone of the clavicle which is lodged below may be bent upwards, and then set the fracture with the fingers. But if part of the clavicle be broken off and unconnected, and if we find it irritating the parts, we must make a straight incision with a scalpel and remove the broken portion, and smooth the remainder with chisels, taking care that the instrument called meningophylax, or another chisel be put under the clavicle to make it steady; and if no inflammation is present, we may use sutures, but otherwise, pledgets. And having prepared various splenia (compresses), we must apply the larger and thicker to the projecting part of the bone; and these, when inflammation is present, are to be dipped in oil, but otherwise they are to be applied dry. And having put a moderate ball of wool under the nearer armpit, we apply a suitable bandage round by the armpits, the fractured clavicle and the scapula, bringing the folds in a proper direction; and if the part of the clavicle connected with the shoulder fall downwards, the middle of a broad thong is to be put under the elbow of the same side, and the whole arm suspended by the neck, and the hand is to be slung in another bandage as in cases of bleeding at the elbow. But if, which rarely happens, the outer part be uppermost, we must not have recourse to this arrangement of the arm. The patient must lie in a supine position, and live upon a spare diet, and if necessary, embrocations and other suitable applications are to be made until the callus is formed. The callus of the clavicle is formed in about twenty days at most.

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COMMENTARY. Hippocrates gives such an account of this accident as clearly bespeaks his intimate acquaintance with the subject. Transverse fractures, he says, are easily healed, whereas such as are oblique prove more difficult to manage. He justly remarks, that the deformity occasioned by this injury appears at first very great, and annoys both the patient and his physician, but that it gradually becomes less, and the patient, feeling little inconvenience from it, grows careless, and the physician, seeing no evil consequences result from this neglect, acquiesces in it, and presently it is found that proper callus is formed. Hippocrates further exposes the mistake of those who endeavour to push down the projecting bone, which, he justly remarks, cannot be effected. The part which projects, as he states, is almost universally the extremity attached to the sternum, the other portion being dragged down by the weight of the arm; and hence the mistake is obvious of those who attempt to push down the upper extremity. He recommends the patient to lie in bed until adhesion takes place, which generally occurs between the fourteenth and twentieth day. (De Articulis, 16.)

Galen directs us to apply four splenia or oblong compresses intersecting one another like the letter Χ. (Comment, et Fragment, apud Nicetæ Collect.) When the fracture is near the shoulder, Galen recommends the spica bandage (De Fasciis), for a drawing and description of which, see Heister’s ‘Surgery,’ (p. iii, c. 4, §1, c. 3.)

Celsus agrees entirely with the account of the matter given by Hippocrates. When the bone is broken transversely, he says, it will sometimes unite readily without the application of a bandage. In general, as he explains, the upper end of the fractured portions is the part attached to the sternum, the other being attached to the shoulder and dragged down along with the arm. He mentions that this is so generally the state of the parts, that some great masters of the art had declared that they had never seen a case in which the end attached to the shoulder projected, but that Hippocrates, who is rich in information upon these subjects, had affirmed upon his own authority that such an occurrence is to be met with. In setting the fracture he properly directs us to raise the shoulder; and his mode of bandaging would seem to have been little different from that now generally followed. He directs us to fill the armpit with wool, and to apply over the fractured portions of the bone a compress three times folded, and moistened in wine and oil; or, if the bone is broken into many fragments, a splint formed of cane (ferula). If the bones incline to the common position, the arm is to be fixed to the side, but if the outer end has a tendency upwards, the arm is to be tied to the neck. The man is to be laid on his back. All spiculæ of bones are to be cut out, if it is found that they are wounding the flesh.

Albucasis follows our author closely. He particularly enjoins the surgeon when there are any projecting spiculæ, to make an incision and cut them out; after which, a suture may be used to heal the integuments, provided the wound is large. A compress, soaked in rose-oil, vinegar, and wine, is to be applied to allay inflammation. He directs the patient to sleep on his back with a pillow under his armpit.

Rhases, Avicenna, and Haly Abbas give exactly the same account of the accident as Albucasis and our author.

SECT. XCXIV.—ON THE SCAPULA.

The scapula is not fractured in its broad and tabular part, but a fracture may sometimes take place at its spine. The fracture being sometimes what is called by expression, sometimes a simple fracture, and sometimes a piece is broken off. The expression, then, is ascertained by the touch, exhibiting a hollow, and occasioning torpidity of the adjacent arm and a throbbing pain. Simple fracture is known by its roughness and local pain. Both are to be managed according to the anti-inflammatory plan of treatment. When a piece is broken off, which also may be ascertained by the touch, if it gives no disturbance it may be fixed by a convenient bandage, but when it moves about and produces irritation, it is to be removed by an incision, and sutures used, as described above. Bandages like those for the clavicle are to be applied, and the patient is to be laid on the opposite side.

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COMMENTARY. Hippocrates has not treated particularly of this fracture.

Celsus treats in general terms of the cheek-bone, breast-bone, the broad bone of the scapula, the spine, os sacrum, &c. If there be an external wound, it is to be healed with suitable dressings; after which the fissure or hole in the bone will fill up with callus. If the skin be entire, he merely enjoins rest, a suitable cerate, and gentle bandages.

Albucasis and Avicenna, as usual, copy from our author. The former states that fractures of the scapula are healed in twenty or twenty-five days. Haly Abbas, like the others, directs us to remove any spiculæ which occasion irritation, to apply soothing cataplasms, and suitable bandages. Rhases remarks that the body of the bone is little subject to fractures, but that its extremities may be broken off. A fracture of the hollow portion of it is ascertained by a rising in the part; fissures are recognized only by the local pain.

SECT. XCV.—ON THE BREAST-BONE.

The middle of the sternum is fractured by simple division and by expression, and the extremity of it is broken off. When, therefore, the fracture is deranged, pain and inequality of the place follow, and there is crepitus upon pressure with the fingers. When by expression, there is violent pain, dyspnœa, and cough, owing to the pleura being irritated; and rarely there is vomiting of blood, a hollow in the fractured place, and yielding thereof. The same treatment is to be applied as that recommended for the scapula. When the fracture is by expression, we may practise Hippocrates’s mode of setting which he recommended for the clavicle when it inclines inwards, having recourse to the supine posture, the application of a cushion upon the back, pressing down the shoulders, and drawing the sides together with the hands. The sides being covered with wool, we apply a circular bandage, having first put on two thongs straight from the shoulders, so that afterwards the two ends may be united in a proper manner, and prevent the circular bandage from falling off.

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COMMENTARY. Hippocrates holds injuries of the sternum to be more dangerous than those of the ribs. He recommends in this case a light diet, rest, silence, bleeding at the arm, and so forth. (De Artic. 50.)

Celsus directs this fracture to be treated upon general principles, as explained in the preceding section.

The Arabians evidently follow our author. Albucasis speaks of applying thin splints.

The reader will find, upon reference to the ninetieth section, that a fracture by expression is a comminuted fracture with depression.

SECT. XCVI.—ON THE RIBS.

Of the ribs, called also spathæ, those which are long admit of a fracture in any part, but the false only at the spine, because there only they are of a bony nature; for at their anterior part they are cartilaginous, and are liable to be crushed, but not fractured. The diagnosis is not difficult, for an inequality presents itself to the fingers of the examiner, and there is crepitus with derangement at the fractured part. When the fractured parts incline inwards there is a violent pungent pain, more severe than that in pleurisy, from the pleura being wounded as with a sharp instrument; there is difficulty of breathing, cough, and often vomiting of blood. The other modes of displacement, then, may be rectified by the fingers, but in that inwards this cannot be done, owing to the difficulty of applying distension. Wherefore, some direct us to give much flatulent food, in order that by the inflation and distension occasioned by it the fracture may be propelled outwards. But this is not necessary, for there is no communication between the chest and the organs of nutrition, and besides, the inflammation will be augmented by repletion. Others apply a cupping instrument, which is not amiss, unless a collection of humours should be occasioned by the suction, and the fracture be thereby pushed more inwardly. Wherefore, Soranus says, “Let the parts be covered with wool dipped in hot oil, and let the intercostal space be filled with compresses, in order that the circular bandage applied, as in the case of the sternum, may lie smooth. And let everything be done, as in pleurisy, according to the degree of accident. But if any great necessity compel us, owing to the pleura being irritated, we must divide the skin and lay bare the broken part of the rib; and then putting the instrument for protecting membranes under, to prevent the pleura from being wounded, cut off properly, and remove the irritating pieces of bone. After this the parts which are not inflamed are to be united and cured as recent wounds; but such as are inflamed are to be covered with pledgets dipped in oil. The diet and treatment must be anti-inflammatory, and the patient is to be laid in the easiest posture.”

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COMMENTARY. Hippocrates gives a full and accurate account of this accident. He remarks that when the broken ends of the bone are not pushed inwards, it seldom happens that fever or any unpleasant symptoms supervene. When fever is not present he thinks that abstinence by occasioning an emptiness of the belly, proves rather prejudicial by removing what otherwise tends to support the part affected, which is thereby made to hang unsupported. In this case a slight bandage will be sufficient. The ribs, he says, become united in about twenty days. When the skin about the ribs is bruised by a blow or any other such cause, much blood, he says, is often vomited up. Galen, in his commentary on this passage, states that when the vessels of the pleura are wounded and blood effused into its cavity, a spitting of blood may take place although the lungs themselves have not been injured. The treatment recommended by Hippocrates consists of bleeding at the elbow, enjoining silence, applying folded compresses with broad bandages, neither too tight nor too loose. He directs us to use a double-headed bandage, and to commence at the seat of the fracture. He approves of gentle aperients and restricted diet for ten days, after which period nourishing food is to be given. He adds, that when the proper treatment is neglected, even if no other inconvenience should result from it, a viscid collection is sure to form in the part. When, in addition to this swelling, a chronic pain gets seated in the part, he advises the actual cautery to be applied. (De Articulis.)

Celsus, with his characteristic elegance and terseness, expounds the rules of practice delivered by Hippocrates. He directs us to apply a bandage, to bleed from the arm, to open the belly; to avoid noise, speaking, tumultuous passions, smoke, dust, and whatever is calculated to excite coughing and sneezing. Gruels only are to be taken before the seventh day, after which bread may be used. When the pain is violent he directs us to apply a cataplasm made from darnel, or barley with fat figs. Should a collection of matter take place it is to be opened with a red-hot iron. When mucus forms about the fracture, he recommends the application of the cautery. The above is but an imperfect outline of his admirable chapter on fractures of the ribs.

Avicenna professedly copies from our author. Haly Abbas, Rhases, and Albucasis give nearly the same account, without the slightest addition of any importance. They all approve of making an incision and extracting the pieces of bones which may happen to be irritating the pleura. Albucasis gives a drawing of the meningophylax, or instrument for protecting membranes during the sawing of bones.

SECT. XCVII.—ON THE BONES OF THE HIPS AND PUBES.

The bones of the ischium or hips are rarely fractured indeed, but admit of the same varieties as those of the scapula. Their extremities, then, are sometimes broken off; there may be fracture along their length, and the middle may be fractured by expression. They are attended with a local pain, a pungent and throbbing sensation, and torpor of the leg on that side if from expression. It is to be set in the same way as that of the scapula, only it does not admit of the extraction of broken pieces by an operation on account of the external parts. If necessary, it is to be set by the fingers, and afterwards we must apply the other convenient treatment, using embrocations, and filling up the hollows of the loins with compresses, in order that the circular bandages which are put on may lie even. The same things may be said with respect to the bones of the pubes, for we have nothing more particular to say of them.

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COMMENTARY. The other authorities do not treat of these cases so minutely as our author, whose account of them is sufficiently accurate.

Celsus merely directs us to treat them upon general principles.

Albucasis recommends the same plan of treatment as our author, with the addition of splints made of wood or leather. These, however, cannot be very much required. He directs the patient to lie on his back or on the sound side.

Avicenna does not treat of these cases of fracture. Haly Abbas and Rhases abridge our author’s account.

SECT. XCVIII.—ON THE VERTEBRÆ, SPINE OF THE BACK, AND OS SACRUM.

The round bodies of the vertebræ may sometimes be crushed, but rarely undergo fracture, in which cases the membranes of the spinal marrow or the marrow itself being compressed, sympathetic nervous affections take place, and death speedily follows, more particularly if the vertebra of the neck be affected. Wherefore, having first given warning of the danger, we must, if possible, attempt to extract by an incision the compressing bone, or if not we must soothe the part by the anti-inflammatory treatment. But if any of the processes of the vertebræ, of which the spine, as it is called, consists, be broken off, it will readily be felt upon examination with the finger, the broken piece yielding and returning again to its position, and, therefore, we must make an incision of the skin externally and extract it, and having united the wound with sutures, pursue the treatment for recent wounds. When the os sacrum is fractured the index-finger of the left hand is to be introduced into the anus, while with the other we manage as we best can the fractured bone; or if we feel any piece broken off, we make an incision and lay hold of it, and apply bandages and suitable treatment.

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COMMENTARY. Celsus remarks that when a piece of one of the vertebræ is broken off a hollow is felt in the place, it is attended with pain, and the person is compelled to bend inwards. The treatment is to be conducted upon general principles, as explained under fractures of the scapula.

Albucasis lays it down as a rule that when a fracture of the cervical vertebræ produces paralysis and insensibility of the arms, the case may be abandoned as hopeless. When, after a fracture of the dorsal vertebræ, it is remarked that there is paralysis and insensibility of the lower extremities, and that the alvine and urinary discharges are passed unconsciously, he, in like manner, pronounces the case to be desperate. When a piece of bone is broken off and occasions great irritation, he recommends us, like our author, to make an incision and take it out.

Haly Abbas and Avicenna borrow everything from Paulus.

Rhases gives many curious remarks upon injuries of the spine, but several of them are borrowed from Galen. (De Locis Affectis.) Galen relates many cases to show that retention of the urine and fæces is a common effect of an injury of the spine. He also mentions that loss of speech is sometimes the consequence of the upper part of the spine being injured. Rhases relates the case of a man who lost the sensibility of his arms from an injury of the last vertebra of the neck, produced by a fall from a horse. He states, that when the injury is below the neck the respiration is never affected. He inculcates that whenever there is paralysis of the limbs, or of any part after a fall, it arises from some injury of the spine. (Cont. i.)

When the sacrum or os coccygis is fractured, he directs us to replace the parts by introducing the finger per anum. (Cont. xxix.)

SECT. XCIX.—ON THE ARM.

When the arm is broken Hippocrates makes the extension thus: he says, “We must take an oblong piece of wood, such as that which is put into the holes at the end of spades, and fastening ropes to its extremities, suspend it transversely from some beam, and placing the man upon some elevated object more erect than what is called the erect sleeping posture, we pass his hand over the above-mentioned piece of wood, so that the middle of the wood may be fitted to the armpit, and his arm being bent at a right angle, an assistant stooping down takes hold of the hand, and then some heavy object, such as a stone, a leaden ball, or the like, is to be fastened to the elbow, and being allowed to hang suspended, in this way you must set the fracture, or instead of a weight an assistant may pull down the arm, and instead of the above-mentioned piece of wood some use the step of a ladder.” Soranus, however, proceeds thus: Having placed the man in a chair, or, which is better, as it occasions less disturbance, in a supine posture, then having put a ligature round the wrist and suspended it from the neck so as to preserve its angular figure, we direct two assistants, the one to apply his fingers below the fracture and the other above, and thus to make the extension. Or if we require stronger pulling we apply two equal pieces of thong to the arm, the one above the fracture and the other below, and giving one of the pieces of thong to the assistant who stands above the patient’s head, and the other to the one at his feet, we order them to make counter-extension. If the fracture be near the top of the shoulder we apply the middle of the thong to the armpit and direct the assistant at the head to hold it, and, while the other pulls in the opposite direction, we make the counter-extension as above. And when the fracture is at the elbow, the ligature is to be applied there or at the wrist. The bones of the fracture being properly set, the extension is to be relaxed, and it is to be bound up according to the method of Hippocrates. When the fracture is free from inflammation and recent, we must use linen bandages of a proper length, and three or four fingers in breadth, which have been soaked in water or oxycrate, but when there is inflammation, thin soft pieces of wool steeped in oil are to be used. And if the fracture be at the middle of the arm the bandaging must commence at the fracture, and after two or three turns the bandaging is to be carried upwards, in order, as he says, that the overflow of blood to the part may be intercepted; and it is to terminate there. A second bandage is then to be applied with its head at the fracture, and, having done as in the former case, carry it from above downwards, and again reverting from thence upwards let it terminate there. There should be a moderate degree of tightness according to our own feeling and that of the patient. If the fracture be near the top of the shoulder, the first bandage should take in the acromion, scapula, and sternum, so as to form what is called the crane bandage. The second one is to extend to the elbow, and reverting from thence to the upper parts it is to take in, with the acromion, the scapula and sternum, like the first bandage. If the fracture be at the elbow, the fore-arm is to be taken in with the bandage, the figure of the elbow-joint being preserved. And so in like manner with the other members, such as the fore-arm, the thigh, and the leg; and when the fracture is in any part near a joint, and not in the middle of the limb, the joint is to be bound along with it. After the bandaging the moderns immediately apply splints, in order to preserve the bones which have been set in their proper shape, tightening them agreeably to the patient’s feeling and the swelling occasioned by the inflammation. But the ancients did not apply the splints until after the seventh day, within which period, as the inflammation had declined, the limb had become less swelled. Hippocrates orders the bandages to be loosed every three days, lest, owing to the part being constantly covered up, distension and pruritus should come on, and that the insensible perspiration might not be obstructed after the bone has become firm; for that by these means not only does a painful pruritus take place in certain cases, but ulceration of the skin is occasioned by the acrimony of the sanious humours. He directs us, therefore, to bathe with tepid water, so as to dispel the humours, but after the seventh day to loose the bandages at greater intervals, because the parts no longer require the expulsion of the humours; the formation of callus thus goes on properly. The splints are to be applied in this manner. Compresses, thrice folded and dipped in oil, are to be put upon the bandages, and if the limb be of equal thickness this is to be done even; but if it is of unequal thickness, the hollow parts are to be filled up with the compresses so as to make the arm of equal thickness for the application of the splints; then the splints being wrapped with a moderate quantity of wool or flax, we apply them around the fracture, being not more than a finger’s breadth distant from one another, binding them moderately tight, and taking care, as much as possible, that the splints do not come in contact with a joint, and being more particularly careful of the inner part of the joint, for there they sometimes occasion ulcers and inflammations of tendons. But there the bandaging must be made slacker; and stronger, on the other hand, where the fracture swells up. It is better that the chest should be moderately bound with the arm, lest by its motions it should derange the position. If inflammation should come on (which we know by the swelling and redness around, and from the limb being more tightly bound than formerly), or if the fracture become deranged, or if, without these occurring, the bandages become slacker, or, on the other hand, tighter than proper, the bandages are to be loosed and everything rectified. The patient is to be laid in a supine position, with his hand upon his stomach, and a soft pillow is to be placed under the arm having a skin upon it to receive the embrocations which run from it. The part is to be bathed with warm oil every day, more especially if inflammation be present, and during the time of inflammation he is to be fed sparingly, and afterwards moderately, to promote the growth of callus. He must lie quiet until the callus is formed, which, in the arm and leg, takes place about the fortieth day. After this the bandages are to be loosed, and after using the bath he is to be treated with plasters suitable to fractures. This mode of procedure is applicable in almost all cases of fracture of limbs.

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COMMENTARY. Hippocrates’s account of fracture of the os humeri, as quoted by Paulus, is from the eighth chapter of his work ‘De Fracturis,’ but our author has used considerable liberties in making the extract. The mode of using the piece of wood for suspending the arm is easily understood, from his own description without the commentary of Galen. (See p. 541, t. v, ed. Basil.) In the edition by Littré it is, moreover, well illustrated by a drawing. (T. iii, p. 445.) He directs the splints not to be applied until the seventh day, in order to give time for the inflammation and swelling to subside. He says, the bone gets consolidated in about forty days. He justly remarks, that when distortion of the arm takes place it is to the outside, that is to say, backwards. His method of bandaging for fractures of the arm and fore-arm was the same. He directs us in the first place to put a cerate to the part, and then to apply the first bandage, beginning at the fracture, and carrying it two or three turns upwards, so as to prevent the blood from falling down into the part. The second bandage is to commence above the fracture, and is to be carried downwards. Afterwards splenia or oblong compresses, spread with cerate, are to be laid over them, and these are to be secured by strips of linen cloth. These bandages are to be removed when they become slack, generally about the third day. On the seventh the ferulæ or splints are to be applied, the limb by that time having lost its swelling, and they are to be allowed to remain until the 24th day after the accident. When swellings arise on any part of a limb from pressure, they are to be anointed with cerate or wine and oil, and wrapped in soft wool; and if the splints be hurting the limb they are to be removed for a time. (De Fract. 21.) When the bandages are taken off, he directs that hot water should be poured upon the limb. He recommends a spare diet unless there be a wound of the integuments. (De Fract. and Galen. Comment.) It may be proper to give some more account of the splenia and ferulæ (νάρθηκες), used by Hippocrates in fractures of the extremities. In his work entitled ‘The Surgeon’s Shop’ (ἰήτρειον), he directs the length of the splenia to be made proportionate to the part which they are applied to, their breadth three fingers, their thickness three or four folds, and their number such as to encircle the limb without doing either more or less. It appears quite clear that they consisted of folded linen. The intention of them was to give some support to the part. He directs the splints to be smooth, even, concave, and somewhat shorter than the length of the bandages, in order not to hurt the sound skin. It appears, then, that the whole apparatus used by Hippocrates in the treatment of fractures, consisted, 1st, of two under-bandages, 2d, of splenia or folded compresses, 3d, of the ferulæ or splints, 4th, of an outer bandage to secure the splints. With regard to the cerate used in the Hippocratic system of bandaging, it is important to state that, from a passage in his treatise, ‘Officina Medici,’ it would appear that the cerate was not only applied to the skin, but that, for the sake of greater security, every fold of the bandages was rubbed with it. See Galen’s Commentary on the work, (T. v. p. 692, ed. Basil,) and Littré’s Hippocrates, (T. iii, p. 316.) It remains to be mentioned, that the bandages were secured by means of a thread or with a needle. (Off. Med. 8.) Nothing can surpass the judgment and precision with which Hippocrates lays down his rules for the application of the bandages. (Ibid.)

Galen describes the splenia as being pieces of linen folded three or four times, which are to be laid along the arm longitudinally. He directs us to spread them with cerate. He says that they support the limb. He says distinctly that all the folds of the bandages should be rubbed with cerate in order to give greater support. All his directions for the treatment of a broken limb are most judicious. When at first there is much pain and inflammation, he recommends bleeding and purging; but when the callus begins to form, he directs the patient to use a nourishing diet. Spiculæ and scales of bone are in general to be allowed to exfoliate of themselves, and not removed forcibly by the surgeon. (Comment. and Fragment. ap. Nicetæ Collect.)

Celsus lays down the principles of treatment in fractures of the arm, fore-arm, thigh, and leg so circumstantially, that we can afford room only for an outline of them. He recommends no time to be lost in getting the displaced parts properly reduced. For this purpose, if the limb be strong, two assistants may be required to pull in contrary directions; and if other means do not succeed, thongs of leather, or linen bandages, may be attached to each end of the broken limb to make extension and counter-extension with them. When the ends of the bone have been adjusted, (which is known by the pain and deformity being removed,) the limb is to be wrapped in linen cloths folded two or three times, and dipped in wine and oil. Six bandages or rollers (fasciæ) are then to be applied. The first is the shortest, which is to be three times rolled round the limb upwards in a spiral direction, and three times generally will be sufficient. The second must be one half longer, and is to commence wherever the bone projects; or if there be no projection, at any part of the fracture; and is to be carried first downwards and then upwards, so as to terminate a little above the former. These are to be secured by a broader linen cloth spread with cerate. The third and fourth bandages are then to be applied upon the principle, that the latter is to be put on in the contrary direction to the former; and further, it is to be observed that the third bandage terminates below, whereas all the others terminate above the fracture. Upon the whole, he adds, it is better to secure the limb with many than with tight bandages, these being apt to occasion mortification. When properly applied they ought not to be loose on the first day, yet such as not to give pain; slacker on the second, and loose on the third day. They are then to be removed and again applied, and a fifth bandage is now to be superadded to them; and again, these are to be taken off on the fifth day, and six bandages put on, in such a manner that the third and fifth may terminate below, and all the others above. Whenever the bandages are taken off, the limb is to be bathed with hot water, and proper fomentations applied to allay the inflammation, which will generally be found to have subsided about the seventh or ninth day. Then the bandages are again to be put on as directed above, and ferulæ or splints are also to be added, taking care to put on a stronger and broader splint at the side to which the fractured bone has a tendency to be protruded. These must all be rounded where they come in contact with a joint, to avoid injuring it; they are only to be secured with such tightness as to keep the bones in their place, and when they get loose their thongs are to be tightened. The bandages are to be removed gradually. These are his general directions for all fractures of the extremities, and it is to be remarked that his mode of treatment is essentially the same as that of Hippocrates. He afterwards describes at considerable length the method of setting the broken ends of the os humeri. After this is accomplished he directs us to bind the arm gently to the side. With regard to the splints, he properly recommends the longest to be applied externally; shorter ones on the brawn of the arm (over the biceps muscle?), and the shortest under the armpit. He advises us to remove them frequently when the fracture is situated near the fore-arm; and at these times the arm is to be bathed with hot water, and rubbed with a soft cerate.

It will be seen that the methods of Hippocrates and Celsus, although the same in principle, differ in the following respects. Hippocrates uses three bandages, Celsus six: Hippocrates uses small compresses, Celsus large pieces of linen: Hippocrates uses cerate, Celsus wine and oil.

The Arabians conducted the treatment in much the same way as the Greeks. In cases of fracture of the arm, Albucasis directs us to make the bandages of soft, thin linen cloth; but of broader and firmer linen if the thigh or leg is to be treated. Below them is to be applied a smooth cloth spread with a suitable liniment. After the under bandages have been put on in the manner already described, the splints are to be applied, provided no swelling nor inflammation be present, for in that case they are to be deferred for a few days. These splints are to be constructed from the middle part of the alcanna, or of pine, or of the palm-tree, or of a tree which he calls calingi.

Avicenna directs us to form the splints of the wood of alcanna, or of oleander, or of pomegranate tree, or the like. The length of the splints is to be made equal to that of the limb, and their greatest breadth about three fingers. They are to be secured with another bandage and pieces of tape made of linen cloth. There is to be an interval of a finger’s breadth between each splint. He says, it is best to apply four splints of such a length as to reach from joint to joint. They are to be smooth and even so as not to injure any part. In cases of fracture of the os humeri he directs us to surround the nearest joint with the bandages, and, if the fracture be in the middle, to make them take in both extremities. He recommends us to foment the limb with vinegar and water, or water alone. The arm is to be fastened to the side and the hand laid on the stomach.

Haly Abbas, in giving directions for the treatment of fractures in general, recommends the splints to be made of pieces of alcanna, or any hard wood. Afterwards he directs the limb to be laid upon a table having a pad (pannus) placed on it, which last is to be secured with fillets. He gives particular directions not to apply the splints over the processes of bones, and when inflammation comes on he forbids splints to be used at all; in that case the patient is to be kept upon restricted diet. The bandages are to be removed in the course of three days.

The directions given by the experienced Rhases about the bandages and splints are very similar to our author’s, and therefore need not be repeated.

See an account of the ancient splenia, or compresses, and of the ferulæ, or splints, in Scultet’s ‘Arsenal de Chirurgie.’ (29, 30.) See also Van Swieten’s ‘Commentary,’ (354.) Van Swieten remarks, that although the eighteen-tailed bandage be supposed a modern invention, a similar one is described by Hippocrates, (De Fract.) and by Galen in his commentaries on the same.

Le Clerc gives a pretty full description of the Celsian method of treating fractures. (Hist. de la Méd.) See also Fabricius ab Aquapendente (Œuv. Chir. ii, 3, and i, 4). We are certain it will be generally admitted that the waxed apparatus of the ancients in the case of fractures was probably quite as efficacious as the starched bandages which have been introduced of late years with so much advantage.

SECT. C.—ON THE ULNA AND RADIUS.

The ulna and radius are sometimes both fractured together, and sometimes one of them only, either in the middle or at one end, as at the elbow or wrist. The worst of all is when both are fractured together, after that the ulna alone, but a fractured radius is, of all cases, the easiest cured. For, although it be larger than the ulna, yet it has this bone as a base and support to it. If only one be fractured, the extension must be applied principally to it, but if both, they are to be stretched evenly, the arm being put into an angular position, so that the thumb may be higher than the fingers, and the little finger lower than any of the others, for thus the ulna will be placed under the radius. If stronger extension be required, especially when both are broken, we must apply it not only with the hands but also with ligatures, as described when treating of the arm; and everything relative to the bandaging and the subsequent treatment, with the application of the splints, is to be done as in that case until callus is formed. The bones of the fore-arm have their callus formed in about thirty days at most. And the fore-arm is to be otherwise arranged in the same manner as the arm, with the exception of those things which are put under it.

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COMMENTARY. Whoever would wish to see a full exposition of the principles upon which these cases of fracture ought to be conducted may consult the first part of Hippocrates’s work. (De Fracturis.) He shows, with a singular precision, the disadvantages of the prone and supine positions of the hand, both of which, it appears, had their advocates in ancient times. The bandages, compresses, and splints are to be applied in the manner described in the preceding section. He insists strongly on the necessity of having the arm and wrist carefully suspended in a broad soft sling, and that the hand be placed neither too high nor too low. Hippocrates takes notice of fracture of the olecranon, as will be explained afterwards.

Oribasius gives a description and drawing of a laqueus calculated to retain the splints, and secure the fore-arm in cases of fracture. (De Laqueis, 2.)

Celsus directs us to sling the arm, with the thumb a little inclined, towards the breast, in a convenient napkin (mitella), the broad part being applied to the arm, and the narrow ends tied behind the neck.

Albucasis treats of this case of fracture very accurately. He calls the ulna the larger of the bones. He directs the arm to be suspended with the thumb uppermost. When the fractured pieces of bone occasion irritation, he advises us to make an incision and extract them. When a troublesome pruritus seizes the arm, he recommends us to remove the bandages and bathe with hot water.

Rhases gives proper directions about not applying the bandages too tight or too slack. When the hand swells he recommends them to be slackened.

The accounts given by Avicenna and Haly Abbas are quite similar to our author’s. Avicenna cautions us not to make the splints too long lest they hurt the hand. None of the Arabians, we believe, have noticed the fracture of the olecranon. Like most imitators, they often fall short of their originals.

SECT. CI.—ON THE HAND AND ITS FINGERS.

The bones of the carpus, metacarpus, and of the phalanges of the fingers, being of a spongy and porous nature, are often crushed but rarely fractured. The patient then being placed on a high seat, we are to direct him to lay his hand prone upon an even table, and the fractured pieces being stretched by an assistant, we arrange them with two fingers, that is to say, the thumb and the index-finger. A tight bandage is to be used at the time that inflammation prevails, for, owing to the porous nature of the bones, a redundance of callus is formed. If the phalanx or finger be simply broken, and it be the large one, called also the thumb, after suitable bandaging, it is to be bound to the palm that it may be kept at rest; but if any of the others, as for example, the index or little finger, it is to be bound along with the one next to it, or if one of the middle, it may be bound along with that on either side, or all may be bound altogether. For they are thus kept best at rest, as if the fractured bones had been supported with splints.

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COMMENTARY. Hippocrates recommends the general treatment applicable in all cases of fracture, with the exception of the splint, which, as Galen explains, is not admissible in these cases.

Celsus says, it will be sufficient when a finger is broken to bind it to one piece of splint (surculum) after the inflammation has subsided.

Albucasis recommends one small splint to be applied upon the thumb when it is fractured. If one of the fingers be broken, it is to be bound up with the others, or one small piece of splint may be used. Avicenna, Rhases, and Haly Abbas treat distinctly of these accidents, but supply no additional information.

SECT. CII.—ON THE THIGH.

The case of a broken thigh is analogous to that of the arm, but in particular, a fractured thigh is mostly deranged forwards and outwards, for the bone is naturally flattened on those sides. It is to be set by the hands, with ligatures, and even cords applied, the one above and the other below the fracture. When the fracture takes place at one end, if at the head of the thigh, the middle part of a thong wrapped round with wool, so that it may not cut the parts there, is to be applied to the perinæum, and the ends of it brought up to the head and given to an assistant to hold, and applying a ligature below the fracture, we give the ends of it to another assistant to make extension. If it is fractured near the knee, we apply the ligature immediately above the fracture, and give the ends to an assistant, with which to make extension upwards; and while we put a ligature round the knee to secure it, and while the patient lies thus, with his leg extended, we arrange the fracture. Pieces of bone which irritate the parts, as has been often said, are to be taken out from above; and the rest of the treatment we have already described in the section on the arm. The thigh gets consolidated within fifty days. The manner of arranging it afterwards will be described after delivering the treatment of the whole leg.

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COMMENTARY. Hippocrates has correctly stated the difficulty attending the management of a fractured thigh-bone, and the disgrace which an ill-managed case entails upon the surgeon. He directs him to make extension and counter-extension, and to apply the bandages and splints in the manner formerly described. He recommends a few turns of the bandage to be brought about the loins, in order to prevent the skin at the top of the thigh from being injured by the splints. He points out the extreme importance of attending to the position of the heel, as if improperly laid, it is capable of deranging the fracture entirely. It gets consolidated, he says, in about fifty days. (De Fracturis.)

Celsus pronounces it impossible to heal a fractured thigh-bone without deformity. The patient, he says, must ever afterwards tread upon his toes; and yet, he adds, the case will be worse if neglected.

Albucasis holds forth greater encouragement. He describes the process of treatment very minutely, directing the surgeon to stuff up all the hollow places in the limb with soft pads before applying the splints. He also recommends him to surround the whole limb with a bandage from the heel to the nates. We are inclined to think, although the language of his barbarous translator is not sufficiently precise, that his splints extended the whole length of the limb.

Rhases, and we believe, he alone of all the ancient authorities, directs the thigh to be laid in a somewhat bent position, and for this purpose he recommends something suitable to be put below it.

Haly Abbas and Avicenna, as usual, borrow everything from our author.

SECT. CIII.—ON THE PATELLA.

The patella is a porous bone kept firmly in its place by the parts above and below, and is often crushed but seldom fractured. It undergoes fracture also through its thickness, and is broken into small pieces, with or without a wound. The symptoms are obvious,—a solution of continuity, a hollow, and crepitation. The fracture is put in order by extending the leg, for thus the divided portions may be brought together with the fingers, until the lips of the fracture mutually touch, and are united to one another, and fractured pieces, when separated, are thus arranged together. For even if callus does not take place, owing to the parts being drawn in different directions by the muscles and tendons from the thigh and leg, which are inserted into it, yet the separation is much diminished. But it occasions much lameness to the patients; for, when they attempt to labour, the knee cannot sustain them long, and in walking their ascent upwards is impeded; but in moving along a plain their lameness is not perceptible. In ascending, however, as the knee cannot bend in raising and setting down the leg, the lameness becomes apparent. And in this case any bone that irritates is to be taken out where it protrudes, and proper treatment applied.

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COMMENTARY. None of the ancient authorities have given so full an account of this accident as our author. Hippocrates and Celsus have omitted it altogether. Soranus merely gives the symptoms, namely, a hollowness in the part and crepitus.

Albucasis recommends us, after arranging the broken pieces of bone, to apply a round splint over it if necessary. Rhases likewise speaks of applying a well-stuffed splint. Haly’s account is distinct but similar to our author’s, from which it is abridged. Neither he nor Avicenna makes any mention of a splint.

SECT. CIV.—ON THE LEG.

The treatment of fractures of the leg corresponds with that of the fore-arm, for it consists of two bones, the thicker of which bears the same name (tibia), and the small one, from its resemblance, has been called fibula. Its fractures also admit the same varieties, being deranged on all sides when both the bones are broken together, and to three when only one, namely, within, without, and the tibia backwards and the fibula forwards. Wherefore it is to be set in the same manner by the hands, or ligatures, sometimes applied to the leg itself, and sometimes to the thigh, (for the knee being a strong joint can bear the extension uninjured,) and ligatures are to be applied likewise below the fracture, as we mentioned under the head of the fore-arm. The case is to be managed otherwise, as described by us in the section on the arm.

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COMMENTARY. Hippocrates has treated of this case at considerable length. The bandages are to be applied as formerly described, and the leg laid on a level board with a soft cushion under it. It is clear that he did not approve of the bent position of the limb. The splints are to be applied on the seventh or eleventh day. Of the fractures of a single bone, that of the tibia, he remarks, is the worse, a fractured fibula being easily managed. He gives particular directions to attend to the state of the heel.

Celsus treats of these fractures in general terms, like those of the fore-arm. Albucasis directs us to apply two splints made of the wood of pines or palms, of moderate thickness, and of such length as to extend from the knee to the feet. One of these is to be placed below the leg and the other above; and they are to be tied in three places, namely, at the extremities and in the middle.

The other Arabians treat of these fractures in more general terms.

SECT. CV.—ON THE FOOT.

The astragalus cannot be fractured by any means, being guarded by bodies on all hands; by the tibia, the fibula, and the os cuboides. But the scaphoides, the bones of the tarsus, and those of the toes, and the cuboides itself, are fractured like those of the carpus, metacarpus, and the fingers of the hand, so that what was said of them is applicable here and need not be repeated.

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COMMENTARY. Hippocrates remarks that these bones can only be fractured by some sharp and heavy body. They are to be treated like fractures in general, only that they do not require splints. He recommends the recumbent position with the foot somewhat elevated, and states, in strong terms, the mischief brought on by unseasonable attempts at walking. (De Fracturis, 10.) Galen, in his Commentary, gives an accurate anatomical description of the bones of the foot.

Celsus is very brief on this case. He conducts the treatment on general principles. Albucasis directs us to make the patient put his foot on the ground, the surgeon is then to place one of his feet on it and stand on it. By this means the derangement of the bones will be rectified. He approves of a splint to the sole.

We find nothing worthy of notice in the works of the other authorities.

SECT. CVI.—ON THE ARRANGEMENT OF THE LIMB.

When the thigh or leg is fractured, the manner of arranging the limb will be as important a consideration to you as the other treatment. For the evenness of the fractured parts is especially preserved by this means when properly performed. Some, therefore, lay the fractured part upon a canal, either of wood or of earthenware, or else they lay the whole limb upon it; others apply it only in cases of fracture with a wound, because, say they, these cannot be bound with splints. But the moderns altogether reject the use of these canals for many reasons, but more especially on account of the pressure occasioned by their hardness. Nor is it improper to apply splints to fractured limbs with a wound, as we shall show afterwards. Let the patient, then, lie upon his back, and let a thick garment, equal to the limb in length, be laid under it, more especially where the fracture is, and let both its ends be convoluted and wrapped round so as to resemble the canal in its middle longitudinal cavity, and let it be covered with a soft skin for receiving the embrocations; and then let the limb be fitted to this canal-like cavity, and let other garments or wool be applied on both sides to prevent the limb from being moved to the sides. And let a small board, covered with rags for sake of softness, be fastened to the sole of the foot; and, for the sake of greater security, let the middle of two or three ligatures be applied under this canal-like garment, and let the broken limb be lightly bound along with it. But if the patient be unable to restrain himself from drawing in his leg, his foot should be fastened to the board by means of ligatures around the ankle, so that he may be prevented even from drawing in his leg involuntarily in his sleep. Some likewise cut out a hole in the middle of the bed, that the patient may void his urine and fæces by it without requiring to be moved until the callus has become formed.

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COMMENTARY. We have already mentioned that Hippocrates approved of the straight position of the limb. With respect to the canals (σωλῆνες) mentioned also by our author he expresses himself in equivocal terms. He says that they prove useful, but not to the extent generally believed. He properly remarks that they do not prevent the body from being moved, and that consequently they cannot be supposed capable of securing the limb entirely from derangement. He is decidedly of opinion that unless they extend from above the ham to the heel they do no good in fractures of the leg. (De Fracturis, 16, ed. Littré.)

Celsus gives the following description of the canals: “Is canalis et inferiore parte foramina habere, per quæ, si quis humor excesserit, descendat: et a planta moram, quæ simid et sustineat eam, et delabi non patiatur: et a lateribus cava, per quæ loris datis, moræ quædam crus femurque, ut collocatum est, detineant.” Galen, in his Commentary on Hippocrates (l. c.) describes these machines as being round externally and hollow within, so as to inclose the limb all around:—περιλαμβάνει τὸ σκέλος ὅλον ἐν κύκλῳ. From these words one might think that the canal of which he speaks was a complete cylinder or cone. But from our author’s direction to lay the limb upon the canal, it would appear that the machine he speaks of was open above, and as such it is represented and described by Scultet (Arsenal de Chirurg. xxii, 6.) His words are: “Il faut que le canal embrasse plus de la moitié du membre;” this, therefore, is a sort of trough. Sprengel calls it a box (boîte, Fr. edit.) Littré translates it by gouttière, l. c. For an account of these and other machines anciently used in fractures of the lower extremities, see Van Swieten (Comment. 354), and Heister (Surgery, ix, 9.) Brunus and Theodoricus make mention of these canals, but do not much approve of them.

Galen informs us that the canals were made of different kinds of wood. He speaks of a surgeon in his time who made them from the wood of the phillyrea. He makes mention of a method of supplying their place by means of a bolster laid below the limb and tied round it with fillets. (Nicetæ Collect. and Comment. l. c.)

Avicenna and Albucasis take notice of these machines, but neither of them with approbation. They also speak of securing the limb in the way described by our author.

The canals would appear to be the machines which Rhases mentions by the name of barangi. (Cont. xxix.)

SECT. CVII.—ON FRACTURES COMPLICATED WITH A WOUND.

When a fracture is attended with a wound, if there be a hemorrhage it is to be first stopped; and if there be inflammation, we must use the applications suitable to it; and if there be contusion of the flesh, we must scarify the flesh to remove all apprehension of gangrene; or if gangrene or any other spreading mortification has come on, we must meet it with suitable remedies. The treatment of each of these cases you have had delivered in the Fourth Book. When none of these symptoms is present, nor much of the bone exposed, we may use hooks and sutures, and effect the cure by the treatment for recent wounds, having first cut out any broken pieces of bone which move about and produce irritation. But if a large bone project, which, for its size, cannot be brought into contact by the extension, it will require consideration. Hippocrates, then, in fractures of the thigh and arm, dissuades from replacing at once the protruding bones, predicting danger from it, owing to the inflammation or perhaps spasm of the muscles and nerves which are apt to be brought on by the extension. But time has shown that this attempt will sometimes succeed. Of whatever bones, therefore, we endeavour to replace the protruded ends, we must not meddle with them when in a state of inflammation, but on the first day, before inflammation has come on, or about the ninth day, when the inflammation has gone off. We may set them by an instrument called the lever. It is an iron instrument about seven or eight fingers’ breadth in length, and of moderate thickness that it may not bend during the operation; with its extremity sharp, broad, and moderately bent. Its sharp extremity, then, is to be put under the protruding prominence of the bone, and by pushing at the other end while moderate extension of the limb is made, we bring the extremities of the fracture together; or, if we cannot do so, we must cut off the projections by counter-perforators (chisels), or saw them off in the manner described when treating of fistulæ. Having removed the spiculæ of bones and set the limb aright, we cure the wound by dressing with pledgets. But in those members which are double or in pairs, we must take care when the bones of either of them are sawn off, that no contraction of the limb take place, but that it be kept of its proper length by extension. The bandaging is to be thus applied: the circular folds are to be arranged on both sides of the wound, and oblique ones according to the length of the sore, so that they may intersect one another in the form of the Greek letter Χ, and prevent the lips of it from gaping. And when the ulcer is foul, we must apply dressing with cleansing ointments; but if clean, with incarnating, and the other articles of known efficacy. Hippocrates used the pitch-plaster, which is said to have been the same as the ointment, tetrapharmacon, called also basilicon. After the sore has incarnated we apply splints. Some apply them from the first, taking care not to hurt the parts about the ulcer, and tightening them according to necessity, or again slackening them. When a scale of bone is going to exfoliate, which we ascertain from the discharge being more copious and thin, we must remove the loose fungous flesh about it, and the bandages must be applied loose; but having removed the scale with a hook or some such instrument, we must have recourse to tighter bandages. During the whole time of the healing of the sore, the dressing called motophylax with some of the anti-inflammatory medicines is to be laid over the wound, to be kept on with a simple bandage, which is to be removed at each dressing; everything else remaining the same as described in the treatment of the arm.

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COMMENTARY. Hippocrates treats of these cases at great length. His method of rectifying the protruded ends of bones by means of a lever, is described by our author. He says, it may be done on the first or second day, but not on the third or fourth, after the inflammation is begun, for fear of occasioning convulsions. Compresses dipped in wine and oil, or soft bandages are to be used, but splints are not to be applied until the sore puts on a healthy appearance. He mentions that some were in the practice of bandaging the limb above and below the wound, and leaving it bare, in order to allow the discharges to escape; but this practice he greatly disapproves of, as tending to produce swelling in the place; and he recommends the whole limb to be well secured with bandages, but then not too tight. He states that all bones which are completely denuded, must exfoliate and come out. When a bone projects and cannot be replaced, he directs the surgeon to cut it off if it irritate the soft parts. No splints are to be applied when there is a bone which it is seen will exfoliate. If it be the summer season, the compresses applied to the wound are to be frequently soaked with wine; but if it be winter, greasy wool is to be dipped in wine and oil and applied. Compound fractures of the thigh or arm, attended with protrusion of the broken bone, are said to be peculiarly dangerous; for if replaced, they are apt to occasion convulsions; and if let alone, they give rise to acute bilious fevers. Some, however, he adds, recover when the bone is replaced. (De Fract. cum Comment. Galeni.) Galen explains, that the danger in cases of fractured femur and humerus arises from their vicinity to important blood-vessels and muscles.

Celsus lays down the rules for conducting the treatment in these cases with great precision. He states, that fractures complicated with a wound of the skin are generally dangerous, especially when it is the humerus or femur. In the latter case he directs us to saw off the ends of the bone. The case of a fractured humerus is more easily managed. The danger is greatly increased when the fracture is near a joint. He recommends us to divide any muscle which may run across the wound, to let blood, and put the patient upon a restricted diet. In other fractures the bones are to be gently replaced. The wound is to be dressed with a pledget dipped in wine, to which roses have been added. This application is borrowed from Hippocrates. The bandages are to be put on somewhat slacker than when there is no external wound. Neither splints nor canals must be used, but broad bandages. The parts are to be fomented with hot oil and wine, and the dressings renewed every day. When a small fragment of a bone projects, if it be blunt, he recommends us to replace it; but if sharp, he directs us to saw it off, and then replace the bones with the hands or a suitable instrument. Sometimes fragments of bones die, and after a time drop out; and sometimes sharp spiculæ irritate the soft parts, in which case he recommends us to enlarge the wound and cut off the projecting points.

The treatment recommended by Albucasis is very judicious. If inflammation be present, he directs us to subdue it by bleeding; and, in that case, reduction is not to be attempted until the ninth day; but in all other cases it is to be done at first. When it cannot be reduced by the hands, an iron instrument seven or eight fingers’ breadth in length, and two fingers broad, is to be used as a lever for this purpose. When the ends of the fracture are sharp and cannot be replaced, they are to be cut off or sawed. His saw bears a considerable resemblance to that of the late Mr. Hey, of Leeds. He recommends an astringent wine as a suitable application, but condemns all cerates which contain oil. The bandages are to be put on very slack. Splints are not to be applied while the wound is irritable and ill-conditioned. When it does not heal, he says we ought to suspect that it is prevented by spiculæ of bones, which are to be sought out and extracted.

Avicenna and Rhases give very proper directions about removing spiculæ of bones, and applying slack bandages, but they evidently copy from Hippocrates and our author.

SECT. CVIII.—ON THE REDUNDANT CALLUS OF FRACTURES.

The superabundant callus of fractures occasions always a deformity, and sometimes also lameness if it be formed near a joint. If, therefore, the callus be newly formed, we use very astringent medicines, and bring it to its form by bandages; and sometimes we effect our purpose by applying a plate of lead to it. But if it is of a stony hardness we make an incision, and pare it off, removing the prominent part by chisels, if need be, and boring it with trephines.

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COMMENTARY. Celsus directs us to rub the limb with oil, salt, and nitre; to pour a great quantity of hot salt water upon it; to apply an emollient ointment; to bandage it tightly, and to give an emetic. He also recommends us to produce revulsion by the application of mustard to another part.

Albucasis recommends nearly the same plan of treatment as our author. When the case is recent, he directs us to make astringent applications, such as aloes, olibanum, and myrrh, with an astringent wine or vinegar. He also speaks of applying a plate of lead; and when the callus becomes hard, he approves of scraping and sawing it off, as directed by our author.

No additional information is to be got from the other Arabians.

Theodoricus, and the other surgical authorities of that age, describe the treatment exactly as the ancients. When the callus is hard, they direct us to scrape or saw it off.

SECT. CIX.—ON DISTORTION FROM THE UNION BY CALLUS.

When bones heal distortedly by callus, no little lameness takes place, more particularly if in the feet. The method then of breaking them over again is not at all to be admitted, as it may occasion the utmost danger; but if the callus be newly formed, we must have recourse to the allusions of a relaxing nature, and to cataplasms, such as those from fat olives and pigeon’s dung, and the other medicines for dissolving callus; and we also dispel it by friction with the hand, and bending it every way. But if it be of a stony hardness, we make an incision of the skin with a scalpel, and separate the union of the bones with chisels, and then cure the fracture as formerly said.

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COMMENTARY. Celsus approves of breaking the bones over again. With this intention he directs us, in the first place, to bathe the limb with much hot water, and rub it with liquid cerate; the callus is then to be moved with the hands, and the ends of the bone properly set; or if that cannot be thus accomplished, a rule is to be wrapped round with wool and bound upon the part, so as to restore it to its proper shape.

Avicenna agrees with Celsus in speaking favorably of breaking the bone over again. He also speaks favorably of the other treatment recommended by our author.

Rhases recommends emollient applications, and gentle attempts to restore the figure of the limb. Albucasis mentions the proposal of breaking the bone again with disapprobation.

SECT. CX.—ON BONES WHICH HAVE NOT UNITED BY CALLUS.

Sometimes fractured bones remain without forming adhesions, beyond the natural period, either owing to their being often loosed, or from too frequent bathing of the part, or from having been moved unseasonably, or from the number of the bandages, or from atrophy of the whole body, by which means the limb becomes emaciated. Wherefore we must endeavour to remove all the other causes, but more especially the atrophy, partly by calefacient applications which attract nourishment to the place, and partly by supplying a sufficiency of food and baths, and whatever also is of a refreshing nature. Among the other symptoms which follow the formation of callus, the bandages then become stained with blood, although no wound be present, which probably takes place from the substance about the callus, when it unites, squeezing out the drops of blood which were distributed to the hollows of the bones.

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COMMENTARY. When the fractured portions do not adhere after a certain time, Celsus directs us to extend the limb, and rub the ends of the bone together, in order to convert them again into the state of a recent fracture, taking care, however, not to hurt the muscles and nerves. The part is then to be fomented, and the splints applied on the fifth day.

Rhases recommends calefacient liniments, friction, and nutritive food.

SECT. CXI.—ON LUXATIONS.

We proceed to the treatment of luxations, which naturally follows that of fractures. A luxation then (to give a definition of it) is a displacement of a member from its proper cavity to an unusual place, by which means the voluntary motion is impeded. We have no other differences of it to mention, except that some are to a greater and some to a less degree. When the bone of a member, therefore, is completely removed from its place, the accident is called by the common name of luxation, but when only moved a little, or brought only to the brim of the cavity, it is called a subluxation.

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COMMENTARY. Celsus gives several important remarks upon dislocations in general, but as most of them may more properly be brought under particular heads, we shall notice them here but briefly. He distinguishes dislocations into two classes; the first consisting of a separation of two bones naturally united, such as the scapula from the humerus, the radius from the ulna, the tibia from the fibula, the os calcis from the bones of the ankle, which last is of rare occurrence, and the second being a removal of the bone of a joint from its proper place. When a dislocation occurs, as he remarks, the finger discovers a cavity in the part, and inflammation and fever come on, followed sometimes by gangrene and convulsions. If not reduced, the limb wastes. In a person who is lean, humid, and has weak nerves (muscles?) the dislocation is most easily reduced, but is more difficult to retain. The inflammation is to be reduced by the application of wool dipped in vinegar; by abstinence, a spare diet, and drinking tepid water. Afterwards friction, exercise, and a more generous diet are to be allowed. (viii, 11.)

See many curious remarks on this subject in Galen’s Commentary on Hippocrates (de Articulis), and in Apollonii Citiensis Scholia in Hip. et Galen.; also Avicenna (iv, 5, 1); Haly Abbas (Pract. ix, 101); Rhases (Cont. xxix, 2.)

SECT. CXII.—ON THE LOWER JAW.

Beginning then again from the upper parts we shall treat of the lower jaw. For the upper being immoveable does not admit of dislocation; but the lower does not indeed readily admit of complete luxation, owing to its heads being firmly fixed to the upper jaw, but it often undergoes subluxation, for the muscles which are fixed to it being relaxed by the constant exercise of mastication and speaking, the jaw is readily slackened from the most common causes. For the term used by Hippocrates signifies slackened. In these cases the part returns to its natural place without trouble. With regard to the complete dislocation of the lower jaw, it will be sufficient to deliver Hippocrates’s account, being, at the same time, brief, complete and clear. He says thus: “The jaw seldom falls out of the joint, but it is often slackened in yawning, as many other irregular actions of muscles and tendons do this. When it falls out of the joint it is marked principally by these symptoms; the lower jaw projects forwards, and is inclined in an opposite direction to the luxation; and the coronoid process of the bone swells out near the upper jaw-bone, and it is with difficulty that they shut their jaws. In these cases the suitable mode of reduction is apparent. For somebody must hold the patient’s head, another grasps the lower jaw internally and externally with his fingers at the chin, while the patient yawns as much as he can conveniently; and we must first move the jaw with the hand hither and thither for a certain time, and order the man to relax the jaw and separate it; and then we must attend to perform three evolutions at the same time, we must move the jaw from its distorted shape to its natural; push the jaw backwards; and then shut the jaws close, and prevent yawning. This is the mode of reduction, and it cannot be performed by any other processes. Very little treatment will suffice afterwards. Having applied a waxed compress, it is to be secured with a loose bandage. But the surest process is to lay the man upon his back, and supporting his head upon well-stuffed pillows, that they may not yield, to get some person to hold the head of the patient. And if both ends of the jaw be dislocated, the treatment is the same, only the mouth cannot be so well shut, for then the jaw is more prominent, but less distorted from the teeth of the upper and lower jaws corresponding exactly together. Reduction is to be immediately performed, and the mode of it has been already described. If it cannot be restored, there may be danger of the life from continued fevers, torpor, and carus. For these muscles being altered and stretched in a preternatural manner produce carus. They frequently have evacuations by the belly, which are purely bilious, and small in quantity; and if they vomit, it is pure bile. These, for the most part, die on the tenth day.” This mode of reduction we have often practised, having first used fomentations of warm water and oil, by a sponge along the dislocated jaw, more especially when there is any difficulty in restoring it to its position. Wherefore, having placed the man upon the ground, we stand behind and operate in the manner described by Hippocrates.

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COMMENTARY. The account here given of Hippocrates’s method of reduction is taken from his work, ‘De Articulis,’ (31.) When a few of his technical terms are explained in the commentary of Galen, the description is sufficiently distinct, and is upon the whole a very correct account of the symptoms and treatment of this accident. The prominence of the coronoid bone is well described by Hippocrates. Galen remarks that the end of the jaw-bone slips under the zygomatic arch. It has been a matter of dispute what Hippocrates means by slackening, or incomplete luxations of the jaw. It is worthy of remark that such an accident is described by Sir Astley Cooper. (See further Littré’s Hippocrates, t. iv, 29.)

Galen’s description of the method of reduction is given in the Collection of Nicetas. (Chirurg. Vet. ed. Cocchius.) It is substantially the same as that of Hippocrates.

A mode of reducing the dislocation by means of a machine is described by Oribasius, in his work De Machinamentis, 30.

The account which Celsus gives of this accident is upon the whole very accurate, and corresponds very well with modern descriptions. If dislocated only at one end, the chin inclines to the opposite side, and the teeth of the upper and lower jaws do not correspond. If at both ends, the whole chin projects outwards, the lower teeth are more prominent, and the muscles appear stretched. The patient being properly seated, and his head held by an assistant, the surgeon having wrapped his thumbs with linen cloths, is to put them into the patient’s mouth, while the fingers are applied externally. The jaw being firmly grasped, the chin is to be shaken, and then, at one and the same instant, the head is to be seized, the chin moved, the jaw forced into its place, and the mouth shut. After reduction, if pain in the eyes and neck has been brought on by the accident, he recommends us to let blood from the arm. The patient is to live upon liquids, and avoid talking.

Albucasis follows Hippocrates in distinguishing dislocations of the lower jaw into partial and complete. In addition to the symptoms already detailed, he mentions a flow of saliva from the mouth, and an inability to speak. When the dislocation is partial or incomplete, he says, it soon returns of itself to its proper place. When the luxation is complete, he directs us to reduce it by introducing the thumbs into the mouth, and grasping the jaw in the manner described by Hippocrates. He states that when not reduced the accident often proves fatal by superinducing fevers and coma. Avicenna, in like manner, affirms, that if not reduced, it may bring on fatal consequences. His account is borrowed entirely from Hippocrates. Rhases and Haly Abbas give exactly the same description of the symptoms and mode of reducing as Albucasis.

Monteggia, Fabricius ab Aquapendente, Sir Astley Cooper, and Mr. Samuel Cooper (the author of the well-known Surgical Dictionary) affirm that there is no foundation for the prognostic of Hippocrates, that the accident will prove fatal if the dislocation be not speedily reduced. We can say, however, from our own personal knowledge, that such fatal consequences do occasionally occur. We once knew a poor woman who was very liable to dislocations of the lower jaw, which we reduced three or four different times. At last, owing to circumstances which it is unnecessary to explain, an interval of more than a day elapsed between the accident and the reduction. By this time she was become seriously indisposed, and died a few days afterwards with all the symptoms described by Hippocrates. We may mention also that Heister states that fatal consequences may result from the accident. (Chirurg. p. i, iii, 4.) The same thing is affirmed also by Brunus (Chirurg. Mag. i); by Theodoricus (ii, 43); and by Guido de Cauliaco (v, 2.)

That species of sub-luxation described by Hippocrates, is mentioned by Guy of Cauliac in the following terms: “Mandibula quandoque mollificatur.” (v, 2.)

SECT. CXIII.—ON THE CLAVICLE AND ACROMION.

The clavicle, at its inner extremity, is not liable to dislocation, for there it is articulated with the sternum, where it admits of no motion. But if from any sudden and violent force from without, it should be torn from its place, it is to be subjected to the same treatment as a fracture. And its extremity which is articulated with the shoulder does not readily fall out of the joint, being prevented by the biceps muscle and the acromion. But neither does the clavicle admit any strong peculiar motion of its own, being made solely for the expansion of the thorax, and hence man is the only animal which has a clavicle. If it should sometimes happen to be dislocated in wrestling, it is to be replaced with the hand, assisted by the application of many-folded compresses, together with convenient bandages. When the acromion is sub-luxated it may be restored to its proper place by the same treatment. It is a small cartilaginous bone connecting the clavicle to the scapula, which is not to be seen in the skeletons. This, if moved a little from its place, exhibits the appearance to inexperienced persons of the head of the arm being dislocated; for the top of the shoulder appears sharper, and there is a hollow from which it was removed; but the cases are to be distinguished from one another by the symptoms about to be enumerated.

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COMMENTARY. The dislocation of the outer end of the clavicle from the acromion is treated of by Hippocrates, who gives a very distinct account of the symptoms and mode of treatment. He warns the surgeon not to confound this accident with dislocation of the humerus, as he had frequently seen done. He directs the surgeon to push down the projecting end of the bone; and then to secure it with compresses, and bind the arm to the side. He holds that the accident always leaves some deformity. (De Articulis, 15.)

Galen mentions that this accident happens most commonly to young persons, and that when not reduced it occasions a wasting of the arm. The account which Galen in this place and, copying from him, our author have given of the accident to which they represent the acromion as being subject, has been the subject of much controversy among modern authorities. See Cocchi (Chirurg. Vet. 133); and Littré (Hippoc. iv, 12.) Hippocrates, whom they both evidently had in view, (de Artic. 13), clearly refers to dislocation of the scapular end of the clavicle; and probably Galen alludes to the same, complicated with separation of the acromion from the scapula in young subjects. We would beg leave to quote what Monro says of the acromion: “This is an epiphyse in children; and in some old subjects I have seen it joined by a cartilage to the spine.” (Anat. of the Bones, p. 231.) Galen states decidedly that in young persons this process is sometimes bent along with the clavicle, and in them that replacement of the parts to their natural state is easily effected. He adds, “as dry wood is not adapted for bending, but such as is sappy and green bear this, in the same manner the bones of growing animals can be bent by force, and more especially such as are porous and fistulous, as the clavicle is.” Galen relates that in his own person he met with the accident while wrestling in the Palestra, and that by using oily fomentations and light bandages, a cure was at last effected. He says he was then thirty-five years old, but adds, that he had never known another person cured who was so far advanced in life. (Ibid. 134.) Avicenna gives the same account of the acromion as the Greeks. (iv, 5,1, 10.)

Neither Celsus nor Oribasius has treated of this case of dislocation.

Rhases, Avicenna, Haly Abbas, and Albucasis agree that dislocations occur more frequently at the acromial than at the sternal end of the clavicle. Desault and Boyer, on the other hand, affirm that the accident occurs oftener at the sternal extremity; but Sir Astley Cooper’s ample experience confirms the correctness of the ancient statement. Mr. Liston also agrees in stating that dislocation at the acromial end is much more frequent than at the sternal.

SECT. CXIV.—ON DISLOCATION OF THE SHOULDER.

The head of the arm, which is articulated with the cavity of the scapula, is often dislocated; but neither upwards, owing to the coronoid process of the scapula, which prevents it, nor often backwards, owing also to the scapula, nor forwards owing to the tendon of the biceps muscle and the acromion. Sometimes, though rarely, it is dislocated inwards and outwards, but frequently, and particularly in those who are lean, downwards. In such persons, however, as it is readily dislocated, so is it also reduced; but in those who are brawny, on the other hand, it is not readily dislocated, and is reduced with difficulty. In some cases from a blow suspicions of dislocation are formed, although none has taken place, owing to the violent inflammation which supervenes. Wherefore, dislocation downwards may be thus ascertained. The affected shoulder, when compared with the sound one, appears very different, the upper part of the arm, whence the dislocation took place, seeming hollow; and (as mentioned with regard to the sub-luxation of the acromion,) the top of the shoulder appears sharper than natural; and the dislocated head of the arm is distinctly felt in the armpit. The elbow also is removed to a distance from the ribs; or, if you attempt it, you can only bring it to the ribs with difficulty; neither can the hand be raised to the ear, owing to the stretching of the elbow; nor can any other varied motions be performed with it. In children, then, and in recent and inconsiderable displacements of the bone, it may be often reduced, as Hippocrates remarks, by the protuberant knuckle of the middle finger of the clenched hand of the surgeon, or of the sound hand of the patient, if he be not a child. But the following are more effectual modes of reduction. Having bathed the man and used relaxing affusions, let him be laid on the ground in a supine posture, and apply a moderately-sized ball, either of leather or some other soft thing to the armpit; and the surgeon being seated with his face turned to the patient upon the affected side, if the right shoulder he dislocated, let him put the heel of his right foot upon the ball previously fitted to the armpit, or if the left, that of the left foot; and seizing the hand of the affected arm, let him pull down to the feet, at the same time making counter-extension by the heel in the armpit, while an assistant, standing behind the head, pulls at the other shoulder in an opposite direction, to prevent the body from being dragged along. There is another mode of reduction, namely, by suspending the patient upon a person’s shoulder. A young man taller than the patient, or standing on some elevated object, by his affected side, (the patient also being in a standing posture) is to apply his shoulder below the patient’s armpit, while he stretches and pulls the patient’s hand towards his own belly, so that the rest of the patient’s body is suspended at the back of the person who supports him. But if the patient be light, another light child is to be suspended from him. For while the arm and the rest of the body are pulled downwards oppositely, the shoulder put under the armpit, readily replaces the dislocated limb. And the same thing may be done by means of the instrument called a pestle. It is a long piece of wood which is erected on the ground upon some other firm object. Its upper extremity, then, being rounded, and neither very thick nor thin, is applied below the armpit of the patient, who either stands or sits, according to the length of the pestle, and the hand being stretched along the pestle and pulled downwards, while the rest of the body is balanced on the opposite side and weighs downwards, the reduction takes place either spontaneously, or with the assistance of another person pulling down. And this may be done with the step of a ladder, as we described when treating of the extension for a fractured arm. Here some round body is to be fitted to the step of the ladder, such as will suit the armpit of the patient, and propel the head of the arm. But if, owing to the oldness of the accident, or the hardness of the body, we find the reduction difficult, we must have recourse to the method by the means of the instrument called ambe. The ambe is a piece of wood about two cubits in length, of the breadth of three fingers, and about two fingers’ breadth in thickness, having the one extremity round and adapted for the hollow of the armpit, like the extremity of the pestle. Having then wrapped its end with linen rags, in order that it may be softer, we adjust it under the head of the humerus in the armpit, and stretching the hand along the wood, we bind it at the arm, fore-arm, and wrist; then bringing the hand with the wood over a transverse piece of wood, fastened between two erect pedestals, or again over the step of a ladder, so that the armpit may be fitted transversely to the step, we draw the hand downwards, and allow the rest of the body to hang suspended on the opposite side; for then the limb will return to its place. After the reduction, we must apply to the armpit a secure and moderately-sized ball of wool, which, if there is no inflammation present, is to be dry, but if there is inflammation, it is to be dipped in oil. Around this, the shoulder, and the other armpit, a bandage is to be put on in the form of the Greek letter Χ, so that the decussation may take place above the affected shoulder; and the arm is to be bound to the sides; and the elbow and hand are to be slung by the neck, so that the limb may not fall out again while the dislocation is recent. After the seventh day or later, having loosed the bandages, we must have recourse to moderate friction, so that the body being rendered firmer, the joint may become less liable to luxations. But if the limb is often dislocated, either owing to its humidity (flabbiness), or from its being long subject to the accident, we must proceed to burning, as formerly described. But since sometimes the fœtus in utero or the child, while growing, sustains a dislocation of the part which is not reduced, the flesh upon the shoulder is nothing reduced from the natural, nor is the hand obstructed in any of its operations, but the bone remains shorter, not increasing in size; and such persons are called weasel-armed. But in the case of the thigh, the bone does not grow and the limb wastes; for, not being able to sustain the weight of the body, it is not exercised. And with regard to all the other members, if they remain unreduced the parts below are greatly impaired.

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COMMENTARY. Hippocrates delivers his opinions respecting dislocations at the shoulder-joint with singular modesty and a remarkable air of truth. He says, that he had never met with a case in which the head of the humerus was not lodged in the armpit, and expresses a doubt whether in reality there be dislocations inwards or backwards. “I will not affirm,” he adds, “whether or not dislocation forwards may take place, only this I can say that I have never seen it.” (De Articulis.) Galen, in his commentary on this work, mentions that he had seen five cases of the uncommon kinds of dislocation, four of which were dislocations forwards. They occurred mostly among the athletæ. In one case, of which he relates the particulars, he effected the reduction with his heel placed in the armpit. Galen states distinctly, that it is the retraction of the muscles which proves the great obstacle to reduction. (Ed. Basil, v, 585.) Hippocrates has described several methods of reduction, most of which are mentioned by our author. By the fist placed in the armpit, as described by our author. By the heel, as likewise described by him. He adds one advice not distinctly given by our author, to apply the ball placed in the armpit on the side within the head of the humerus, and not upon it. The process by suspending the patient upon the shoulder of another person is next described by him. Those by the pestle and ladder are afterwards clearly described. He then describes the ambe and the application of it to the reduction of dislocations in nearly the same terms as our author. We may here mention, by the way, that the description of the ambe given by Boyer, does not correspond exactly to the instrument recommended by Hippocrates. See drawings of Hippocrates’s ambe in Heister’s ‘Surgery’ (x, 4); in Scultet’s ‘Arsenal de Chirurgie’ (xxii, 1); and in Littré’s edition of Hippocrates (iv, 91.) Hippocrates describes other less important processes of reduction with a Thessalian chair, and a door. He remarks, that persons in a reduced habit of body are most liable to dislocations, and illustrates this position by some very acute observations on the occurrence of these accidents in cattle. After reduction, he directs that a ball of soft wool should be placed in the armpit and secured with a bandage and a sling; and he attaches great importance to well-regulated friction afterwards.

Celsus mentions two kinds of dislocation at the shoulder-joint, namely, downwards and forwards. He describes the methods of reduction by the hand, and by a wooden instrument (spathula lignea) resembling the ambe of Hippocrates. His description of the latter method is very distinct. His mode of reducing dislocations inwards merits attention. The man is to be laid on his back, and a strip of cloth or a thong of leather being placed in the armpit, its two ends are to be brought behind the patient’s head and given in charge to an assistant, while another takes hold of the arm; the surgeon is then to push back the patient’s head with his left hand, while with the other he raises the fore-arm and arm, and pushes the bone into its place. After reduction the armpit is to be stuffed with wool, and suitable bandages applied.

Oribasius treats of dislocations downwards, outwards, and forwards; and gives a very elaborate description of complicated machines for reducing them. Of these it is impossible to convey any correct idea without proper plates. We must be content, therefore, with referring the reader to his work. (De Machinamentis.)

Albucasis describes three kinds of dislocation at the shoulder, namely, downwards, inwards, below the pectoral muscle, and upwards, about which he expresses himself somewhat doubtful. He denies the possibility of dislocations forwards and backwards, the former being prevented by the muscles and latter by the scapula. His methods of reduction are exactly the same as those mentioned by Paulus.

Avicenna expresses himself as being doubtful whether any dislocation takes place at the shoulder except downwards, at least, he adds, he had no experience of any other case. He gives the symptoms of it very accurately, and describes all the methods of reduction mentioned by our author. He approves of the cautery to obviate the tendency to repeated dislocations.

Haly Abbas questions the occurrence of dislocations upwards, forwards, inwards, or backwards. He appears, therefore, to agree with Hippocrates in considering that downwards as the only unequivocal case of dislocation. He recommends the processes of reduction described by our author.

Rhases remarks, that owing to the shallowness of the glenoid cavity and the weakness of the ligaments the bones at the shoulder are more subject to luxations than those of any other joint. He describes the symptoms very accurately. The top of the shoulder, he says, is sharper than natural, the head of the humerus is felt in the armpit, the arm cannot be brought to the sides without pain, nor raised to the head at all. He remarks correctly that when the accident happens during delivery or in childhood, the arm does not grow to its natural size. He mentions that venesection is often of great use in reducing dislocations. He also recommends the warm bath. He denies the possibility of a dislocation in any other direction except downwards.

The ancient modes of reduction are recommended and described by Guy of Cauliac (v, 2); and Theodoricus (ii, 47.)

SECT. CXV.—ON THE ELBOW.

Inasmuch as the elbow-joint is more complicated than that of the shoulder, so, in like manner, are its dislocations more difficult to manage; for they are less readily occasioned, and more difficultly reduced, owing to the number of its processes and cavities. Sometimes it undergoes sub-luxation only, but often it is completely dislocated in every direction, and more especially forwards and backwards. It is easily recognised even by the sight, and the dislocated bone may be felt in the place to which it has been removed, while a hollow appears in the place whence it was moved. A comparison with the sound arm particularly discloses the nature of the accident. Reduction then must be made immediately before inflammation comes on, for, if this has supervened, it is difficult to cure, and some such cases become utterly irremediable, more especially if the dislocation was backwards; for of all the dislocations at the elbow-joint, that backwards is the most painful and dangerous. Small displacements then may be restored by a moderate degree of extension, the assistants keeping the hand extended, pulling, and making counter-extension at the fore-arm and arm, while the surgeon with the palm of his hand pushes the dislocated bone into its natural place. Hippocrates rectifies the dislocation forwards by bending the hand suddenly so as to force the palm straight to the shoulder of the same side; and that backwards again by frequent and strong extension; inasmuch as dislocations forwards are produced by violent extension, and those backwards by violent flexion. If the dislocation has continued long unreduced, we must have recourse to stronger extension, such in particular as that described by Hippocrates for a fractured arm, where he has recourse to the piece of wood adapted to a spade. Some of the moderns manage the matter thus: Two assistants stretching the arm as aforesaid, the one holding at the armpit, and the other below at the wrist, the surgeon, standing opposite the patient, grasps the arm with the palms of both his hands near the joint, and giving orders to bind a long folded robe or broad swathe round his hands and the arm of the patient, and to pull outwards and downwards towards the hand, whilst he, following the same course, drags the parts with his hands thus secured until they pass the articulation of the joint. The arm should be first anointed with oil, to render the part slippery and easily moved with the palms of the surgeon’s hands. Thus the dislocated parts being violently pulled by the hands of the assistants will return to their proper place. After the reduction the arm is to be bent to an angular position, and treated with oblong compresses and suitable bandages.

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COMMENTARY. No author, ancient nor modern, has given so complete a view of the accidents to which the elbow-joint is subject as Hippocrates. In his works (De Fracturis, De Articulis, and Mochlicus,) he has treated of this subject with surprising accuracy and skill. He describes the following injuries of the elbow-joint: 1st. Complete luxations, laterally, anteriorly, and posteriorly. 2d. Luxations of the radius, anteriorly, posteriorly, and laterally. 3d. Fracture of the olecranon. 4th. Fracture of the apophysis of the humerus. We must give his description of the last-mentioned injury in his own words: “It sometimes happens that the head of the humerus is broken at its apophysis; and this, although it appear a more serious accident, is, in fact, less so than many other injuries of the joint.” It is singular that this distinct account of a very common injury of the joint should have been overlooked or misunderstood by all his commentators and the surgical authorities down to the present day. We have often met with it in our own practice, and seen many instances in which it had been misapprehended in the practice of other surgeons. It is only within the last five or six years that it has been described in any modern work on surgery. Lateral luxation of the radius is described by him under the name of diastasis. (De Fracturis, 44; De Articulis, 20.) The Commentaries of Apollonius Citiensis and Galen are worth consulting although they contain no new matter. Galen remarks that in dislocations of the radius, the power of flexion and extension is often not much impaired; and this, we may add, is confirmed by modern observation. Galen’s account of fractures of the olecranon is remarkable for its precision and accuracy. (Chirurg. Vet. 84.)

Celsus describes four different kinds of dislocation at the elbow, namely, forwards, backwards, and to either side. He also mentions that rare variety, in which there is a dislocation of the ulna, while the radius remains in its place. (See Sir Astley Cooper’s Lectures.) The other varieties are all well described, and suitable methods of treatment recommended. When there is a dislocation forwards the arm is extended, but cannot be bent; when backwards, on the contrary, it cannot be extended, and is shorter than natural. When to either side, the arm is somewhat bent towards that side from which the bone has been moved. He lays it down as a general rule for treating all such dislocations, to extend both the members concerned in different directions, until the bones are separated from one another, and then to push them into their right position. When the dislocation is forwards, he directs us to make strong extension with the hands or with thongs, and then placing some round body upon the anterior part of the arm, to push the fore-arm over it suddenly to the shoulder. This method is well described by Hippocrates, but rather indistinctly by Paulus. In all the other cases, the best method, he says, is to make reduction in the same way that it is performed for the replacement of fractures.

Oribasius mentions the four ordinary kinds of dislocation at the elbow-joint, and describes methods of reducing them by machines. He has likewise described the separate dislocation of the radius from the humerus, and he is the only Greek authority, as far as we know, who has described the separate luxation of the ulna, but which, as stated above, had been noticed by Celsus. We need scarcely remark that a few cases of this uncommon accident have been reported of late years.

Albucasis says that the fore-arm is dislocated in all directions, but more especially backwards and forwards. His description of the mode of reduction is evidently copied from Paulus. Avicenna likewise borrows his whole account from our author.

Rhases and Haly Abbas describe the ordinary cases of complete luxation at the elbow-joint, but we believe that neither they nor any of the Arabians take notice of the dislocation of the radius from the ulna, nor the abruption of the apophysis of the humerus.

SECT. CXVI.—ON DISLOCATIONS AT THE WRIST AND FINGERS.

Dislocations at the wrist and fingers are attended with no difficulty, unless accompanied with a wound. This case, therefore, will be treated of under the head of dislocations with a wound. Those without a wound may be remedied by moderate extension and the anti-inflammatory plan of treatment.

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COMMENTARY. Hippocrates says that the hand is dislocated inwards and outwards, but most frequently inwards. In the former case it is found impossible to bend the fingers, and in the latter to extend them. He also makes mention of dislocations to either side. He directs us to make counter-extension upon a table, and to push down the projecting end of the bone with the hand or the heel. He also describes the separate dislocation of the radius and ulna; and, upon the whole, his account is very little different from that given by Sir Astley Cooper in his ‘Lectures,’ and by Mr. Liston in his ‘Elements of Surgery.’

Celsus describes, in his usual elegant manner, the dislocations forwards and backwards. He denies the possibility of the lateral dislocations, and, in fact, it is now acknowledged that if ever they do occur they are incomplete. Like Hippocrates, he directs us to replace dislocations of the fingers by making extension upon a table. He does not make mention of the separate dislocation of the lower end of the radius.

Oribasius mentions the dislocations forwards and backwards, and likewise the separate dislocations of the radius and ulna. Sometimes, he says, the radius is dislocated, while the ulna remains in its place, and sometimes the ulna is dislocated while the radius remains. He describes the process of reduction with machines.

Albucasis, Avicenna, and Haly Abbas describe very accurately the dislocations forwards and backwards. They state that immediate reduction is peculiarly required in the case of this accident. Avicenna recommends a strengthening plaster to be put on the part before the splints are applied. When the joint, after reduction, is found to have lost the power of motion, Albucasis recommends us to pour hot water upon it and apply friction.

Rhases states that the ulna is more apt to be dislocated separately than the radius, which generally undergoes fracture rather than luxation. The fingers, he says, are mostly dislocated inwards.

SECT. CXVII.—ON THE VERTEBRÆ OF THE SPINE.

The vertebræ of the spine, when completely dislocated by accident, occasion instant death; for the spinal marrow undergoes extraordinary compression; and even when one of its nervous processes is compressed, it brings on dangerous symptoms. It often suffers sub-luxations, and when this takes place forwards it gets the name of repandation; when backwards, that of gibbosity; and when sideways, that of wry-neckedness. When there is a small sub-luxation of many vertebræ together, the distortion occasions a circular flexure of the spine, and in this case some are apt to be deceived, and take it for a complete dislocation of one spine, whereas a complete dislocation of one spinal vertebra does not produce a circular but an angular flexure of the spine, which is attended with more danger. When the dislocation is inwards, it cannot be reduced because no counter-pressure can be made on the belly. But those who imagine that they can effect anything in this case by stretching the patients upon a ladder, by apply cupping instruments, or administering sternutatories, or by producing coughing, or by inflation, are sufficiently exposed by Hippocrates. But since, often the breaking off of some of the small bones of the spine leaves a hollow appearance (as has been mentioned when treating of fractures), some have taken this for a dislocation forwards; and it being speedily healed, (for its callus is soon formed,) they have given out that a dislocation forwards is readily cured, although in fact it be wholly incurable, or difficult at least, to cure. For retention of the urine and fæces takes place, with coldness of the body; but this state is followed afterwards by an involuntary discharge of the excrements. These symptoms arise from the nerves and from muscular sympathy, and the patients soon die, more especially if the upper parts and the vertebræ of the neck be affected. But that gibbous state of the spine which mostly takes place from infancy, is a protracted affection and not speedily fatal; but, as Hippocrates has shown, it leads to disease and is incurable. But when this state occurs from an accident, the contrivances to remedy it with a ladder, suspending the patient erect, and inflation with a bladder, are altogether ridiculous. But the method of rectifying it, recommended by Hippocrates, will be alone sufficient. For, he says, a board, in length and breadth such as to contain the man, or a bench equal to it, is to be placed near a wall, being extended along the wall, and not more than a foot distant from it, and some robes are to be spread over it to prevent the body from being injured. Then the man, being bathed, is to be laid on his face along the board or bench, and a thong is to be twice passed round his breast by the armpits along the back; and the extremities of the thong are to be fastened to a pestle like a piece of wood erected on the floor at the extremity of the board or bench, and this to be given to a person standing behind the patient’s head to hold, so that when the lower parts are secured oppositely, and the upper pulled towards the head, extension may be made at the proper time. Then another thong being bound round both the feet above the ankles, and again another above the loins, so that its two ends may meet upon the haunch-bone, the extremities of these thongs are to be again united together, and bound to another pestle-like piece of wood resembling that already described; and this pestle, like the former, is to be erected near the extremity of the board or bench at his feet; and then we are to order the assistants to make counter-extension by these pieces of wood. Others effect this part of the operation by what are called aselli. They are axles turned upon an erect piece of wood, which is placed at each extremity of the large board or bench, at the feet and head of the patient, and the thongs are to be wrapped round them. While the extension is thus made, we press down the prominence of the back with the palms of the hands, and if necessary we may sit upon it without apprehension. If the spine is not thus made straight, and the patient can endure pressure, we may scoop out from the adjoining wall a furrow opposite the prominence of the back, so that the length of the furrow may not be greater than a cubit, and it must be in a situation neither much higher nor lower than the patient’s spine. But this furrow ought rather to be prepared beforehand, and on this account we directed the board at first to be placed near the wall. Then one extremity of a board is to be introduced into the furrow, while we press the other downward until it is clear that the spine is rectified. According to Hippocrates, extension alone without the board, and again the treatment with the board alone, is sufficient to accomplish the purpose. If this be true it will not be improper, in cases of dislocation anteriorly and laterally, to make the aforesaid extension without the compression. After the reduction, a thin piece of wood three fingers in breadth, and of such a length as to comprehend the dislocated part and some of the sound vertebræ, is to be wrapped round with a piece of linen or some flax, on account of its hardness, and applied to the spine with suitable bandages. And the patient must be kept upon a spare diet. If afterwards any remains of the protuberance are to be discovered, we must use relaxant and emollient applications, with the pressure by means of the plate. Some use a plate of lead.

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COMMENTARY. Our author’s account of dislocations of the spine is entirely condensed from Hippocrates’s work ‘De Articulis,’ and the commentary of Galen on the same. The description of the methods of reduction is so plain, that we need not take up time in illustrating it. It will be remarked that he makes mention of a mode of reducing these dislocations by means of axles or aselli. In the days of Hippocrates they were acquainted with only three of the mechanical powers, namely, the lever, the wedge, and the axis in peritrochio. The last mentioned is called by him asellus. (See De Fracturis cum Comment. Galeni.) Hippocrates makes mention of a mode of reducing dislocations of the spine, by succussion in a ladder, but expresses himself unfavorably of it as being a procedure which none but charlatans would practice. He speaks with becoming contempt of those who have recourse to ostentatious modes of performance ad captandum vulgus.

Celsus states very decidedly the fatal nature of dislocations of the uppermost vertebræ. Even those below the diaphragm are designated as highly dangerous. They happen either forwards or backwards. Those above the diaphragm occasion paralysis of the hands, vomitings, contractions of the tendons, difficulty of breathing, pain, and relaxation of the ears. Those below the diaphragm produce paralysis of the lower extremities, suppression of urine, or an involuntary discharge of it. Even these cases, he adds, prove fatal within three days. He says, that Hippocrates’s mode of reduction by counter-extension and pressure on the part with the heel, applies only to cases of incomplete luxation.

Oribasius describes the method of reduction by means of a machine, as mentioned by our author. It will readily be understood that the whole process consisted in making counter-extension upwards and downwards, and pressing upon the part which projects with a piece of wood. (De Machinamentis.)

Albucasis explains the nature of the accident and the methods of reduction in much the same terms as our author. The patient is to be laid upon a board or bench of sufficient length, spread with some soft thing to prevent him from being hurt. Then a pole or piece of wood is to be fastened at each extremity of the bench; and a rope or swathe, being carried round the patient’s body by the armpits and above his head, is to be fastened to the upper pole, which is not to be fixed firm in the ground; and another rope is to be brought round below the part affected, and fastened to the pole at his feet. Powerful counter-extension may be thus made, while the surgeon presses upon the protruded part with his hand and pushes it into its place. If these means do not succeed, he directs us to fasten a piece of wood into a hole in the wall opposite the protuberant part of the patient’s back and to press down with it. Other methods are also described by him. After reduction he directs us to apply a splint with bandages, as recommended by our author.

Avicenna describes all the methods of reduction here mentioned; and in the Latin edition of his works there are plates to illustrate his descriptions. Judging from our own experience of such cases, however, we would say that such contrivances can seldom be required to reduce these dislocations, as there is much less difficulty in the reduction than in keeping the parts in place afterwards.

Haly Abbas copies the description given by Hippocrates of the mode of reduction. After the parts are restored to their place, he recommends us to apply a board (tabula lignea) three fingers broad, and of such a length as to comprehend the dislocated vertebræ and some of the adjoining ones; and to bind it firmly on to prevent a recurrence of the displacement.

The ancients were well acquainted with the curvature of the spine occasioning paralysis of the lower extremities. Alsaharavius remarks that it occurs most frequently in childhood, and arises from an inflammation or collection of humours between the vertebræ. Sometimes, he adds, it is occasioned by a gross flatus. This is the disease called spina ventosa. When connected with a collection of blood in the part, he recommends bleeding, clysters, and various emollient applications. When it arises from flatulence he prescribes the hermodactylus. If the usual means do not succeed he approves of the actual cautery. (Pract. xxviii, 9.)

But no ancient author has treated so fully of curvature of the spine as Rhases. He states that it occurs most frequently in childhood, and often proves fatal by occasioning pressure on the thoracic viscera. The disease, he says, may arise from a fall, a blow, an abscess, or a gross flatus contained in the vertebræ. In cases of paralysis of the lower extremities connected with this disease, he approves of applying the actual cautery to the back. (Cont. i.) He states correctly that dislocations of the upper vertebræ often prove suddenly fatal. He directs the surgeon to keep them reduced with a splint extending the whole length of the spine. (Cont. xxix.) On the spina ventosa or gibbositas, see further Serapion (v, 26.) For the cure of it, he recommends first discutient plasters, and if these do not succeed he advises recourse to the actual cautery. (v, 27.)

SECT. CXVIII.—ON DISLOCATION AT THE HIP-JOINT.

The other bones of the human body sometimes undergo subluxation, and sometimes complete luxation, but the articulations at the hip and the shoulder are subject only to complete luxation, more especially the hip-joint, because it has a deep and round cavity which is further strengthened by a strong brim. The limb, then, being subject to displacement from its cavity by some great violence, many differences arise according to the greater or less degree of the dislocation. Dislocation at the hip-joint takes place in four ways, or rather places; for it is dislocated either inwards, outwards, forwards, or backwards; inwards and outwards frequently, more especially inwards; but forwards and backwards very rarely. When the dislocation is inwards, the affected leg, if compared with the sound one, appears longer, the knee is more prominent, the patient cannot bend the leg at the groin, and a swelling is clearly felt in the perineum, from the head of the thigh being lodged there. When the dislocation is outwards, the symptoms are the contrary to these; for the leg appears shorter, there is a hollow in the perineum, a protuberance about the nates, the knee is turned inwards, and the leg can be bent. When the dislocation is forwards, the patient can stretch the leg without pain at the knee, but when he attempts to walk he cannot turn the foot inwards; the urine is retained, the groin is swelled, the buttocks appear wrinkled and destitute of plumpness; and in walking he supports himself upon his heel. Those who experience a dislocation backwards can neither extend the ham nor the knee, nor can they bend the limb before bending the groin also. The leg appears shorter, the groin looser, and the head of the thigh is to be felt at the buttock. When, then, from infancy, or simply, when for a length of time the limb has been neglected after being dislocated, and allowed to remain so, the cure is impracticable, callus having been already formed. But when the luxation is recent, it may be managed in the way recommended by Hippocrates. We must, then, proceed immediately to the reduction, for dislocations at the hip-joint, when allowed to remain long, are wholly irremediable. In general, then, in all the four kinds of dislocation, the reduction may be accomplished by rotating it, by bending the limb, and by extension. For if the accident be recent and the patient young, we may sometimes succeed in reducing the limb by grasping and rotating the thigh this way and that. When the dislocation is inwards we may sometimes accomplish our purpose by bending the limb at the groin inwards frequently and strongly. If the dislocation does not yield to these means we must have recourse to extension, first with the hands, certain assistants grasping the thigh and leg and pulling the limb downwards, while others grasp the body at the armpits and pull upwards. Or, if a stronger extension be required, the leg may be bound with twisted cords or thongs, above the ankle, and a little higher than the knee, lest it suffer injury; but it is not necessary to secure the breast in this manner, for, as has been said, the hands may be put under the armpits for this purpose. And the middle of a soft and strong thong is to be applied to the perineum, and brought up to the shoulders anteriorly by the groins and clavicles, and posteriorly along the back, and the two ends are to be given to an assistant to hold. Then, all pulling together so as to raise the patient’s body, extension is to be thus made. This mode of extension is applicable generally in all the four varieties of dislocation. But the manner of replacement varies according to the nature of the dislocation. If the bone has been dislocated inwards, let the patient be stretched by having the middle of a thong applied to the perineum between the head of the bone and the perineum, and let the thong be brought upwards by the adjoining groin and the clavicle, and let a young man with both his arms grasp the thigh which is affected in its thickest part, and pull strongly outwards. This mode of reduction is easier than any of the others. When the limb does not thus yield we must have recourse to other contrivances more complicated but more efficacious than these. Let the man be stretched upon a large board, or bench, like that upon which we stretch those who have dislocation of the spine, and along nearly its whole length let certain gutters be scooped out, in breadth and depth not more than three fingers, and not more than four fingers distant from one another, so that the extremity of the lever being inserted into them may impel the limb wherever it is required. In the middle of the board, or bench, let another piece of wood be fastened about a foot in length, and in thickness like that which is inserted in the extremity of a spade, so that when the man is pulled along, this piece of wood may come between the perineum and the head of the thigh, so as to prevent the yielding of the body when pulled by the feet, and thereby often obviating the necessity of making counter-extension; and at the same time when the body is extended this piece of wood will push the head of the thigh outwards. The extension is to be made in the manner described above, more particularly by the foot. But if it is not thus reduced, the erect piece of wood is to be taken away, and two other pieces of wood fastened on the sides of it like posts, not more than a foot in length, and let another piece of wood be adapted to them like the step of a ladder, so that the figure of the three pieces of wood may resemble the Greek letter Η; the middle piece of wood being fixed a little below the upper extremities. Then the man being laid on the sound side, we bring the sound leg between the two posts below the piece of wood corresponding to the step of a ladder, while the affected one is brought above it, so that the head of the thigh is to be adapted to it; but a folded garment is to be first wrapped about it to prevent the thigh from being bruised. Then another board of moderate breadth, and of such a length as to extend from the head of the thigh to the ankle, is to be bound along the inner side of the thigh. Then extension being made either by the pestles mentioned in treating of the dislocation of the vertebra, or some other instrument, the leg is to be pulled downwards along with the board which is fastened to it, so that by the force exerted the head of the thigh-bone may return to its proper place. There is another mode of reduction without making extension upon a board, which is much commended by Hippocrates. The patient’s hands, he says, are to be bound loosely to the sides, and a soft but strong thong put round both his feet at the ankles and above the knees, four fingers distant from one another, so that the affected leg when stretched may come two inches lower down than the other. The man is afterwards to be suspended with the head two cubits distant from the ground. Then an expert young man is to seize the affected thigh in his arms, at its thickest part, where the head of the thigh is lodged, and suddenly suspend himself from the man, by which means the joint will readily return to its place. This mode of reduction is simpler than any of the others, being performed without much apparatus, but many now reprobate it as dangerous. If the dislocation is outwards, the extension is to be made as above, but the thong at the perineum is to be passed by the opposite parts, I mean the groin and clavicle. The surgeon is to propel the limb from without inwards, the lever being fastened into one of the furrows formerly prepared, and an assistant fixing the sound nates that the body may not yield. In dislocations forwards, the patient being stretched, a strong man is to apply the palm of the right hand to the affected groin, and press down with the other hand, so that the depressing force may be exerted downwards, and to the knee. In dislocations backwards, the man is not to be stretched so as to raise him up, but he is to lie upon a hard body as in dislocations outwards; and, as we mentioned with regard to dislocations of the vertebra backwards, the man is to be laid on his face upon a board or bench, and the ligatures are to be applied, not to the loins, but to the leg as mentioned a little above. But the depression, by means of a board, is to be applied at the buttocks, where the dislocated bone is lodged. And thus much respecting dislocations at the hip-joint occasioned by some external cause. But since dislocation sometimes takes place at the hip-joint, as at the shoulder, owing to a collection of humours, we must, in this case, as we mentioned in the other, have recourse to burning.

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COMMENTARY. Although the descriptions given by the medical authorities who preceded and followed our author will be found in the main exactly the same as his, we are induced to give a brief outline of them, in order to illustrate by every means in our power a subject so important as the one now on hand.

Every subsequent author is indebted to Hippocrates for his lucid and correct exposition of dislocations at the hip-joint. He says truly that the thigh-bone is dislocated in four directions, namely, inwards, which occurs frequently; outwards, the most frequently of all; backwards and forwards, both very rarely. The following are the symptoms of dislocation inwards, as described by him. The leg is longer than natural, the buttocks outwardly appear hollow; the knee, foot, and leg are turned out; the patient cannot bend his thigh at the groin; and the head of the thigh-bone occasions a tumour in the perineum. This appears evidently to be the variety described by modern surgeons as the dislocation inwards and downwards, the head of the bone being lodged near the thyroid foramen. The symptoms described by modern authors are exactly the same as those mentioned by Hippocrates. Having seen cases of it, we can bear testimony to the correctness of Hippocrates’s description. The symptoms of dislocation outwards as enumerated by Hippocrates are, shortening of the limb, relaxation of the inner part of the thigh, and projection at the buttock, inclination of the knee, leg, and foot inwards, with inability to bend the limb. This case is described by modern authors as a dislocation upon the dorsum of the ilium. From personal experience we can also testify to the accuracy of the description of it given by Hippocrates. The next variety is the dislocation backwards, which, he remarks, is of rare occurrence. It is rather obscurely marked by inability to extend the leg at the hip-joint and ham, relaxation of the flesh in the groin, distension of the nates, a slight degree of shortening and inclination of the limb. He states that the head of the bone is situated below the flesh of the nates. This assuredly is the dislocation backwards upon the tuber ischii, the symptoms of which are admitted by Sir Astley Cooper to be sufficiently obscure. Hippocrates describes with great accuracy the appearance which the limb puts on afterwards when the dislocation is not reduced. (De Articulis.) Reduction, he says, may be accomplished by the hands, with a bench, or with a lever. All these modes of reduction are mentioned by our author, and therefore we shall not take up time in describing them. (Ibid. and De Vectiariis, 15.) The figure of the bench of Hippocrates, given by Littré, would appear to us excellent, and it renders the description easily understood. (Hippocrat. Op. t. iv, 44.) Littré also gives an excellent figure of the reduction by suspension. (Ib. 291.)

Apollonius Citiensis gives a most elaborate and interesting commentary on the methods of reduction recommended by Hippocrates in cases of dislocation at the hip-joint. These methods, however, may be best learned by examining the figures given in the Index Galeni, or in H. Stephens’s Latin Translation of Oribasius (Ap. Med. Art. Princip.), or in Littré’s Edition of Hippocrates (iii, and iv.) There is one curious passage in the commentary of Apollonius, which we must not pass by. He says that Hegetor, one of the followers of Herophilus, had maintained that dislocation of the thigh being attended with rupture of the tendon fixed into his head (ligamentum teres) it was impossible ever afterwards to keep the ball of the femur in the acetabulum. This, Apollonius correctly argues, is contrary to experience and the authority of the ancients. (Ed. Dietz, p. 35.)

Celsus describes the different modes of dislocation at the hip-joint in the following terms: “Femur in omnes quatuor partes promovetur, sæpissime in interiorem; deinde in exteriorem; raro admodum in priorem, aut posteriorem. Si in interiorem partem prolapsum est, crus longius altero et valgius est: extra enim pes ultimus spectat. Si in exteriorem, brevius varumque fit, et pes intus inclinatur; calx ingressu terram non contingit sed planta ima; meliusque id crus superius corpus, quam in priore casu, fert, minusque baculo eget. Si in priorem crus extensum est, implicarique non potest; alteri cruri ad calcem par est, sed ima planta minus in priorem partem inclinatur: dolorque in hoc casu præcipuus est, et maximè urina supprimitur. Ubi cum dolore inflammatio quievit, commodè ingrediuntur, rectusque eorum pes est. Si in posteriorem, extendi non potest erus, breviusque est; ubi consistit, calx quoque terram non contingit.” His statement, however, that dislocations inwards are of most frequent occurrence of any is at issue with that of Hippocrates, who more correctly states that the dislocations outwards are the most common of all. He likewise describes clearly the methods of reduction. If the muscles of the limb be weak, it will be sufficient to make extension by means of thongs applied at the groin and the knee; but if strong, it will be better to fasten them to the upper extremities of two sticks loosely fixed in the ground, and to make counter-extension by pulling the ends of the sticks in opposite directions. A more powerful method is by stretching the limb upon a board having axles at both ends with thongs fastened to them, by turning which such powerful extension could be made as would be sufficient even to break the muscles and tendons. When these are stretched, if the bone is dislocated forwards, some round body is to be placed in the groin, and the knee is to be suddenly carried over it, for the same reason and in the same manner as in dislocations at the shoulder. In the other cases the surgeon is directed to push the bone towards its place, while an assistant propels the hip-joint.

Oribasius mentions the four varieties of dislocation at the hip-joint. In three of them, he says, the leg is extended and cannot be bent; but in the dislocation backwards, it is bent and cannot be extended. He has described the method of reducing these dislocations by machines, of which he gives plates.

Albucasis describes the four varieties of dislocation and the methods of reduction in much the same terms as Paulus. His modes of reducing them are: 1st. By rotating the limb in all directions. 2d. By making extension and counter-extension with the aid of two assistants. 3d. By suspending the patient, and getting a strong assistant to grasp the affected leg and swing himself by it. 4th. By making extension with ropes fastened to two sticks or pieces of wood as recommended for dislocations of the spine. When the dislocation is forwards, the surgeon is to press down the prominent part with his hands; but if backwards, a board is to be used in the manner described by our author.

Avicenna agrees with Hippocrates, in opposition to Celsus, that dislocation outwards (on the dorsum of the ilium) is of more frequent occurrence than the dislocation inwards (on the foramen ovale.) His description of the modes of reduction is evidently taken from Paulus.

Haly Abbas describes the four varieties mentioned by Hippocrates, and recommends much the same treatment. The account of them given by Rhases is exactly the same.

The earlier modern writers on surgery, describe the four varieties of dislocation at the hip-joint in the same terms as the ancients. They evidently follow the Arabians. See Theodoricus (ii, 51); Guido de Cauliaco (v, 2, 7.) From the contents of this section it will be clearly seen how erroneous is the statement made by the late Sir Astley Cooper, that the profession was entirely ignorant of the nature of these accidents until within these last few years.

SECT. CXIX.—ON DISLOCATION AT THE KNEE.

The knee is dislocated in three ways: inwards, outwards, and towards the ham; for it is prevented by the patella from being dislocated forwards. Using, then, the same modes of extension, sometimes by the hands alone, and sometimes by cords, we must have recourse to suitable bandages, and the other suitable treatment, the part being in particular preserved free from motion.

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COMMENTARY. Hippocrates, like our author, mentions three directions in which the bones of the knee-joint may be dislocated: namely, inwards, outwards, and backwards. He has not noticed the dislocation forwards, which is, in fact, a very rare case. Celsus mentions, however, that Meges had related a case of dislocation forwards, which was successfully treated by him. But most of the other authorities, he says, have denied the possibility of such an occurrence. He directs the surgeon to reduce dislocations at the knee upon general principles, by making extension and counter-extension. Hippocrates represents dislocations at the knee as being of more frequent occurrence, but less dangerous, than those of the elbow.

Oribasius, like our author, treats only of three kinds of dislocation at the knee. Albucasis denies the possibility of a dislocation forwards. He directs the surgeon, in making reduction, to turn his back to the patient, and take the limb out between his knees; then while an assistant makes extension at the foot, he is to replace the bones with his hands. This seems a very proper method of reduction.

Avicenna likewise mentions only three modes of dislocation. He has described dislocation of the patella, a case omitted by our author. He directs us after making reduction, to fill the hollows with compresses, and then to apply splints and bandages. He says that the knee is often dislocated in walking. He must surely allude to a species of sub-luxation first well described by the late Mr. Hey, of Leeds; for a complete luxation is a very rare occurrence, and is never occasioned but by great violence.

Haly Abbas and Rhases describe only three kinds of dislocation at the knee, and deny the possibility of a dislocation forwards. Both evidently copy from our author.

The earlier modern surgeons, as usual, adopt the views of the Arabians, and accordingly deny the possibility of a dislocation forwards. See Theodoricus (ii, 52.) They would appear to have been wholly unacquainted with the works of Celsus, and to have derived all their information from the Arabians.

Dislocations at the knee-joint are now found to be of much rarer occurrence than they are represented to be by the ancient authorities. In fact only a very few cases have been reported in modern times. We would beg, therefore, to refer our readers to a case related in the ‘Medical Gazette,’ Dec. 16, 1842, by the author of this Commentary. It is necessary to remark, however, that several typographical mistakes occur in the Report, which are partly corrected in a subsequent number of the same periodical.

SECT. CXX.—ON DISLOCATION AT THE ANKLE, AND ALSO OF THE TOES.

The articulation at the ankle, if but a little displaced, is remedied by moderate extension; but if completely dislocated, it requires greater force. We may endeavour therefore, in this case, to make strong extension by the hands; but if reduction does not take place, having stretched the man on the ground in a supine posture, we are to fasten into the floor a long and strong peg, between his two thighs, so as to prevent the body from yielding to the extension by the foot; or rather let the peg be fastened before the man is laid down; or if we have the large board at hand on the middle of which, as we said, a wooden peg a foot long is fastened, we may make the extension upon it. An assistant then grasping the thigh, and making counter-extension, another assistant is to pull the foot with his hands or by a thong, and the surgeon is to rectify the dislocation with his hands, while some other person keeps the other foot down below. After the reduction it is to be bound carefully, some folds of the bandage being carried along the front of the foot, and some towards the ankle; but we must take care not to include the posterior tendon which is inserted into the heel. And the man is to be kept from walking for forty days; for those who attempt to walk before the cure is completed impair the actions of the part. If from a leap, as commonly happens, the bone of the heel is moved from its place, or if any inflammatory state is brought on, it is to be remedied by gentle extension and reduction, anti-inflammatory embrocations and secure bandages, the man being kept also in a quiet state until the part is restored. And dislocation of the toes, as we said with regard to the fingers, may be remedied without difficulty by moderate extension. In all these luxations and sub-luxations, after the reduction, and rest for a suitable number of days, any inflammation or swelling which may remain in the joints, and occasion a protracted impairment of the function thereof, is to be cured by emollient applications, the materials of which must be known to every one who is conversant with the matters relative to our art.

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COMMENTARY. Hippocrates states that dislocation at the ankle is generally produced by leaping from a great height. He remarks that the accident gives rise to excessive swelling of the part. When the parts have been reduced, he directs us to apply a bandage to retain them properly in position, which, he says, it requires some address to perform in a suitable manner. He recommends us to reduce dislocations of the toes and of the bones of the foot like those of the hand. His account of dislocations of the astragalus and of the os calcis is curious, but there is some difficulty in clearly apprehending his views. We need scarcely say that it is a subject still requiring elucidation.

According to Celsus, dislocations at the ankle-joint may take place in all directions. He recommends us to reduce them with the hands, by making extension and counter-extension. He advises us to make the patient lie in bed longer than in ordinary cases.

Oribasius makes mention of only three modes of dislocation at the ankle; namely, inwards, outwards, and backwards.

According to Albucasis, dislocation at the ankle can only take place inwards or outwards. When the bones of the tarsus are displaced, he directs us to restore them by making the patient put his foot upon the ground; and the surgeon, by placing his foot upon it and standing erect, is to push them into their place. After reduction, a splint is to be put under the sole, and secured with bandages. Rhases, Avicenna, and Haly Abbas evidently copy from our author. They give the same account as Hippocrates of dislocation of the astragalus.

Luxations of the tarsal bones are described in Sir Astley Cooper’s ‘Surgical Lectures,’ and other modern works. Modern authors are agreed that dislocations may take place in all directions, and that they may be complete or incomplete. It will be remarked that Paulus makes mention of sub-luxations.

This is the place where we shall be expected to give some account of the knowledge possessed by the ancients of the nature and treatment of Club-foot. It is singular that Hippocrates is almost the only ancient author who has treated of the subject in an interesting manner, and of him one need have little hesitation in affirming, that he displays more practical acquaintance with it than any other writer until the time of Stromeyer. He states that there are more than one variety of this impediment; that it is not, properly speaking, a dislocation, but a declination of the foot from its natural position; and that most cases of congenital club-foot admit of cure, if it be attempted before the limb is much wasted. He gives minute directions for restoring the limb to its proper shape by the fingers, and for securing it with waxed bandages and compresses, above which a piece of stout leather or a plate of lead is to be bound. Over all a leaden boot, like the Chian shoes, may be applied if necessary. By these means, he does not hesitate to declare that the deformity may be generally overcome more readily than one would have believed, “without cutting or burning, or any other complex mode of treatment.” (De Articulis, 62.) Galen’s commentary on this chapter is of use in illustrating the text of Hippocrates, but supplies no additional information for any practical purpose. (v, 642, ed. Basil.)

SECT. CXXI.—ON DISLOCATIONS WITH A WOUND.

In the case of dislocations with a wound the utmost discretion is required. For these, if reduced, occasion the most imminent danger, and sometimes death, the surrounding nerves and muscles being inflamed by the extension, so that strong pains, spasms, and acute fevers are produced, more particularly in the case of the elbows, knees, and joints above, for the nearer that they are to the vital parts the greater is the danger they induce. Wherefore, Hippocrates, by all means, forbids us to apply reduction and strong bandaging to them, and directs us to use only anti-inflammatory and soothing applications to them at the commencement, for that by this treatment life may sometimes be preserved. But what he recommends for the fingers alone, we would attempt to do for all the other joints: at first, and while the part remains free from inflammation, we would reduce the dislocated joint by moderate extension, and if we succeed in our object we may persist in using the anti-inflammatory treatment only. But if inflammation, spasm, or any of the afore-mentioned symptoms come on, we must dislocate it again if it can be done without violence. If, however, we are apprehensive of this danger (for perhaps if inflammation should come on it will not yield,) it will be better to defer the reduction of the greater joints at the commencement; and when the inflammation subsides, which happens about the seventh or ninth day, then, having foretold the danger from reduction, and explained how, if not reduced, they will be mutilated for life, we may try to make the attempt without violence, using also the lever to facilitate the process. We are to apply the same treatment to the ulcer as recommended for fractures with a wound.

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COMMENTARY. Hippocrates, as stated by our author, was decidedly averse to immediate reduction in cases of dislocation complicated with an external wound. Hence, in compound dislocations at the ankle, he forbids us to interfere at first, as attempts at reduction will certainly bring on convulsions or gangrene. Modern experience agrees with that of the father of medicine as to the danger attending these accidents. Compound luxations at the wrist, he says, prove fatal if reduced, but if let alone they generally get better. (De Artic. 64.) Compound dislocations at the knee are said to be particularly dangerous. (Ibid. 66.)

Celsus follows the line of practice recommended by Hippocrates. In cases of compound dislocations at the shoulder and hip-joint, he states that the danger is great if they are left unreduced, but pronounces death to be certain if they are reduced. Like Hippocrates, he approves of immediate reduction only in dislocations of the bones of the feet and hands. Even these, however, are not to be interfered with while the parts are in an inflamed state. He approves of bleeding, a spare diet, and rest. When a naked bone protrudes and cannot be got restored to its place, he advises it to be sawed off. (viii, 25.)

Galen gives his unqualified sanction to the practice of Hippocrates. See his commentary on the work ‘De Articulis’ and ‘Nicetæ Collectio.’

Albucasis, like our author, recommends gentle attempts at reduction before swelling and inflammation come on, and soothing treatment afterwards.

The practice of Haly Abbas differs nothing in principle from that of our author and Albucasis. If reduction has not been performed early, he forbids it until the inflammation has subsided.

Rhases appears to have copied his rules of treatment from our author. He recommends us, if possible, to replace the parts before inflammation comes on, but forbids it while they are in that state, for fear of occasioning convulsions and death.

SECT. CXXII.—ON DISLOCATION COMPLICATED WITH FRACTURE.

If a dislocation be attended with fracture without a wound we must apply the common extension, and replacement by the hands, as described for simple fractures. But if complicated with a wound, we must apply the suitable treatment from what has been said of fractures with a wound, and dislocations in particular.

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COMMENTARY. Haly Abbas says that when a wound, a fracture, and a dislocation are combined in one case, each is to be treated upon general principles.

Albucasis directs us to remove any spiculæ of bone which may protrude in such cases. He exhorts the surgeon to act cautiously but confidently, as such conduct will prove most pleasing in the sight of his Creator, and redound to his own glory.

END OF VOL. II.

C. AND J. ADLARD, PRINTERS, BARTHOLOMEW CLOSE.