THE
                             SYDENHAM SOCIETY

                                INSTITUTED
                                MDCCCXLIII

                         [Illustration: SYDENHAM]

                                  LONDON
                                MDCCCXLVI.




                                   THE
                               SEVEN BOOKS
                                    OF
                             PAULUS ÆGINETA.

                        TRANSLATED FROM THE GREEK.

                                   WITH
                               A COMMENTARY
                EMBRACING A COMPLETE VIEW OF THE KNOWLEDGE
                             POSSESSED BY THE
                       GREEKS, ROMANS, AND ARABIANS
                                    ON
            ALL SUBJECTS CONNECTED WITH MEDICINE AND SURGERY.

                            BY FRANCIS ADAMS.

                            IN THREE VOLUMES.
                                 VOL. II.

                                  LONDON
                     PRINTED FOR THE SYDENHAM SOCIETY
                               MDCCCXLVI.

        “MULTUM EGERUNT QUI ANTE NOS FUERUNT, SED NON PEREGERUNT.
        SUSPICIENDI TAMEN SUNT, ET RITU DEORUM COLENDI.”
                                            (SENECA, EPIST. LXIV.)

                       PRINTED BY C. AND J. ADLARD,
                            BARTHOLOMEW CLOSE.




CONTENTS OF THE SECOND VOLUME.


                              FOURTH BOOK.

  SECT.                                                               PAGE

    1. On Elephantiasis                                                  1

    2. On Leprosy and Psora                                             15

    3. On Lichen                                                        24

    4. On Pruritus, or Prurigo                                          27

    5. On Leuce                                                         31

    6. On white and black Alphi                                         33

    7. On Stigmata, from the works of Archigenes                        36

    8. On Exanthemata                                                   37

    9. On Epinyctides                                                   39

   10. On Phlyctænæ, or Bullæ                                           41

   11. On Burns                                                         42

   12. For those beaten with Scourges                                   45

   13. To make Hairs grow on a part that has been burnt                 46

   14. For Excoriations                                                 47

   15. For Myrmecia and Acrochordon                                     48

   16. On Ganglion                                                      50

   17. On Phlegmon                                                      51

   18. On external Abscesses                                            54

   19. On Gangrene and Sphacelus                                        59

   20. On Herpes                                                        61

   21. For Erysipelas                                                   65

   22. On Phyma, Bubo, and Phygethlon                                   71

   23. On Furunculus                                                    73

   24. On Terminthus                                                    75

   25. On Carbuncle, or Anthrax                                         ib.

   26. On Cancers                                                       79

   27. On Œdema                                                         83

   28. On Emphysema                                                     84

   29. For Sprains and Contusions                                       86

   30. On Contusions of the Flesh and Ecchymosis                        87

   31. On Rupture and tearing of the flesh                              88

   32. On Scirrhus                                                      ib.

   33. On Strumæ, or Scrofula                                           91

   34. On Steatoma, Atheroma, and Meliceris                             94

   35. Of Favi                                                          97

   36. On the simple Ulcer                                              99

   37. On Agglutinants                                                 101

   38. On painful and inflammatory Sores                               102

   39. On unconcocted Ulcers, and such as have not suppurated          103

   40. On hollow Ulcers                                                104

   41. Medicines for cleansing foul Ulcers                             106

   42. For Worms in Ulcers                                             107

   43. On fungous Ulcers                                               108

   44. On spreading Ulcers, putrid Ulcers, and Phagedæna               109

   45. On Ulcers requiring Cicatrization                               112

   46. On the malignant Ulcers called Chironian and Telephian          114

   47. For black Cicatrices                                            118

   48. On sinuous Ulcers                                               119

   49. On Fistula                                                      122

   50. For Sores which break out again                                 125

   51. On Ulcers in the Joints                                         126

   52. Those things which extract Shafts, Javelins, Thorns, and
         the like                                                       ib.

   53. On Hemorrhage from Veins and Arteries                           127

   54. On Wounds of the Nerves                                         132

   55. On Ancylosis                                                    137

   56. On Relaxation of the Joints                                     139

   57. On Worms                                                         ib.

   58. On Ascarides                                                    144

   59. On Dracunculus, or the Guinea-Worm                              150

                               FIFTH BOOK.

    1. On the Preservatives from venomous animals in general           155

    2. The general treatment of all persons bitten or stung by
         any venomous animal                                           157

    3. On persons bitten by mad Dogs, and on Hydrophobia               162

    4. For the Bites of Dogs that are not mad                          168

    5. On Wasps and Bees                                                ib.

    6. On the Phalangia, or venomous Spiders                           169

    7. On the Bite of the Spider                                       171

    8. On the Sting of the Scorpion                                     ib.

    9. On the Land and Sea Scolopendra                                 174

   10. On the Stellio, or spotted lizard                               175

   11. On the Mus araneus, or shrew-mouse                               ib.

   12. On Vipers and Echidnæ                                           177

   13. On the Amphisbæna and Scytala                                   180

   14. On the Dryinus. The Introduction from Galen                     181

   15. On the Hæmorrhus, Prester, or Dipsas                            182

   16. On the Hydrus, or water serpent                                 185

   17. On the Cenchrinus                                               186

   18. On the Cerastes and Asp                                         187

   19. On the Basilisk                                                 189

   20. On the Sea Pastinaca and Muræna                                 191

   21. On the Sea-Dragon                                                ib.

   22. On the Sea-Scorpion                                             192

   23. The preparation of the blood of the Sea-tortoise                 ib.

   24. On persons bitten by Crocodiles                                 193

   25. On persons bitten by a Man                                       ib.

   26. On Poisons                                                      194

   27. On the preservatives from Poisons                               195

   28. The general treatment of those who have taken any sort
         of deleterious substance                                      196

   29. A Catalogue of simple deleterious substances                    200

   30. On Cantharides                                                  201

   31. On the Buprestis                                                203

   32. On the Salamander                                               204

   33. On the Pityocampa, or pine-caterpillar                          205

   34. On the Sea-hare                                                  ib.

   35. On the Red Toad or marsh frog                                   206

   36. On Leeches                                                      207

   37. On the Chamæleon                                                208

   38. On Henbane                                                      209

   39. On Coriander                                                    210

   40. On Psyllium, or Fleawort                                        211

   41. On Conium, or Hemlock                                            ib.

   42. On the juice of the Poppy                                       213

   43. On the juice of the Carpesia                                    218

   44. On Mandragora, or Mandrake                                       ib.

   45. On Aconitum, or Wolfsbane                                       220

   46. On Ixia                                                         221

   47. On Ephemeron, or Meadow Saffron                                 222

   48. On the Smilax, or Yew                                           223

   49. On the Strychnos Furiosa, called Dorycnium, by some             224

   50. On the Sardonian Herb                                           225

   51. On the horned Poppy                                             226

   52. On Pharicum                                                      ib.

   53. On Toxicum                                                      227

   54. On Mushrooms                                                    228

   55. On Bulls’ Blood                                                 230

   56. On coagulated Milk                                              231

   57. On Heraclean Honey                                              232

   58. On Gypsum                                                       233

   59. On Ceruse                                                       234

   60. On Lime, Sandarach, and Arsenic                                 235

   61. On Litharge                                                     236

   62. On Lead                                                         237

   63. On Mercury                                                      238

   64. On white Hellebore, Thapsia, Elaterium, black Agaric, wild
         Rue, Gith, and the Down of the Cactos                         239

   65. On domestic articles, such as Wine and cold Water               243

                       APPENDIX TO THE FIFTH BOOK.

       On feigned Diseases, and the Detection of them                  244

       On professional Impostors                                       245

  SIXTH BOOK.

    1. Preface to the Surgical part                                    247

    2. On burning of the Head for Ophthalmia, Dyspnœa, and
         Elephantiasis                                                 248

    3. On Hydrocephalus                                                250

    4. On Arteriotomy                                                  253

    5. On Angiology, or section of the temporal vessels, and
         on burning the same                                           254

    6. On Hypospathismus                                               256

    7. On Periscyphismus                                               258

    8. On suture of the upper Eyelid, and other modes of operating
         for Trichiasis                                                259

    9. On burning of the Eyelids by medicines                          264

   10. On Lagophthalmos, or Hare-eye                                   265

   11. On the suture of the under Eyelid, and the burning of it
         by medicines                                                  266

   12. On Ectropion, or eversion of the lower Eyelid                   267

   13. On Anabrochismus and burning with iron                          269

   14. On Hydatids                                                     270

   15. On adhesion of the Eyelids                                      272

   16. On Chalazia, or tumours resembling hailstones                   273

   17. On Acrochordion and Encanthis                                   274

   18. On Pterygia                                                     275

   19. On Staphyloma                                                   277

   20. On Hypopyon of the eye                                          278

   21. On Cataracts                                                    279

   22. On Ægilops, or fistula lachrymalis                              284

   23. On imperforate Meatus Auditorius                                286

   24. On substances that have fallen into the meatus auditorius       287

   25. On Polypus                                                      289

   26. On Maimed Parts                                                 292

   27. On Epulis and Parulis                                            ib.

   28. On the Extraction of Teeth                                      294

   29. On constriction of the Tongue, or tongue-tied persons           295

   30. On Antiades, or indurated tonsils                               297

   31. On the Uva                                                      298

   32. On thorny substances fixed in the pharynx                       300

   33. On Laryngotomy                                                  301

   34. On Abscess                                                      303

   35. On Strumæ, or scrofulous glands                                 307

   36. On Steatoma, Atheroma, and Meliceris                            309

   37. On Aneurism                                                     310

   38. On Bronchocele                                                  314

   39. On Ganglion                                                     315

   40. On Venesection                                                  316

   41. On Cupping                                                      324

   42. On burning the Armpit                                           328

   43. On preternatural fingers, and on persons having six fingers     329

   44. On the operation of burning for Empyema                         330

   45. On Cancer                                                       332

   46. On male breasts resembling the female                           334

   47. On burning over the Liver                                       335

   48. On burning over the Spleen                                      336

   49. On burning over the Stomach                                      ib.

   50. On Dropsies                                                     337

   51. On Exomphalos, or Prolapsus of the Navel                        340

   52. On Wounds of the Peritoneum, and on falling down of the
         Intestine or Omentum, where Gastroraphé also is described:
         from the Works of Galen                                       342

   53. On Deficiency of the Prepuce                                    346

   54. On Hypospadiæum, or imperforate Glans Penis                     347

   55. On Phimus, or Phimosis                                           ib.

   56. On Adhesion of the Prepuce to the Glans                         349

   57. On Circumcision                                                  ib.

   58. Of Thymi on the Penis                                           350

   59. On Catheterism, and Injection of the Bladder                    351

   60. On Calculus                                                     354

   61. On the Parts about the Testicles                                363

   62. On Hydrocele                                                    365

   63. On Sarcocele and Tophi of the Testicles                         369

   64. On Cirsocele and Pneumatocele                                   370

   65. On Enterocele, or Intestinal Hernia                             372

   66. On Bubonocele, or Inguinal Hernia                               377

   67. On Rhacosis, or Relaxation of the Scrotum                       379

   68. On Castration                                                    ib.

   69. On Hermaphrodites                                               381

   70. On Extirpation of the Nympha and Cauda Pudendi                   ib.

   71. On Thymi, Condylomata, and Hemorrhoids about the Female
         Parts of Generation                                           382

   72. On Imperforate Pudendum and Phimus                              383

   73. On Abscess of the Womb                                          385

   74. On Embryulcia and Embryotomy                                    387

   75. On Retention of the Secundines                                  392

   76. On burning the Hips                                             394

   77. On Fistulæ and Favi                                             396

   78. On Fistulæ in Ano                                               399

   79. On Hemorrhoids, or Piles                                        403

   80. On Condylomata, or Excrescences, and Fissures                   405

   81. On Imperforate Anus                                              ib.

   82. On the Excision of Varices                                      406

   83. On the Dracunculi, or Guinea-Worms                              409

   84. On Amputation of the Extremities                                 ib.

   85. On Pterygia about the Nails                                     414

   86. On a bruised Nail                                               415

   87. On Clavi, Myrmecia, and Acrochordones                           416

   88. On the Extraction of Weapons                                    418

   89. On Fractures and their Differences                              427

   90. On Fractures of the Bones of the Head                           429

   91. On Fracture and Contusion of the Nose                           443

   92. On Fracture of the Lower Jaw, and Contusion of the Ear          445

   93. On Fracture of the Clavicle                                     447

   94. On Fracture of the Scapula                                      450

   95. On Fracture of the Breast-Bone                                  451

   96. On Fracture of the Ribs                                         452

   97. On Fracture of the Bones of the Loins and Pubes                 454

   98. On Fracture of the Vertebræ, Spine of the Back, and Os Sacrum   455

   99. On Fracture of the Arm                                          464

  100. On Fracture of the Ulna and Radius                              464

  101. On Fracture of the Hand and its Fingers                         465

  102. On Fracture of the Thigh                                        466

  103. On Fracture of the Patella                                      468

  104. On Fracture of the Leg                                          469

  105. On Fracture of the Foot                                         470

  106. On the Arrangement of the Limb                                   ib.

  107. On Fractures complicated with a Wound                           472

  108. On the redundant Callus of Fractures                            476

  109. On Distortion from the Union by Callus                           ib.

  110. On Bones which have not united by Callus                        477

  111. On Luxations                                                    478

  112. On Dislocations of the Lower Jaw                                479

  113. On Dislocations of the Clavicle and Acromion                    482

  114. On Dislocation at the Shoulder                                  484

  115. On Dislocation of the Elbow                                     489

  116. On Dislocations at the Wrist and Fingers                        492

  117. On Dislocations of the Vertebræ of the Spine                    493

  118. On Dislocation at the Hip-Joint                                 498

  119. On Dislocation at the Knee                                      505

  120. On Dislocation at the Ankle, and also of the Toes               506

  121. On Dislocations with a Wound                                    509

  122. On Dislocation complicated with Fracture                        510




PAULUS ÆGINETA.




BOOK FOURTH.


SECT. I.—ON ELEPHANTIASIS.

Well, in my opinion, did Aretæus the Cappadocian say, that the power of
remedies ought to be greater than those of diseases; and that for this
reason elephantiasis is incurable, because it is impossible to find a
medicine more powerful than it. For if cancer, which is, as it were,
an elephantiasis in a particular part, is ranked among the incurable
diseases by Hippocrates himself, how much more is not elephantiasis
incurable, which is, as it were, a cancer of the whole body? But the
black bile from which this affection is formed, having a double origin,
(for it arises either from the melancholic and feculent part, and, as it
were, dregs of the blood, or from yellow bile, both being overheated);
the first variety of the black bile produces the reddish elephantiasis,
which is the more mild, or to speak more truly, less malignant variety;
the others which are more malignant, being accompanied with ulceration of
the whole body and falling off of the extremities, are produced by the
latter variety, or that from yellow bile overheated. Wherefore, those
who are already overpowered by the disease, must be abandoned; but when
the affection is in its commencement, so as that none of the extremities
has fallen off, nor the surface of the body become ulcerated, nor the
hard swellings appeared, and the face merely appears foul, but not
altogether unseemly, we must attempt the cure. For not a few, by merely
burning the head, have prevented many who were beginning to be affected
from being overpowered by this disease. Wherefore, at the commencement
of the disorder, we must have recourse to venesection repeatedly, more
especially if in spring, when the complaint is most apt to occur, and
has its exacerbations. After an interval of a few days, say nine or
ten, we may purge them with the pottage of colocynth, not once only but
frequently, proportioning the dose of the medicine to its strength.
Purging with hiera also suits well with them. After the interval of about
ten days again, we must give them the vinegar of divided milk, not in
less quantity than three heminæ, nor in greater than five, and on the
following days they are to be supported with milk that is not divided
into parts, or new-drawn milk; by which means, if the affection yield,
the same food may be continued; but if it remains in the same state,
after eating acrid things, they must be made to vomit with radishes and
frumentaceous articles of food. After these things, purging with white
hellebore is proper, twice if possible when in spring, but once only
if in autumn. Those, however, who are thoroughly overpowered by the
complaint, must be neither bled nor put on a course of hellebore. For
neither can a translation of the disease from the superficies to the
inner parts, nor a diminution of the offending matter, be any longer
accomplished by these means; but the matter is to be determined to the
stomach and bowels, and alteratives (metasyncritica), used to dry and
constrict the skin. Dry-cupping is also to be applied over the mouth
of the stomach and to the hypochondria, and dropaces used to the same
places; but after a short interval, the same process is to be repeated,
beginning by purging with hiera, and omitting the venesection, which
would prove rather deleterious than beneficial. This process is to be
repeated three or four times in a year, more especially in the seasons
of spring and autumn. The draughts before meals, most suitable for them,
are a cyathus of vinegar, with a cyathus of cedria, and two cyathi of
the juice of unripe cabbage—they are given mixed together, morning and
evening; or, the dried leaves of the herb ironwort, to the amount of a
drachm in one cyathus of wine; or, a drachm of hartshorn and a cyathus of
the vinegar of squills, is given after the morning walk every day; and
other things are to be administered at the same season, such as drs. v
of washed squills in honied water, or in honey, as a linctus; or Cyrenaic
juice, to the amount of a bitter vetch, mixed with honey and butter; or,
dr. ss of the shavings of hartshorn, with two cyathi of wine; or, drs.
iij of Æthiopian cumin, with honey, as a linctus. But a more suitable
remedy is a drachm of the theriac trochisk, triturated in a cyathus of
fine wine, and drunk; and a drachm of the trochisk of squills may in like
manner be taken in a draught. And they praise the juice of calamint as
a most effectual remedy when drunk, and say that the dose to commence
with is three cyathi, which may be increased to six. But of all others
the theriac of vipers is the most effectual remedy, both in a draught
and when rubbed in externally. But where plenty of these animals can
be procured, nothing answers so well as eating the flesh of the vipers
boiled in white broth, with much water, salts, leeks, and dill, to the
separation of their back-bones, their head and tail being first cut off
to the extent of four fingers’ breadth, and their entrails and skin taken
away. And theriac salts are in the same celebrity when taken with other
food. By using them thus, it happens that the scales, or, as it were, the
bark, falls off from the skin.

The regimen is to be as follows: After sleep, having been first rubbed,
and the bowels evacuated, let the patient have recourse to gestation
and vociferation, then to friction and gymnastic exercises of all
kinds, partly by leaping, but more especially by using the halcteres
and leather bag. Having wiped off the sweat, let him be rubbed with the
grease of a boar, of a wolf, of a goat, or of some winged animal, or
with fresh butter; and after a short interval let him bathe, having his
body anointed with the juice of fenugreek, of ptisan, or with a little
ammoniac dissolved in vinegar. After the bath, having got his body wiped,
let him anoint with the oil of lentisk, of wild vine, or of myrtles;
and with a little wine, containing alum and ammoniac, so as to be of
the thickness of the sordes of baths. Having had his body rubbed again
with soft rags, let him rest for half an hour, after which, having drunk
water, let him make himself vomit by putting his fingers or a feather
down his throat. Having vomited, let him drink the wine of wormwood or
of marjoram. The food should be barley bread, or a cake of dried barley
flour, and of potherbs, the beet, the lettuce, the radish, leeks, and
cabbage sweetened in two waters, and capers. Of sea animals, he may
take oysters, pelorides, urchin, all shell fishes, limpets boiled with
beets, and old pickle in place of medicine. But let him abstain from wine
during the whole continuance of the complaint, and from venery; only he
may take a little thin watery wine at the time of his recovery from the
purging, at which season all acrid substances must be abstained from,
except condiments. Give him ptisan, eggs and chondrus, milk and honey,
with bread, mallows, dock, skirret, and fishes with tender flesh; and
of fowls, those which contain wholesome juices; and of fruits, the fig,
grape, and raisins: but of sweetmeats, those which are prepared from pine
kernels, toasted almonds, or bastard saffron. He may take food twice a
day, as it is injurious to subsist upon one meal. After taking care of
the internal parts, let him use detergent ointments (smegmata) in the
bath, from the decoction of beet, or of fenugreek with aphronitrum, soap,
or myrobolan, and sometimes apply depilatories. Purslain triturated with
vinegar is detergent and also the slender houseleek, and the roots of
dock boiled in vinegar, and alum with salts, and red arsenic in equal
proportions with wine and oil of lentisk. Also the composition for
alphos, consisting of alcyonium, nitre, myrtle, sulphur, and the dried
leaves of the wild fig, being rubbed in dry with vinegar; and that
from the burnt shell of the cuttle-fish, and pumice, nitre, and burnt
Cimolian earth, gum, unripe galls in equal quantity, sprinkled dry, or
rubbed in with vinegar. And this one is admirable: Of the roots of dock
a bunch to the amount of a handful, of natron, dr. xl; of frankincense,
dr. xxv; of sulphur, dr. xxv; it is rubbed in with Egyptian vinegar. And
this one is efficacious: Of arsenic, dr. x; of sulphur vivum, dr. viii;
of costus, dr. xii; of quicklime, dr. iv; of wax, dr. iv; of dried bay
berries, dr. xii; these things are mixed with the juice of white poplar
leaves, or with a thick decoction, and they are rubbed in, having the
consistence of honey.—_Another_: Two fasciculi of the roots of dock are
to be boiled in vinegar, pounded in a mortar and triturated, then of
alcyonium, lb. j; of aphronitrum, oz. viij; of sulphur vivum, lb. j; of
the burnt shells of cockles, oz. iv; of chamæleon with its roots, oz.
iv; these things are pounded together until they are of the consistence
of the sordes of the baths, and are then rubbed in often in the sun,
if summer, but if winter, in the bath, until it occasions sweating. And
the dry smegma of Æsculapius would agree excellently with these cases,
and all the smegmata about to be described, even unto those for alphos,
and also those now mentioned, are applicable for those complaints. And
the tumid excrescences, whether inflammatory or ulcerous, are to be
rubbed with Indian buckthorn: or horned poppy, or aloe, or the Andronian
trochisk, or that of Polyides; and let cataplasms be applied of chondrus
with the juice of knot-grass or plantain; or of pellitory of the wall,
triturated; and the leaves of the green Melisian herb, when pounded with
axunge and applied, are wonderfully efficacious, for they redden the
parts, but the redness is easily repressed by the application of bread;
or of the cerate made from almond oil. By this means their natural colour
is restored. When the parts are ulcerated, plasters are suitable: that
from diphryges, and the apple one with wine, that called coracium, that
made from oxymel, the Andronian trochisk, pompholyx and calamine. It
is a symptom that the whole disease is becoming more moderate when the
first ulcers are cicatrized. For the dyspnœa of persons labouring under
elephantiasis give a draught of five or six slaters in three cyathi of
honied water. And some of the general remedies described for dyspnœa will
be applicable for them. Of the natural baths we must select, as being
most particularly useful, the aluminous and chalybeate, and if possible,
such as are cold. It is also particularly serviceable to drink them. And
the use of the sand of the sea-shore has the same effect, and so have all
the sudorifics. But since this affection is one of those which are easily
communicable, no less so than the plague, they are to be removed as far
as possible from cities, and lodged in inland and cold situations, where
there are few inhabitants, if this can be accomplished; for so they may
descend from thence to surrounding places. This is proper partly on their
own account and also on account of those whom they might come in contact
with. For they themselves will thus enjoy the use of a more commodious
air, and they will not communicate the evil to others.

       *       *       *       *       *

COMMENTARY. Consult Lucretius (vi, 1112); Celsus (iii, 25); Pliny (Hist.
Nat. xxvi, 5); Scribonius Largus (102); Cælius Aurelianus (Pass. Tard.
iv, 1); Marcellus (De Med. xix); Serenus Samonicus (11); Octavius
Horatianus (i, 32); Isidorus (Orig. iv, 8); Vegetius (Mulom. i, 9);
Aretæus (Curat. Morb. Chron. ii, 13); Plutarch (Symp. viii, Quest. 9);
Galen (ad Glauc. ii, 10; de Causis Morb. 7); Oribasius (Morb. Curat. iii,
62; Synops. vii, 5); Pseudo Dioscorides (Euporist. i, 105); Aëtius (xiii,
120); Actuarius (Meth. Med. ii, 11, and iv, 15); Nonnus (Epit. 233);
Psellus (op. medicum); Leo (vii); Myrepsus (De Med. comp.); Avicenna (iv,
3, 3, 1); Serapion (v, 14); Avenzoar (ii, 7, 12, 26); Albucasis (Chirurg.
i, 49); Haly Abbas (Theor. viii, 15, Pract. iv, 3, ix, 69); Alsaharavius
(Pract. xxxi, 2); Rhases (ad Mansor, v, 35, ix, 93, Contin. xxxv, 26.)

We owe the earliest notice which we have of this disease to the poet
Lucretius, who briefly mentions it in the following lines:

    “Est elephas morbus qui propter flumina Nili
    Gignitur Ægypto in mediâ neque præterea usquam.”

Celsus says that elephantiasis is a chronic disease, almost unknown in
Italy, but very common in certain countries. He calls it an affection of
the whole body, even of the bones. The upper part of the body is covered
with frequent spots and tumours, the redness gradually changes to black,
the skin is thickened, and covered with hard asperities like scales; the
body wastes, but the face, legs, and feet swell; and when the disease
is protracted, the fingers and toes become buried in the swelling, and
a slight fever comes on, which finishes the patient’s sufferings. Such
is his description of the disease. His treatment consists in bleeding
at the commencement, abstinence, then supporting the strength, purging,
exercise, sudorifics, and friction. Baths are to be rarely used; fatty,
glutinous, and flatulent articles of food are to be avoided, but wine is
to be allowed, except at the beginning. The body is to be rubbed with
pounded plantain.

According to Pliny, elephantiasis was never known in Italy until the days
of Pompey the Great, when it was imported from Egypt, and raged for a
time, but soon became extinct. He describes it as affecting the face in
particular with hard, rough, black maculæ, which sometimes spread to the
bones, the toes and fingers being swelled.

Serenus Samonicus, who is said to have flourished about the beginning of
the third century, thus describes the disease:

    “Est elephas morbus tristi quoque nomine dirus,
    Non solum turpans infandis ora papillis,
    Sed cito præcipitans funesto fata venino.”

His remedies are the juice of the bark of the juniper, the ashes and
blood of the weasel, mint, and various external applications, consisting
of ceruse, Egyptian paper, roses, &c.

Scribonius Largus recommends sulphur with common oil for lepra, “et quam
elephantiam dicunt,” but he gives no description of the latter.

It is greatly to be lamented that Cælius Aurelianus’ account of
elephantiasis has come down to us in an imperfect state. His description
is entirely lost, and his detail of the treatment is in a mutilated
state. It appears, however, that his views were similar to those of
Celsus, and that he considered it to be a malignant disease, affecting
principally the skin. He approves of rubbing stimulant ointments into
the skin, and of using medicinal baths, especially the aluminous and
chalybeate. When the applications produce ulceration of the skin, he
directs us to treat it upon general principles. He makes mention of
vomiting by radishes, and latterly by means of the white hellebore. He
approves of a sea voyage and change of scene. He says the first author
who described elephantiasis was Themison, the same person that is damned
to everlasting fame in one of the lines of Juvenal: “Quot Themison agros
autumno occiderit uno.” (Sat. x, 221.) If this statement be correct,
it is clear that Celsus cannot be of so early a date as is generally
believed, that is to say, the Augustan age, for Themison flourished
towards the end of the first century, P. C. He was the founder of the
Methodical sect. Cælius also blames Themison for recommending bleeding
and vomiting unseasonably, and disapproves of his directions respecting
the applications to the skin. It appears that he also disapproved of the
theriac of vipers, and of giving to drink water in which red-hot iron had
been extinguished. There can be no doubt, from the circumstances which he
mentions, that the disease was thought contagious in his time.

Octavius Horatianus, who lived under the emperor Valentinian, gives a
pretty full detail of the treatment, but his description of the symptoms
is defective. He makes mention, however, of _maculæ_, which affect
principally the face; he contends that the whole system is attacked with
the disease, and that the flesh is corrupted. His remedies are much the
same as those recommended by the other authorities, namely, bleeding,
purging, vomiting, the theriac of vipers, and rubbing with the usual
applications for scabies. He also speaks favorably of the natural and the
sea-water baths.

Marcellus the Emperic, who is supposed to have flourished in the reign of
Theodosius, recommends, like Serenus, mint, juniper, and mezereon, for
elephantiasis. He describes it as being attended with hard excrescences
of the extremities, eruptions on the face, and disease of the bones. He
speaks of its being endemic in Ægypt.

The disease, elephantiasis, according to Isidorus, is so called from
its resemblance to the elephant. The skin in it is hard and rough, from
which it gets its appellation, because the surface of the patient’s body
resembles that of an elephant; or because it is a mighty affection, as
the elephant is one of the largest of animals.

Vegetius, the great ancient authority on veterinary surgery, describes
elephantiasis as it affects cattle. The symptoms are hardness and
roughness of the skin, squamæ, eruptions on the feet and head, and a
fetid discharge from the nose. He approves of bleeding, and the other
means recommended by the regular surgeons.

We shall next give the descriptions of the Greek authorities.

Aretæus gives a most elaborate but surely somewhat overstrained
description of elephas, which he paints in colours the most hideous and
disgusting. We shall endeavour to convey to the reader an idea of his
sketch, stripping his picture of its flowery ornaments, and contracting
its bulk. The disease is called _elephas_, he says, from its magnitude,
_leontium_ or _morbus leoninus_, from the supposed resemblance of the
eyebrows to those of the lion; and _satyriasis_, from the venereal
desires with which it is attended. The disease is described as escaping
notice at first, being deep-seated and preying upon the vitals, but
afterwards it is determined to the superficies, commencing sometimes with
the face, and at other times with the extremities. The belly is dry,
because, as he ingeniously remarks, the distribution of the food is
performed regularly, and the vitiated parts strongly attract the chyle
to them as a pabulum to the disease. There are large callous eminences
on the skin, and the veins appear enlarged, owing to a thickening of the
vessels and not to a plethora of blood. The hairs of the head, pubes, and
other parts of the body, drop off. The face in particular is affected
with callous tubercles or warts, and it is not uncommon for the tongue,
and most parts of the body, to be also covered with them. The eyebrows
are thickened, stripped of their hair, and hang down like those of the
lion. The general appearance of the skin, covered as it is with hard
tubercles, and intersected with deep fissures, is said to bear some
resemblance to that of the elephant. Sometimes particular members, such
as the nose, feet, fingers, the whole hand, or the pudenda, will die and
drop off; and it is not uncommon for incurable ulcers to break forth on
different parts of the body. Dyspnœa, and a sense of suffocation, are
occasionally present. He says, it is dangerous to have any intercourse
with persons labouring under the disease, no less so than in the case of
the plague, as both are readily communicated by respiration. He directs
us, at the commencement, to abstract blood freely, because blood is the
_pabulum morbi_. He recommends us to purge with hiera, and to procure
vomiting by radishes, but more particularly by the white hellebore,
upon which he bestows a glowing and eloquent eulogy. Like our author,
he approves of the theriac of vipers. He makes mention of many external
applications of a detergent nature, and in particular praises a soap
used by the Celts for cleaning their clothes. He also commends natron,
alcyonium, sulphur, alum, ammoniac with vinegar, and the like, for the
same purpose. When the flesh is livid, he directs us previously to make
deep incisions in it. The diet is to be plain and digestible; sulphureous
baths are to be used: the patient is to swim frequently in sea-water, to
take a sea voyage, and otherwise not neglect suitable exercise.

Plutarch informs us that it was disputed in his time whether or not
elephantiasis was a new complaint.

Galen, as far as we can recollect, has nowhere treated very particularly
of elephantiasis, but in his work ‘De Causis Morborum’ he has briefly
mentioned that in this disease the nose becomes flattened, the lips
thick, and the ears extenuated, the whole appearance resembling that of
a satyr: and in his work entitled ‘De Curatione ad Glauconem’ he ranks
elephantiasis with cancerous swellings, and says that the disease is
common about Alexandria, owing to the heat of the place and the food of
the inhabitants, which consists principally of lentils, snails, pickles,
the flesh of asses, and the like, all which things have a tendency to
engender the melancholic humour. The temperature of the place likewise,
he shrewdly remarks, determines the superfluities of the system to the
skin. He recommends the treatment which we have already had occasion to
mention, namely, bleeding, purging, and the theriac of vipers. In the
‘Isagoge,’ the black and white hellebores are particularly commended.
Galen elsewhere calls it contagious. (Lib. ii, Simpl. de carne viperæ.)

Oribasius gives no description of the disease, but briefly recommends the
theriac of vipers, and in certain cases purging and bleeding for the cure
of it.

The account given by Aëtius is principally taken from Archigenes, and
is very circumstantial. The disease, he remarks, has been called by the
several names of elephantiasis, leontiasis, and satyriasis. Suspicions,
he says, have been entertained of its being contagious, and he is of
opinion that it is unsafe to hold intercourse with those who are ill of
the disease, as the air becomes contaminated by the effluvia from their
sores, and by their respiration. The disease, he says, is insidious,
for it begins in a concealed manner internally, and does not make its
appearance on the skin until it is confirmed. Men are more subject to
it than women, and intemperate climates predispose to it. The first
symptoms of the disease are torpor, slow respiration, constipated bowels,
urine like that of cattle, continued eructations, and strong venereal
appetites; and when it is determined to the skin, the cheeks and chin
become thickened and of a livid colour, the veins below the tongue are
varicose, and eminences are formed all over the body, but especially on
the forehead and chin. The body becomes increased in bulk, and is borne
down by an intolerable sense of heaviness. Those affected with it become
pusillanimous, and shun the haunts of men. Though the disease, when
confirmed, is of the most hopeless description, he forbids us to abandon
the sick at the commencement. His treatment is almost the same as our
author’s: venesection at the beginning, purging with colocynth or hiera,
and vomiting with radishes or white hellebore. Some, he says, having
remarked that eunuchs escaped taking this complaint, have castrated
themselves as a preventive. He makes mention of all the medicinal
substances recommended by our author, namely, iron-wort, Cyrenaic juice,
the theriac of vipers, &c. For the cutaneous affections he recommends a
great many external applications, containing white hellebore, sulphur,
rue, natron, aloes, and even arsenic. He also speaks of cataplasms,
depilatories, and detergent ointments. He is very particular in directing
that the diet be light and wholesome.

Actuarius calls elephantiasis a cancer of the whole body, which preys
upon all the flesh, and derives its origin from black bile corroding
everything like fire. The first symptoms of it are a falling off of
the hairs of the eyebrows and chin, tumours on the face, an alteration
of the appearance of the eyes, a change of the voice, turgidity of the
sublingual veins, and afterwards cutaneous eruptions of an intractable
nature. He then states that elephantiasis, lepra, psora, and impetigo
are diseases of different gradations of malignity. In another place he
has given the treatment, which is exactly the same as that recommended
by Aretæus, namely, bleeding, purging with hellebore, detergent and
desiccative applications to the skin, &c.

Some applications, seemingly of little efficacy, are recommended for
elephantiasis in the ‘Euporista’ of the Pseudo-Dioscorides.

Nonnus, as usual, abridges our author’s detail of the treatment, and
omits the description. He says it arises from a melancholic humour, which
corrodes the extremities. According to Psellus, the disease is produced
by _melancholy adust_ and the lees of putrid blood.

The account of elephantiasis given by Leo is brief and imperfect. The
disease, he says, is produced by a melancholic humour, which has become
putrid, and corrodes the extremities. It is, he adds, almost incurable,
but may be benefited by purging with the dodder of thyme, by the theriac,
and burning the head at the bregma. The affection, he says, is also
called satyriasmus.

Myrepsus merely mentions some of the common remedies for elephantiasis,
such as arsenic, turpentine, litharge, &c. He gives no description of the
disease.

We now proceed to the Arabians.

Avicenna gives a very circumstantial account of elephantiasis, under the
name of _juzam_ or _judam_, which his translator renders by _lepra_.
He calls it a cancer of the whole body, which arises from black bile,
and is sometimes attended with ulceration, and is sometimes without
it. The disease, he says, is contagious: it is produced by living upon
the flesh of asses, lentils, &c., and is endemic in Alexandria. It is
sometimes called _leonina_, because the face assumes the stern appearance
of the lion’s. He states that, although it begins internally, its first
symptoms are manifested on the extremities. He then describes minutely
the symptoms, namely, redness of the face, inclining to lividity; falling
off of the hairs, enlargement of the veins, affection of the breathing,
thickening, and discoloration of the lips; and afterwards ulceration of
different parts of the body, corrosion of the cartilages of the nose,
then falling off of the nose and extremities, loss of voice, &c. The
treatment he gives with great minuteness, but as it is little different
from that of the Greeks, we need scarcely enter upon it. Suffice it to
say that he mentions early bleeding, purging with hellebore, colocynth,
scammony, &c.; the theriac of vipers, the application of the cautery
to the head, and so forth. Enough has been said to show that this
description applies to the elephantiasis of the Greeks. Considerable
confusion, however, has arisen in consequence of his translator applying
the term _elephantia_ to a very different disease, namely, to an
enlargement of the leg with varicose veins, now generally known by the
name of the _Barbadoes leg_. This complaint he directs to be treated at
first with local bleeding and astringents; but when ulceration takes
place, it is to be remedied only by amputation.

Serapion, in like manner, describes the elephantiasis of the Greeks by
the name of _lepra_. The face, he says, is swelled, livid, and covered
with hard pustules, the hairs of the eyebrows fall off, the whole aspect
becomes hideous, the voice is changed, the perspiration becomes vitiated,
and ulceration seizes different parts of the body. The disease, he says,
takes its origin from the liver, in which the office of sanguification is
improperly performed. His remedies are bleeding, hellebore, the theriac,
&c.

Avenzoar describes the _lepra_ as a cancer arising from contact with
other lepers, or from unwholesome food. He recommends to purge away the
melancholic humour with scammony, colocynth, black hellebore, &c. The
_elephantia_ he describes as a disease in which the leg is swelled like
the leg of an elephant. He considers it almost incurable.

Albucasis gives an account of the operation of burning the head for
_lepra_, i.e. the elephantiasis of the Greeks.

The translator of Haly Abbas, namely, Stephanus Antiochensis, who says
he wrote about the year 1127, describes the disease which we have been
treating of by the name of elephantia. Like the others, Haly represents
it to be a general cancer arising from black bile. He says it proves
contagious by respiration. Among the symptoms, he mentions falling off of
the ciliary and superciliary hairs, dryness of the nose, which sometimes
falls in; in short, he enumerates the same symptoms as the preceding
authorities. For the cure he directs us to bleed from the arteries behind
the ears, those of the temples, or from a vein in the arm; to give
emetics, such as hellebore; to avoid cold; to apply cupping-instruments
to the scrobiculus cordis; to administer the theriac, &c. He recommends
externally decoctions of beans and vetches at first; and afterwards
stimulant lotions, containing arsenic, sulphur, quicklime, and so forth.
He also applies the term elephantia, and sometimes elephas, to the
swelled leg, which he considers to be a species of varix.

Alsaharavius describes four varieties of _lepra_, namely, the leonina,
elephantia, serpentina, and vulpina. The disease, he says, may be
contracted, 1st, by an hereditary taint; 2d, by the use of corrupted
food, such as the flesh of buck-goats, cows, &c.; 3d, by contagion,
through the medium of the respiration. He describes all the gradations
of the disease with greater minuteness than any other ancient author.
In its last stage, he says, the nose falls in, the hairs drop off, the
voice is lost, ulcers break out on the skin, the extremities mortify and
fall away, and the breath is fetid. His treatment varies according to
the circumstances of the case, but, upon the whole, it is scarcely at
all different from that of the others. By the name of elephantia he also
describes the _swelled leg_, which he pronounces to be a very intractable
disease. He directs us, however, to have recourse to bleeding,
melanogogues, abstinence from gross food, emetics, and various external
applications of a stimulant nature, among which he mentions burying the
leg in hot sand.

The translator of Rhases also applies the term _lepra_ to the
elephantiasis of the Greeks. The colour of the eye, he says, is changed,
the voice becomes rough, the face is swelled, like a bladder, and red
with nodes, the hairs fall off, and the extremities at last become
swelled and ulcerated. There is nothing peculiar in his treatment.
He describes, likewise, the _swelled leg_ by the name of elephantia
or elephas. He says that, when tubercles arise on it, it is utterly
incurable; but that when simply enlarged, it may be remedied by
bleeding in the arm, cupping, emetics, attenuant food, and the like.
In his ‘Continens,’ he calls the lepra (elephantiasis) hereditary and
contagious. He says, it is a general cancer, arising from black bile. For
the _swelled leg_ he recommends, as in his other work, bloodletting and
emetics, with stimulant applications, containing pearlashes, sulphur,
&c., and also tight bandages.

Such is the history of elephantiasis given by ancient authors.

The earlier of our modern writers on medicine, describe elephantiasis
as a species of lepra, of which they enumerate four varieties, namely,
elephantia, leonina, alopecia, and tyria. This arrangement is evidently
taken from Alsaharavius. Such is the account which Platiarius gives of
these diseases. In like manner, the Pseudo-Macer ranks elephantiasis with
lepra:

“Est lepræ species elephantiasisque vocatur,” &c. Upon this passage
Cornarius makes the following annotation: “Vulgus medicorum Arabas in hoc
secuti lepram cum elephantiasi confundunt. Immo lepram pro elephantiasi
accipiunt.”

Guido de Cauliaco’s account of the disease is also nearly the same as
that of Alsaharavius. He states decidedly that the disease is contagious,
and recommends bleeding, purging, the actual cautery, the theriac of
vipers. (vi, 1.) Rogerius remarks that the disease is contracted _per
coitum_. (i, 15.) And here, by the way, we may be permitted to state
that we have long been convinced that the syphilis of modern times is a
modified form of the ancient elephantiasis. This opinion is maintained
by several of the writers of the Aphrodisiacus, and also by the learned
Sprengel, who gives a very interesting disquisition on Syphilis in his
‘History of Medicine.’

It appears that the disease in its ancient form is still prevalent in
certain parts of the world; as, for example, in the Sardinian States,
where it is still looked upon as being both contagious and hereditary.
It is also endemic in Norway: nay, it is reported to have broken forth
with all its ancient character in the province of New Brunswick. In the
East, elephantiasis and leontiasis are still considered as aggravated
forms of leprosy. (See Heber’s Travels, ii, 50; and Niebuhr’s Travels,
xxvii, 11.) We may be allowed to add, in conclusion, that a great mass of
misapprehension has prevailed in modern times regarding the elephantiasis
of the Greeks and Arabians. We trust the above sketch will remove the
difficulties which formerly beset this subject.


SECT. II.—ON LEPROSY AND PSORA.

Both these affections consist of an asperity of the skin, with pruritus
or wasting of the body, having their origin from a melancholic humour.
But leprosy spreads over the skin more deeply in a circular form,
throwing out scales which resemble those of fishes. But psora is more
superficial and variously figured, and throws out furfuraceous bodies. In
these cases we must premise venesection when the body appears more than
usually plethoric; but, if not, we must by all means purge with those
things which evacuate black bile. Externally we may use in common either
of the hellebores; and have washed lime dried, and, when going to use it,
we may dilute it in water until it attain the thickness of the wrestler’s
sordes, and anoint.—_Another_: Of sage, of the tears of Æthiopian olive,
of each, dr. viij; of the bark of capper’s root, of gum, of each, dr.
xiij; anoint with vinegar, in the sun. Anemone, when applied, and the
root of the white vine particularly, remove psora. But the following
are compound remedies: Of the flour of darnel, one chœnix; of the white
cardamom, dr. iv; of the scum of natron, dr. j; of copperas, dr. viij; of
the middle roots of asphodel, dr. iv; having triturated them in vinegar,
and made of the thickness of a cerate, anoint, having first applied
nitre to the part; and having removed it, (which do about the third
day,) and washed with cold water, again anoint.—_Another_: Of the juice
of kings’ spears’ roots, oz. vj; of sulphur vivum, of manna, of each,
dr. x; of natron, dr. viij; anoint, mixing with vinegar. The following
simple remedies are particularly applicable for psora: Stavesacre, bitter
lupins, cardamom with vinegar, the root of lily with honey, turpentine
rosin, sulphur, chick peas, goat’s dung; and these compound ones—mix
equal parts of chalcitis and misy with wine, and anoint the more humid
kinds of psora.—_Another_: Boil the tender leaves of rose-bay in a
sextarius of oil until they are dried, and, throwing away the leaves,
add to the oil oz. iij of white wax, and, after it is dissolved, cool
and sprinkle upon it oz. j of sulphur vivum, and anoint in the sun or
in the bath. Some boil also squills with the rose-bay.—_Another_: Of
diachylon, oz. ij; of wax, oz. ij; of oil of roses, oz. j; of litharge,
oz. iij; of ceruse, oz. iij; of liquid pitch, oz. vj; of the dross of
silver, oz. ij; of siricum, oz. ij; of vinegar, what will be sufficient
for the trituration of the dry things.—_Another_: Of ceruse, oz. ss; of
starch, oz. ss; of lead, oz. j; of red lotuses, or of alkanet, oz. ij;
of wax, oz. vj; of oil of roses, oz. ix; boil the alkanet properly with
the oil of roses, and then add the other things.—_Another_: Take ten
eggs, or as many as are required, and having macerated in the most acrid
vinegar until their shell become tender; boil in the vinegar the yelks
of them; having triturated with rose-oil and what remains of the vinegar
a moderate quantity of litharge, anoint, when of the consistence of the
sordes of oil in baths.—_Another_: Three yelks of eggs out of vinegar;
of rose-oil, oz. vj; of sulphur vivum, oz. iij; having triturated the
yelks of the eggs and the sulphur with the vinegar, add the cerate.
And litharge triturated with vinegar and rose oil, until it be of the
consistence of a plaster, cleanses the most acrid kinds of psora; and the
detergent ointments from dock, and the most of those for elephantiasis,
answer well in general with leprosy and psora.

       *       *       *       *       *

COMMENTARY. See Hippocrates (de Usu Humidorum, Epidem. ii); Galen.
(Meth. Med. xiv; de Causis Sympt. iii, 6; et alibi); Oribasius (Morb.
Curat, iii, 58); Aëtius (xiii, 134); Actuarius (Meth. Med. ii, 11);
Nonnus (Epit. 234); Pseudo-Dioscor. (Euporist. i, 128); Leo (vii, 15,
18); Pollux (Onomasticon, iv, 9); Æschylus (Choeph. 274); Alexander
Aphrodisiensis (Prob. i, 146, and ii, 42); Celsus (v, 28); Scribonius
Largus; Octavius Horatianus (i, 31); Serenus Samonicus; Marcellus (de
Med. xix); Isidorus (Orig. iv, 8); Psellus (op. Medicum); Vegetius
(Mulom. iii, 71); Geopon. (xviii, 15); Serapion (v, 2); Avicenna (iv, 7,
2, 9); Avenzoar (ii, 7, 4); Haly Abbas (Theor. viii, 16; Pract. iv, 4);
Alsaharavius (xxxi, 1, 2, 3, 4); Rhases (ad Mansor. v, 31 et seq.; Divis.
117, et seq.); Contin. (xxxvi.)

As in the preceding chapter, we shall here give a separate account of the
views of the Greeks, Latins, and Arabians, beginning, in this instance,
with the Greeks.

Hippocrates makes only casual mention of these diseases, and has nowhere
marked their distinguishing characters. In one place he calls leprosy
a blemish rather than a disease; and in another he remarks that some
varieties of it itch before rain. He speaks of vinegar, and of lime and
water as remedies for it. It is proper to apprize the reader that the two
works quoted above from the Hippocratic Collection are, most probably,
not genuine.

Galen also is very deficient on the subject of lepra, having nowhere
given a complete description of it, although he notices it incidentally
in many parts of his works. In one place he calls elephas, leuce, and
alphos cognate affections. Alphos, he says, is much more superficial than
leuce. In another, he attributes these complaints to the melancholic
humour which becomes fixed in the skin. In the ‘Isagogue,’ which,
however, seems not to be a genuine work of his, it is said that lepra is
an affection of the skin, which becomes whiter and rougher than natural,
the roughness resembling that from prominent psydracia. Psora is said to
partake more of the nature of ulceration. Both are represented as arising
from a saltish phlegm, and as being cured by phlegmagogues, and ointments
rubbed into the skin. It is also stated that leuce is distinguished from
lepra by there being no roughness of the skin in the former disease. In
another place he mentions psora as a disease most inveterate to cure.
(Facult. Natur. i, 13.)

Oribasius thus distinguishes leuce, alphos, melas, lepra, and psora
from one another. Leuce is occasioned by a pituitous and viscid blood,
which, in process of time, renders the colour white. Alphos arises in
like manner, but the superficial skin only is affected, and not the whole
flesh. When a pituitous humour is the cause of the complaint, it puts
on the appearance of alphos, and when the melancholic, of melas. Lepra
affects mostly the deep-seated parts, and psora the superficial. For all
these complaints he recommends a mixture of lime and water and some other
such things.

In the ‘Euporista,’ generally ascribed to Dioscorides, there is given a
long list of medicinal articles for lepra, such as the flour of darnel
with sulphur, hellebore with vinegar, verdigris, cantharides, &c.

Aëtius, copying from Archigenes, thus marks the difference between
lepra and its cognate diseases. Lepra differs from leuce and alphos,
inasmuch as lepra is distinguished by roughness and a sense of itching,
and yet the skin only is affected, and when it is removed, the flesh
below is discovered to be sound; but in leuce, the flesh below assumes
an unnatural degree of whiteness, while the surface of the part is very
smooth, and when rubbed it soon becomes red, especially in those who
are readily cured; and alphos is altogether superficial, having the
appearance of a scale fastened to the skin. Lepra differs from psora,
inasmuch as in psora the substances which appear on the skin are of a
furfuraceous nature, while in lepra they resemble the scales of a large
fish. He omits the constitutional treatment so judiciously stated by our
author, but his local applications are little different. They contain
hellebore, sulphur, misy, verdigris, liquid pitch, cantharides, natron,
copperas, myrrh, galls, vinegar, &c., mixed in various proportions.

Actuarius states that lepra is next to elephantia in malignity, and that
it is distinguished from psora by spreading deeper and having scales of a
circular shape like those of fishes; whereas, psora is more superficial,
and its scales are furfuraceous and of no determinate shape. Both are
attended with asperity of the skin, and itching. Leuce holds the same
place to alphos that lepra does to psora, that is to say, leuce is
more deep-seated, and affects the colour of the hair, while alphos is
more superficial, and the hair is in general unchanged. For all these
affections he recommends an application containing copperas, black
hellebore, arsenic, and cantharides, mixed with oil, cedar resin, or rose
oil.

Psellus states correctly that the scales in leprosy assume a circular
shape.

Nonnus marks the distinction between these diseases very accurately.
Lepra arises from a corroding humour, and hence scales fall from the
surface of the skin, and it is attended with pruritus. But lepra is more
deep-seated, and affects the skin circularly; whereas psora is more
superficial and variously figured. Leuce and alphos albus and niger, he
says, are allied; but leuce is deeper seated, so as to change the colour
of the hairs, whereas the alphi are more superficial affections.

Pollux, like most of the others, states that in leuce, when the skin is
pricked, it does not bleed, and that the disease is difficult to cure.
Alphos and melas, he says, are easily cured.

Although Myrepsus has not described these diseases, he gives
prescriptions for various compositions to remove them. The most active
ingredients in them are hellebore, natron, sulphur, quicksilver, sal
ammoniac, quicklime, bay-berries, &c.

Alexander Aphrodisiensis mentions psora among the contagious diseases,
but says that lepra and leuce are not contagious.

Chrysostom alludes to the common opinion that psora is a contagious
disease. The poet Æschylus gives a short description of leprosy in his
‘Chöepheræ’ by the name of lichenes. (l. 277.)

Celsus nowhere uses the terms lepra and psora, and therefore there is
considerable difficulty in comparing his account of these cutaneous
affections with the descriptions of the Greeks. Alphos, melas, and leuce,
he describes very intelligibly, connecting them together by the generic
term of vitiligo. We shall give his own characteristic description of
these diseases:—“Ἄλφος vocatur ubi color albus est, fere subasper, et non
continuus, et quædam quasi guttæ dispersæ esse videantur: interdum etiam
latius, et cum quibusdum intermissionibus serpit. Μέλας colore ab hoc
differt quia niger est et umbræ similis: cætera eadem sunt. Leuce habet
quiddam simile alpho, sed magis albida est et altius descendit; in eâque
albi pili sunt, et lanugini similes. Priora curationem non deficillimam
recipiunt: ultimum vix unquam sanescit.” Another class of cutaneous
affections he connects by the generic term of impetigo, and it is to be
remarked that they are all squamous diseases, and not pustular, like
the complaints to which Drs. Willan and Bateman have applied the term.
His second species of impetigo (as Bateman remarks) appears to be the
psora of the Greeks:—“Alterum genus pejus est, simile papulæ feræ, sed
asperius rubicandiusque, figuras varias habens: squamulæ ex summâ cute
discedunt, rosio major est, celerius et latius procedit, certioribusque
etiam quam prior temporibus et fit et desinit. Rubra cognominatur.” His
third species bears some resemblance to the lepra nigricans of Willan and
Bateman:—“Tertia etiamnum deterior est: nam et crassior est et durior, et
magis tumet, in summâ cute finditur, et vehementius rodit, _ipsa quoque
squamosa sed nigra_, &c. Nigræ cognomen est.” His account of the fourth
species seems to refer to the lepra vulgaris:—“Quartum genus est quod
curationem omnino non recipit distans colore: nam sub-albidum est et
recenti cicatrici simile: squamulas habet pallidas, quasdam subalbidas,
quasdam lenticulæ similes: quibus demptis nonunquam profluit sanguis.”
For all these diseases he recommends a composition containing sulphur,
natron, and rosin.

Scribonius Largus describes several compositions, “ad lepram, quæ quasi
impetigo est cum prurigine cutis,” and for scabies. They contain sulphur,
Æthiopian cumin, vinegar, frankincense.

Serenus Samonicus makes mention of a few popular remedies for scabies,
prurigo, and papulæ, but he gives no description of these complaints.

Octavius Horatianus recommends for scabies (meaning, we suppose, the
psora of the Greeks,) bleeding, purging, frequent baths, and external
applications containing natron, frankincense, and sulphur. He does not
mention lepra by name, nor does he seem to allude to it at all.

Marcellus recommends for lepra a composition containing equal parts of
natron, frankincense, litharge, and sulphur pounded with vinegar.

Vegetius says that the scabies of cattle “contagiosa est et transit in
plures.” Probably Virgil alludes to the scab of sheep in this line: “Nec
mala vicini pecoris contagia lædant.” (Ecl. i.) He mentions, as remedies
for it, sulphur, litharge, pitch, hellebore, &c. (Georg. iii, 449.) See
also Geopon. (xvi, 18, xviii, 15); Columella (viii, 5); and Gratius
(Cyneget. 412).

Isidorus gives the following definitions of the complaints we have been
treating of: “_Lepra_ vero cutis asperitas squammosa lepidi similis unde
nomen accepit: cujus color nunc in nigridinem vertitur, nunc in alborem,
nunc in ruborem. _Scabies_ tenuis asperitas et squammata est. Impetigo
est sicca scabies; prominens a corpore cum asperitate et rotunditate
formæ. Hanc vulgus _sarnam_ appellat.”

Justin applies the terms _vitiligo_ and _scabies_ to the diseases treated
of in this chapter. See Hist. (xxxvi, 2.) We now turn to the Arabians.

In the Latin translation of Serapion, lepra and psora are described
under the generic term of “impetigines in quibus excoriatur et
scinditur cutis;” but they are further distinguished from one another
by the specific titles of _albaras_ nigra and pruritus. The former is
characterized as arising from the melancholic humour, and as casting off
round scales. The latter is said to consist of pustules, which appear
on different parts of the body, are variously figured, and cast off
furfuraceous scales. The leuce is described by the name of _baras_, as
arising from viscid, pituitous blood, and being produced by a defect
of the assimilative faculty. In it the flesh itself is said to be
changed to a white colour. If, when pricked with the head of a needle it
bleeds, there is a probability of cure; but if it does not bleed, it is
incurable. The two alphi are described by the names of _morphea alba_
and _nigra_. The morphea alba resembles the white albaras (leuce) only
that in the latter the affection of the skin is more deep-seated, and the
hairs in it are turned to a white colour; but in morphea the only change
is in the external appearance of the skin. The morphea nigra (melas?) is
said to resemble the albaras nigra (lepra nigricans?) only that it is
more superficial.

In the Latin translation of Avicenna by Bullonensis, alphos albus and
niger are distinguished by the names of _morphea alba_ (or _alguada_),
and _morphea nigra_; leuce by that of _albaras_; and lepra by those of
_albaras_ nigra and _impetigo excorticativa_. The specific differences
between them are stated with great precision. The morpheæ are superficial
affections of the skin, but the albaras affects also the flesh,
penetrating sometimes down to the bone. All these diseases are said to
arise from a weakness of the assimilative faculty. In the _albaras_
nigra, or leprosy, the skin is said to be covered with scales, like those
of a fish. Like the authorities formerly quoted, Avicenna states that in
_alguada_ (alphos albus) the hairs do not change their colour, but that
they do so in _albaras_. The puncture of a needle likewise extracts blood
from the _guada_, but not from the _baras_.

Avenzoar makes mention of the _morphea_ alba and nigra, but has not
described them particularly. These authors seem to have treated lepra
and psora like the Greeks, by bleeding, melanogogues, and abstergent
applications to the skin, such as the two hellebores, lime, lupines, &c.

In the translation of Haly Abbas, leuce is correctly described by the
name of _lepra_. It is represented as a whiteness sometimes affecting
the whole body, and it is said to be occasioned by debility of the
assimilative faculty. When the hairs are white, and the skin does not
bleed when pricked with a lancet or needle, the disease is incurable.
Alphos albus is described by the name of _morphea_ alba, and is
distinguished from the former by the whiteness being more superficial,
and the colour of the hairs remaining unchanged. In the morphea nigra,
that is to say the alphos niger, the colour is said to be black, owing
to the prevalence of black bile, and if rubbed a furfuraceous scale
falls off, and it becomes red. The lepra nigricans is described by the
names of _impetigo_ and _sarpedo_, as an asperity of the skin, inclining
to blackness or redness, and terminating in round scales, like those
of fishes. For the cure of lepra, he directs us to abstain from all
articles of food which engender phlegm, to take hiera of colocynth, with
pepper, &c., and also the theriac of vipers, and various other internal
medicines. He recommends various external applications, containing
sulphur, arsenic, hellebore, spurge, &c.

Alsaharavius describes three varieties of _morphea_. 1st. The morphea
terrestris, which is attended with furfuraceous scales on the skin, and
tingling. This is evidently the psora of the Greeks. 2d. The morphea
alba, which consists of a more superficial whiteness of the skin than the
_albaras_ (leuce): this is the alphos albus. 3d. The morphea nigra, is
like the former, only that the colour is black. This must be the alphos
niger. All these affections he treats upon much the same principles as
the Greeks, namely, by evacuants, and stimulant applications to the skin,
such as sulphur, hellebore, &c. _Albaras_ he describes as a deep-seated
whiteness of the skin, and directs us to prick the skin with a needle,
and if it does not bleed the disease is to be set down as incurable.
This, of course, is the leuce of the Greeks. He treats it upon much the
same principles as the morpheæ. He appears not to make any distinction
between the leuce and the lepra.

Rhases describes the lepra of the Greeks by the term _impetigo_; alphos
albus by that of _morphea_ alba; alphos niger by that of _morphea_ nigra;
and leuce by that of _albaras_. There is nothing very particular in his
treatment of leprosy. It may be worth while to mention, however, that he
strongly recommends leeches to the affected part, at the commencement.
Scabies, he says, is formed by a salt diet, old wine, and neglect of the
bath. For the cure of it, he recommends bleeding, purging, and various
external applications, some of which contain quicksilver, nitre, vinegar,
and the like. In his ‘Continens’ he gives a full account of these
diseases, upon the authority of preceding writers. He gives the names of
_baras_ to lepra, and _morphea_ alba to alphos. He recommends stimulant
applications containing cantharides, nitre, with vinegar, &c. He says
that he had found a mixture of sal ammoniac and oil of eggs an excellent
application.

It will be remarked that the leuce of the Greeks, the leuce and fourth
species of impetigo of Celsus, and the albaras of most of the Arabians,
are the same as the _lepra vulgaris_ of Drs. Willan and Bateman; that the
alphos of most of the Greek authorities and of Celsus, and the morphea
alba of most of the Arabians, correspond to the _lepra alphoides_ of
our English nosologists; that the melas, alphos niger, and common lepra
of the Greeks, Celsus’ third species of impetigo and his melas, and the
morphea nigra and impetigo of most of the Arabian translators, apply
to the _lepra nigricans_ of our modern arrangement; and that the psora
of the Greeks, Celsus’ second species of impetigo, and the scabies of
Octavius Horatianus, and of most of the Arabian translators, comprehend
both the _psoriasis_ and _scabies_ of Willan and Bateman.

Since many of the ancient authorities speak of _scabies_ as being
infectious, they must have applied the term to the true itch, with which
it is not likely, as Rayer maintains, that they were wholly unacquainted.

The earlier modern writers, such as those of the Schola Salernitana,
Platearius, Guy of Cauliac, and Lanfrancus, jumble together the Latin
and Arabian names, so as to produce no ordinary degree of confusion.
Guy of Cauliac, indeed, maintains that there is little necessity for
distinguishing lepra, alphos, melas, impetigo, gutta rosacea, and such
like cutaneous complaints from one another, as they are all varieties of
the same disease. Lanfrancus, however, is of a different opinion. (i, 3,
6.)


SECT. III.—ON LICHEN.

Lichen is formed by the mixture of a thin and acrid ichor with other
gross humours, and passes readily into leprosy and psora; wherefore
it requires to be treated by the most desiccative applications. After
general depletion, if necessary, the following simple medicines will
be proper: chick-peas, hellebore, the urchin which dwells among rocks,
pitch mixed with cerate and rosin, the dung of the land crocodile,
that of starlings fed solely upon rice. And many have cured the
complaint when occurring on the chin, or other parts of the body, by
this application alone: take several grains of wheat and place upon a
stithy red-hot, and taking the fluid which flows from them while yet
warm, anoint the part affected with lichen. The lichen of children is
to be rubbed frequently with human saliva. The gum of the plum tree,
when rubbed in, is beneficial in these cases. When the complaint is
protracted, the leaves of the chaste tree, triturated with vinegar, are
to be applied, or the leaves of capers in like manner. The following are
compound applications: Dissolve sulphur with rosemary in vinegar, or
with ammoniac, and anoint. A trochisk for lichen: Of artificers’ glue,
dr. iv; of frankincense, dr. iij; of vinegar half a cyathus; dissolve
in vinegar, and anoint.—_Another_: Of chalcitis, of gum, of each, dr.
viij; of sulphur vivum, of misy, of each, dr. vj; of the flakes of
copper, of acacia, of each, dr. ij; anoint with vinegar.—_Another_:
Of sulphur vivum, of spuma nitri, of each, dr. iv; of the seeds of
rosemary, lx; triturate with vinegar, and anoint only the part which is
affected, not touching the sound skin. When dry, wash it away with cold
water.—_Another_: Of white hellebore, dr. viij; of the flour of lupines,
of burnt shell-fishes called buccina, of natron, of each, one chœnix; rub
with it dry. They call that variety of lichen _agrius_ which is nowise
remedied by moderately desiccative applications, and is exacerbated by
more acrid ones. These cases are therefore to be treated by applications
which are sufficiently strong, without being pungent, such as this: of
horned poppy, of frankincense, of alcyonium, of bitumen, of sulphur,
of gum, of each, oz. j; anoint with vinegar. Boil African pitch with
vinegar, and, when dissolved, anoint.—_Another_, for lichen and prurigo:
Of copperas, of sulphur vivum, of natron, of frankincense, equal parts;
use for lichen with vinegar, and for prurigo with wine.—_Another_, for
lichen: Of ammoniac perfume, of the flour of bitter vetch, of the flour
of lupines, equal parts; add to vinegar.

       *       *       *       *       *

COMMENTARY. See Hippocrates (de Humor., de Affect.); Galen. (Isagoge, de
Med. sec. loc. v); Oribasius (Morb. Curat. iii, 59); Aëtius (viii, 16);
Actuarius (Meth. Med. ii, 11); Marcellus (19); Nonnus (236); Celsus (v,
28); Pliny (H. N. xxvi, 2); Serapion (v, 2); Avicenna (iv, 7, 3, 3);
Alsaharavius (Pract. xxxi, 7); Rhases (Divis. 117); Haly Abbas (Pract.
iv, 10.)

Dr. Bateman states, that the exact acceptation of the term lichen cannot
well be ascertained from the writings of Hippocrates; but Dr. Willan
affirms that he restricted it to a papular eruption on the skin.

In the ‘Isagoge,’ usually ascribed to Galen, two varieties are described,
the lichen mitis, and the lichen agrius, in both of which scales are
formed upon the skin, which appear almost ulcerated when they are
removed. They are to be cured by cholagogues internally, and liniments
externally.

Galen remarks the tendency of the disease to pass into lepra and scabies.
To prevent this, he directs desiccative and detergent applications, for
the preparation of which he gives various prescriptions. One of these,
which bears the name of Pamphilus, is a powerful escharotic, composed of
orpiment, realgar, burnt copper, and cantharides. (Med. sec. loc. v.) He
says it affects principally the chin, but is apt to spread over the face.

Oribasius, Aëtius, Actuarius, and Nonnus, treat of the complaint in
nearly the same terms as our author. Their translators improperly render
it by impetigo. Leo ascribes the origin of the disease to hot and
corrupted blood.

Celsus describes the lichen of the Greeks by the name of _papula_, of
which he mentions two varieties. In the first, he says, the skin is
merely roughened by small pustules, is reddened and slightly corroded;
the middle is somewhat smoother, and it spreads slowly, generally in
a round shape. This description would seem to apply to the _lichen
circumscriptus_ of Drs. Bateman and Willan, although the latter author
thinks that it possessed a wider signification. The second variety, he
says, is called ἀγρία by the Greeks, and in it the skin is more rough,
red, and corroded. The more it departs from the circular form the less
tractable is it, and, unless removed, it is said to pass into impetigo.
From this account it is clear that the lichen of the Greeks, in its
original form, was different from impetigo. Celsus recommends friction
with the saliva of a fasting person, and also mentions a composition
containing natron, frankincense, sulphur, &c.

The translator of Serapion improperly renders the name of this affection
by the term impetigo. His remedies are nearly the same as our author’s,
namely, the saliva of a person fasting, compositions containing
hellebore, natron, the ashes of starlings, &c.

In the translation of Avicenna it is likewise described by the name of
impetigo. It is called a species of dry achor, by which is no doubt
meant papula. It is stated that it has a tendency to pass into lepra or
psora. The remedies which are recommended are human saliva, the chaste
tree, capers, leeches (which are not mentioned by the Greeks), likewise
gum arabic dissolved in vinegar, mustard and vinegar, salt water, the
roots of king’s spear, &c. Haly Abbas recommends stimulant liniments of a
similar kind.

Rhases briefly recommends lotions of vinegar and ammoniac, and, when it
becomes inveterate, leeches, strong friction, &c. His translator also
misapplies the term impetigo to it.

The lichen appears to be the cutaneous complaint which Alsaharavius
describes by the name of _alcoab_. He represents it as a superficial
ulceration, and mentions four species of it.

Dr. Willan confirms the statement of the ancient authorities, that the
disease has a tendency to pass into lepra and psora. The species called
_lichen tropicus_ by Dr. Willan, seems to be the _hidroa_ of Hippocrates
(Aph. iii, 21); the _sudamen_ of Pliny (xxiii, 45); one of the _essere_
of Haly Abbas (Theor. viii, 17); one of the _alsara_ of Alsaharavius
(Pract. xxx, 8); and the _hasef_ of Avicenna (iv, 7, 3, 8). See also
Galen’s ‘Commentary’ (v, 261); ed. Basil. Galen says it is attended with
pruritus, asperity, and ulceration. Avicenna and Rhases particularly
commend bleeding, cleansing the skin, and the cold bath. Most of Rhases’
authorities in his ‘Continens,’ recommend for the _asaf_, or sudamen,
cooling and astringent applications, containing roses, myrtles, galls,
sandals, camphor, and the like. They attribute the complaint to profuse
perspiration. In certain cases, Rhases directs us to allay the pruritus
or tingling, with hot water and the flesh of melons. He also approves of
purging with tamarinds and myrobalans. (Cont. xxxvi.) See also ad Mansor.
(v, 30). Mercurialis is of opinion that Virgil alludes to the sudamina in
the following lines:

    “Verum etiam invisos si quis tentarat amictus,
    Ardentes papulæ atque immundus olentia sudor
    Membra sequebatur.”

                                 (Georg. iii, 565.)

We shall briefly notice in this place the singular disease of the face
which prevailed in the Roman empire during the reign of Tiberius, called
_mentagra_ by Pliny, in his curious description of it, but which he says
was named _lichenes_ by some. He represents it as a contagious disease,
which was readily propagated by kissing. It attacked principally the
higher class, the lower and middle ranks and women having generally
escaped it. The seat of it was commonly the chin, but it sometimes spread
over the whole face, and affected even the neck, breast, and hands.
The only means of cure was burning with caustics down to the bone. (H.
N. xxxvii; see also Marcellus, 19.) We are inclined to think that it
must have been some variety of elephantiasis. Modern authorities have
ranked it under _sycosis_, but it would appear to have been a much more
intractable disease. The sycosis is distinctly described by Celsus, among
the diseases of the hairy parts. He recommends for it elaterium, linseed,
or figs boiled in water, &c. (vi, 3.)


SECT. IV.—ON PRURITUS, OR PRURIGO.

The prurigo occurring in old age is not to be thoroughly cured, but may
be alleviated by the remedies mentioned below: but that which arises from
a cacochymy in other ages, is to be cured by evacuation, being formed by
a bilious or pituitous humour that has become putrid, or by a saltish
one. It is known by attending to the age, temperament, diet, season of
the year, situation, and the like. If, therefore, it appear to prevail in
the blood contained in the veins, we must begin with venesection; but
if it offend rather by its quality, we must evacuate it by corresponding
medicines, and turn our attention to external applications. Wherefore we
must use the bath at all times before a meal; and sometimes, after eating
a little, it may be used a second time, for the affection is of difficult
humectation. They are to be rubbed with the decoction of fenugreek, or of
beet, or of barley-meal, or of wild or of garden mallows, or of ptisan;
and along with these may be joined the flour of beans, or of lupines, or
of myrobalan (ben), or of the detergent ointment called _peponaton_. If
it is protracted, we may use the bath in like manner, and foment with
the decoction of sage, of tamarisk, of the herb mercury, of marjoram,
of pennyroyal, of bay berries, of the root of the wild cucumber, of
capers, of strained ley, of vinegar and brine; and then the parts are
to be sprinkled with dried natron, or with the lees of vinegar, or with
the composition containing of spuma nitri one sextarius, of rosemary,
of sulphur vivum, of each, lb. j, of cimolian earth, lb. ss; or this:
of aphronitrum, of sulphur vivum, of burnt alcyonium, equal parts; to
be used dry, or with some of the decoctions already mentioned; and, if
you please, sprinkle some dried hellebore, without grease. But rub in
with vinegar and oil, stavesacre pulverized, or sulphur, or red arsenic,
or all together; or mustard, with the refuse of expressed myrobalan,
and vinegar and oil; or with snails burnt and triturated with honey
or the roots of dock, or the detergent ointments prepared from them,
as described under the head of Elephantiasis; or with some of the
applications for scabies. If the parts become ulcerated, use the plaster
called parygron, or that prepared from pompholyx; or melt oz. j of wax
in a cyathus of oil of privet, and sprinkle upon it of sulphur vivum oz.
j. _Another_ application for prurigo: Of large nuts in a rancid state,
oz. j; of sulphur, oz. j; triturate with the juice of parsley, and use
in the bath with much friction. This alone has proved sufficient for the
cure of many cases of scabies and prurigo; and green parsley by itself,
when pounded and rubbed in while the patient is in the bath, has been
of great service: and in like manner, pellitory of the wall and maple
rosin dissolved with rose oil, and rubbed in.—_Another_: Bruise three
ounces of pure and very white rice, and, having strained, triturate with
strong vinegar until it become of the thickness of the sordes of the
oil in baths; and adding separately of sulphur vivum pulverized, oz. j;
and mixing properly, use in the bath with much friction. When there is a
greater redundance of humours, it will be better to mix the ingredients
in equal proportions.

       *       *       *       *       *

COMMENTARY. See Hippocrates (Aphor. iii, 31); Galen (Comment. et alibi);
Oribasius (Morb. Curat. iii, 22); Aëtius (xiv, 20); Actuarius (Meth. Med.
ii, 11); Nonnus (237); Alexander Aphrodisiensis (Probl. i, 24); Myrepsus
(pluries); Pliny (xxviii, 5); Octavius Horatianus (i, 31); Marcellus (de
Med. 4); Isidorus (Orig. iv, 8); Serapion (v, 6); Avicenna (iv, 7, 3,
6); Haly Abbas (Theor. viii, 17, and Pract. iv, 6); Alsaharavius (Pract.
xxxi, 5); Rhases (Divis. 121); Avenzoar (ii, 7, 2.)

The prurigo of Dr. Willan is here distinctly described, and a suitable
method of treatment recommended.

Hippocrates remarks that prurigo is common in old age. The reason which
Galen assigns for this is, that the superfluities of the system are
then not properly discharged by the skin. He says in another place,
that pruritus may either be produced by external substances, such as
nettles, squills, &c., or it may arise from indigestion and the neglect
of cleanliness.

Oribasius gives an account of the disease not very different from our
author’s. Among other applications, he recommends one consisting of opium
mixed with liquid cerate.

Aëtius speaks highly of the sulphureous bath for the cure of this disease.

Actuarius characterizes the disease very well, when he says that it is
allied to lichen, and that when rubbed either nothing runs from the
place, or some slight humidity of various colour and consistence. He
assigns, as a reason for its frequency in old age, that the pores of the
skin then get constricted.

Alexander Aphrodisiensis assigns, as the reason why the warm bath proves
useful in cases of pruritus, that it dispels the phlegm, which is the
cause of the complaint.

Celsus gives a particular account of scabies, but says nothing of prurigo.

Octavius Horatianus recommends us, when the patient is young, to bleed,
purge, and use baths medicated with frankincense, natron and sulphur.
He also says that the cold bath, and friction with the oil of roses,
myrtles, &c., will do much good.

Isidorus uses the term prurigo: “Prurigo vocatur perurendo et ardendo.”
Marcellus also uses this term, and recommends much the same substances as
the others.

This affection is clearly described by the Arabians, and is rendered
pruritus by most of their translators. Serapion recommends us, if there
is a sanguineous plethora, to bleed, and then to purge with myrobalans,
colocynth, and black hellebore, and along with these the warm bath is to
be used, and the liniments for removing the pruritus, containing vinegar,
roses, nitre, &c. The prurigo senilis he pronounces to be incurable.
Rhases and Avicenna recommend similar remedies. They treat of prurigo and
scabies together, and there is no doubt of their alliance. Hence Bateman
says that prurigo, when neglected, terminates in scabies. Haly Abbas
says that scabies and prurigo arise from a saltish phlegm. Scabies, he
says, consists of reddish pustules, which appear most frequently between
the fingers and upon the arms. Prurigo, he adds, is apt to run into
scabies. He recommends, as a lotion, vinegar with rose-oil, the use of
the warm-bath, and other remedies like those of our author. Alsaharavius
says that the disease arises from debility of the expulsive faculty of
the body or constriction of the pores. He praises highly the hot bath.
Avenzoar states that pruritus arises from bile or a sharpness of the
blood.

Our author has omitted to treat of _phthiriasis_, for an account of
which see in particular Cælius Aurelianus (de Tard. Pass. iv, 2); also,
Aristot. (Hist. An. v, 32); Galen (de Comp. Med. sec. loc. i, 8);
Pliny (Hist. Nat. xxvi, 86); Haly Abbas (Pract. iv, 7); Plutarchus (in
Vitâ Syllæ.) The authorities quoted by Rhases recommend compositions
consisting of stavesacre, white hellebore, arsenic, nitre, sulphur,
sublimed mercury, and the like. (Contin. xxxvi.) Antiochus, Herod of
Judæa, Philip II of Spain, and many other celebrated personages, are
said to have died of phthiriasis. Virey accounts for the disease in the
following manner: “Il est, en effet, tel tempérament muqueux, telle
dégénération des humeurs lymphatiques, dans le phthiriasis ou la maladie
pédiculaire, que ces insectes y trouvent une pâture inépuisable, qu’ils
se propagent avec une extrême exubérance sous le peau, pénétrent dans le
tissu cellulaire, et établissent d’énormes colonies parmi les ulcères
qu’ils y forment.” (Hist. des Mœurs des Anim. ii, 207.) Aldrovandi gives
a very full history of phthiriasis. (De Insectis, v.)


SECT. V.—ON LEUCE.

Leuce is a change of the skin to a white colour, occasioned by a viscid
and glutinous phlegm. Since all the kinds of leuce are not curable,
you may form a diagnosis of it in this manner. Pierce the leuce
superficially, not deeper than the skin, with a needle, and if blood
flow, the complaint may be cured; but if a milky moisture be discharged,
it is incurable. Or, rub it with a rough woollen rag, and if the part
become red, the complaint may be cured; but if it remain of the same
colour, it cannot be cured. And those kinds which attack a great part of
the body are to be supposed more difficult to cure than those which are
confined to a small space, and old cases than recent. Some, therefore,
in leuce, have approved of burning by iron, consisting simply of the
application of heat. Others, dreading the pain of burning, and the scar
arising from it, as being no less unseemly than leuce itself, have had
recourse to escharotic medicines, such as they say will produce a scar
of the natural colour. Others rejecting all these things on account
of the difficulty of their application, have used dyes (paying more
consideration to the deception than the utility which they produce,)
which are, of all others, the most to be rejected, owing to the speedy
renewal of the affection. We must use, then, the under-mentioned remedial
powers: Of adarce, of rosemary seed, of sulphur vivum, of each, equal
parts; bruise and strain singly, and then, having triturated together
for a sufficient number of days, anoint in the sun, but not in great
quantity, lest the skin be ulcerated; and, after some time, a little
hellebore and galls may be added in like manner.—_Another_: Macerate the
tops of the black fig in vinegar, and having triturated, mix equal parts
of aphronitrum, sulphur vivum, and the fruit of tamarisk, and having
rubbed natron into the part, anoint and expose to the sun, taking care
lest an ulcer be produced. But Archigenes having mixed a sufficiency of
quicklime with fig-leaves, used them in like manner: or, he says, having
rubbed the leuce with white hellebore until the part perspire and become
of the same colour as the rest of the body, anoint with sinopis or melian
earth; or, having perforated them with needles until they bleed, anoint
with sinopis in vinegar; or, having first rubbed them as formerly said,
anoint with the fresh juice of figs, or rub in so much with the leaves of
it.

       *       *       *       *       *

COMMENTARY. In the second Section we have stated so fully the nature of
the leuce, and the difference between it and its cognate affections,
that it will be unnecessary for us now to resume the subject. It is
there mentioned that leuce is Celsus’ third species of vitiligo, and the
_baras_ of all the Arabian translators, with the exception of Stephanus
Antiochensis, the translator of Haly Abbas, who applies the term _lepra_
to it. It was therefore the white species of leprosy. All the medical
authorities represent it as an intractable disease, not only the cuticle
being altered in structure, but also the flesh below, and even the hairs,
having undergone a change of colour. All direct us to prick the skin with
a needle, and, if it bleed, the cure is to be attempted; but if a slight
colourless fluid issue from it, the case is to be abandoned as hopeless.
They consider it as arising from debility of the assimilative faculty
of the part which can no longer convert the nutritive juices into their
proper consistence. All recommend nearly the same treatment. The diet
is to be regulated with a strict abstinence from gross food; if there
be plethora, venesection is to be premised; then drastic purgatives and
emetics are to be given, and the parts affected are to be rubbed with
stimulant and caustic applications, containing hellebore, nitre, sulphur,
misy, red arsenic, &c., or even the actual cautery may be applied. In
short, all treat the disease in nearly the same manner as our author.
(See in particular Serapion and Avicenna.)

Aristotle, we believe, is the first Greek writer who makes mention of
leuce. He calls it a disease in which all the hairs of the body turn
white. (Hist. Nat. iii, 11.)

“The snow-white leprosy” of the ancient Jews was the leuce of the Greeks.
Moses describes very correctly the method of distinguishing it from the
alphos and melas; (Leviticus, c. xiii.) The symptoms of leuce are given
in the 3d verse; of the alphos in the 4th; of the melas in the 6th. He
calls it contagious, which might lead us to suspect that elephantiasis
was mixed up with the leprosy of the Jews. This opinion is further
confirmed from what is mentioned by Josephus of its being said that his
countrymen were driven out of Egypt because they were affected with
leprosy. (See also Justin. xxxvi, 20, and Tacit. Hist. v, 3.) Now we
know that elephantiasis was endemial in that country. (See chap. i.) The
English translation of this chapter is very inaccurate, the translators
having evidently failed to recognize the nice distinction between cognate
diseases, laid down by the Jewish legislator.

Leuce is still common in tropical climates. Negroes affected with it
are called Albinos. It is merely an aggravated variety of the _Lepra
vulgaris_.


SECT. VI.—ON WHITE AND BLACK ALPHI.

The formation of alphos is similar to that of leuce, but the latter
produces a deep change of the skin, so that the hairs grow of a similar
colour, whilst the alphi affect the skin superficially, except that
when continued, they extend more deeply, so that the hairs grow white,
owing to the humour which causes it. From the pituitous humour then
they are produced white, but black from the melancholic. Wherefore, a
common application for both is washed lime dissolved in water, or, the
root of dracunculus applied with vinegar; in like manner, either species
of hellebore, the decoction of bitter lupines poured on the part, and
their flour when applied as a cataplasm with vinegar or oxymel, the
bark of the root of capers with vinegar, the root of lily with honey,
onions with vinegar rubbed into the part in the sun, the dung of the
land crocodile, and in like manner, that of starlings, when they are fed
solely upon rice, and the burnt shells of the cuttle-fish. The following
is a compound application: of alcyonium, of natron, of each, oz. ij; of
white hellebore, of sulphur vivum, of each, oz. j; and some also add the
burnt lees of wine.—_Another_: Of sulphur vivum, of the spuma nitri, of
each, dr. iv; rosemary seeds, vij; triturate with vinegar. But rub only
the part affected with alphos, not touching the unaffected parts, and
when dry, wash with cold water.—_Another_: Of the flour of lupines, of
buccina, and natron, of each, a chænix; of white hellebore, dr. viij; rub
with it in a dry state.—_Another_: Of the flour of bitter vetches, lb.
ij; of the seeds of rocket, of bitter almonds, of the root of the wild
cucumber, of each, lb. j; triturate with wine and honey and anoint, and
after an interval of an hour wipe it away with a sponge. It applies also
for freckles, warts, and other spots on the skin.

A tried remedy for white alphos: of sulphur vivum, ii sextarii, of
quicklime whitened, oz. iv; five whites of eggs, of nard-oil and vinegar,
a small quantity. The sulphur is first pounded, then we add to it the
oil of nard, and again triturate; then the vinegar is poured in, and
the mixture is again triturated. But the quicklime is to be washed
separately, once, twice, and thrice, and then we add it to the sulphur
with the white of the eggs and triturate; and we pour out the collected
fluid; but leaving a small quantity so that the ointment may admit of
anointing, we use it thus.—_Another_ tried remedy: Take sulphur vivum,
dried fig leaves, aphronitrum, alcyonium, Cimolian earth, and myrtle,
use with vinegar.—_Another_ of Archigenes: Rub in equal parts of fig
leaves dried in the shade, of sulphur, and of alum with vinegar, or of
fig leaves, dr. iv; of nitre, dr. ij; of burnt alcyonium, dr. ij; anoint
with vinegar in the bath. But red arsenic with one half of sulphur is
excellent for removing the black alphos; thus having cleansed the part
with natron, anoint with it in the sun. For white alphos: of copperas,
of verdigris equal parts, of natron the double, rub without fat: or, of
rosemary seeds, of sulphur vivum, of adarce, equal parts; triturate with
vinegar, rub, and anoint; but when it is dry, bathe by rubbing. This
applies also to the white species.

       *       *       *       *       *

COMMENTARY. We have again to refer the reader to the second chapter for
an account of these complaints, and an exposition of the differences
between them and the affections to which they are allied. It will be
seen that they are varieties of the genus vitiligo of Celsus, and that
they bear a near resemblance to leuce, from which they are chiefly
distinguished as being mere superficial affections of the skin. The
Arabians treat of them under the names of morphea alba and nigra. Dr.
Willan makes them to be varieties of lepra, in which opinion we fully
coincide with him.

The description of the two diseases by Actuarius is so precise that
we shall give it in lieu of all the others. The alphi, he says, are
superficial, but sometimes extend in depth, so that the hairs appear
of the same colour. The white species is tried as to the depth it has
spread, by being pricked moderately with a needle; when blood flows
though the needle has only penetrated the skin, the disease is curable,
but if the discharge be milky it is incurable, inasmuch as the flesh is
converted into the disease. Others, he adds, rub the part with rough
towels, and if it become red they have good hopes, but if it remain of
the same colour they abandon all hopes of recovery. They are of a more
aggravated nature when they affect different parts of the body and are
inveterate. The alphi, he says, are generally milder than leuce, and can
be cured by gentler means, but when they become inveterate they require
similar treatment. The difference between the white and the black alphos
is produced by the colour of the prevailing humour.

There is scarcely any difference of opinion among the authorities
respecting the general plan of treatment. Haly Abbas has correctly
remarked, that the alphi are to be cured by the same sort of remedies
as lepra (leuce?) only that they do not require so strong applications.
The Arabians greatly commend their myrobalans with ginger, mastich,
parsley, &c. Their internal applications are powerful detergents and
escharotics, such as hellebore, natron, sulphur, vinegar, arsenic,
copperas, &c. Celsus says nothing of internal remedies, but recommends
external applications of a stimulant nature, containing sulphur, alum,
nitre, frankincense, alcyonium, &c. In the ‘Isagoge’ it is said that all
these complaints are to be cured by phlegmagogues, and by abstergent
applications externally.

Guy of Cauliac, and the other medical authorities of that age, describe
these diseases by the names of _Morphea_ alba and _M._ nigra. They
recommend applications containing sulphur, alum, natron, arsenic, and the
like. As usual they are the mere copyists of the Arabians.


SECT. VII.—ON STIGMATA, FROM THE WORKS OF ARCHIGENES.

You may remove stigmata by rubbing in that which sticks to a chamber-pot,
along with the most acrid vinegar, or rub of quicklime, p. j; of red
natron toasted, p. ss; with water, in the sun: but when it ulcerates let
it be healed like an ulcer. But Crito says, for stigmata, having first
scrubbed the part with nitre (soda), cover it with an application of
turpentine; then having bound it, let it remain for six days, and on the
seventh perforate the stigma with a needle, and having wiped away the
blood with a sponge, after a little time rub with some powdered salt.
Then, having applied the medicine, allow it to remain for five days. It
is this: of frankincense, of natron, of the lye of quicklime, of wax, of
each, dr. iv; of honey, dr. viij; having loosed it, you will find the
blackness upon the application.—_Another_ ointment: Of pepper, dr. ij;
of rue, dr. iv; of realgar, dr. iv; of orpiment, dr. j; of honey, q.
s. Anoint with it, have previously scrubbed the part with natron, and
done otherwise in like manner as for the former. Taking it away after
three days, and cleaning away the blackness, anoint with it again; for,
he says, it removes the complaint in twenty days, without ulceration or
cicatrix.—_Another_ called Criticum: Of frankincense, dr. iv; of nitre,
dr. ij; of copperas, dr. iv; of wax, dr. vj; of pepper, dr. iij; of lime,
dr. iij; of thapsia, dr. iij; of orpiment, dr. iss; of realgar, dr.
iij; of honey, q. s; use as the former. Oribasius says, that crowfoot
(ranunculus) if applied, or the leaves of capers, take away the marks.
But if they be deep seated upon only a small extent of skin, form an
eschar by a cold cautery, and thus remove them.

       *       *       *       *       *

COMMENTARY. Consult Aëtius (viii, 12); Actuarius (Meth. Med. vi, 8);
Scribonius Largus (§ 231); Avicenna (iv, 7, 2, 7); Pseudo-Dioscor.
(Eupor. i, 116.)

Aëtius explains that by stigmata are meant the marks of injuries on
the face or any part of the body. To eradicate them he recommends
compositions containing quicklime, natron, arsenic, &c.

The Pseudo-Dioscorides recommends the ranunculus, the juice of the leaves
of capers, or that of mandragora, &c.

Actuarius copies from our author.

Scribonius Largus mentions a composition containing garlic, cantharides,
sulphur, chalcitis, &c.

Avicenna recommends friction with natron and the other substances
mentioned by our author.

Dr. Willan defines the stigma, “a small speck on the skin, occasioning no
elevation of the cuticle.” The ancient authorities, it will be perceived,
apply the term in a wider sense.


SECT. VIII.—ON EXANTHEMATA.

Exanthemata are formed by thick humours impacted in the skin, and more
especially if the cuticle be thick. In these cases, then, even if the
humours are deep-seated, they must be first purged away; for unless you
do this in the first place, before attempting to dispel them, you will
only impact them the more firmly, instead of evacuating them by the skin.
But if the deep-seated parts be free from crudities, you may evacuate the
humours by the skin, and not produce revulsion of them to a distance,
which is the case, if you attempt to evacuate them by the belly or
emetics. But the cure of humours fixed in the skin, is to be accomplished
by fomentations and calefacients, more especially when the exanthemata
happen to be broad, for these are formed by a cold and thick humour.
Wherefore, take of the tender leaves of bay, of manna, and of rue equal
parts, triturate together, and dissolving frankincense in honey, anoint
with it; or, having boiled and pounded tender beet, apply as a cataplasm;
or, take of wax, dr. viij; of sulphur the same quantity; of salt, dr.
vj; triturate them dry, and having poured on them half a cyathus of oil,
boil all together, and use the plaster that is formed. But one must
attentively sit by while the boiling is going on. It is a very excellent
medicine.

       *       *       *       *       *

COMMENTARY. See Hippocrates (Epidem. et alibi); Galen (Meth. Med. v);
Alexander (i, 5); Oribasius (Synops. vii, 7); Morb. Curat. (iii, 21);
Aëtius (v, 129); Actuarius (Meth. Med. ii, 11; i, 23); Celsus (v, 28);
Pseudo-Dioscor. (Euporist. i, 106); Haly Abbas (Theor. viii, 17; Pract.
iv, 8).

As stated in another place, the Greeks used the term exanthema in a
much laxer signification than it is applied in Dr. Willan’s ‘System
of Cutaneous Diseases.’ Hippocrates in particular may be mentioned as
applying it to various classes of these affections. Alexander describes
the exanthemata of the head as superficial ulcerations, which are red and
rough. Does he allude to porrigo? He recommends for the cure of them a
composition of litharge, ceruse, alum, the green leaves of rue, vinegar,
and myrtle oil.

Galen says that exanthemata is a term applied by some to all ulcerative
and rough affections of the skin, which, according to Archigenes, stand
in need of desiccative applications. In another place he mentions
the exanthemata as a common symptom of the plague. Aëtius in like
manner gives from Herodotus an interesting account of fevers which are
accompanied with exanthemata. Both have been supposed to allude to the
smallpox, but we agree with Dr. Willan, that this interpretation of their
descriptions is altogether fanciful.

Our author follows Oribasius closely.

According to Actuarius exanthemata, properly speaking, are produced by
thick humours either formed in the skin or in the whole body, and being
detained by the density of the epidermis.

Celsus describes the exanthemata under the generic term pustulæ. His
words are: “Earum plura genera sunt. Nam modo circa totum corpus partemve
asperitudo quædam fit, similis iis pustulis, quæ ex urticâ, vel ex sudore
nascuntur: ἐξανθήματα Græci vocant. Eæque modo rubent, modo colorem
cutis non excedunt.” For pustules of all kinds he recommends exercise,
restricted diet, and abstinence from all things of an acrid and attenuant
nature, which regimen is likewise to be enforced upon the nurse, if
the child be at the breast. If the patient be strong, he is also to be
put into the hot bath, and rubbed with natron and a mixture of wine
and oil. If this treatment does not succeed lentils are to be applied,
especially if the pustules be large; and after the outer skin has been
removed they are to be treated with gentle applications. Such is the
plan of cure recommended by the great Roman authority. His directions
respecting the diet are particularly important, and appear to be quite
in accordance with the practice of the modern physicians, who recommend
the _half-starving system_ in all such complaints.

For red exanthemata the Pseudo-Dioscorides recommends ceruse with oil of
bays and sulphur, pure bark with wax, &c.

The exanthemata are described by the name of pustulæ parvæ in most of the
translations of the Arabians. The exanthemata is, we think, the first
species of _Serie_ described by Haly Abbas.

For the opinions of Alsaharavius and Haly Abbas about the exanthemata of
infancy, see Book i, 6.

Dr. Willan thinks that the nettle-rash was comprehended under the term
exanthemata. He is also of opinion that the _benat noctis_ of Avicenna is
the nettle-rash. It would appear, however, that the _benat noctis_ was
the same as the _sera_ or _epinyctis_. See Rhases (Cont. xxxvi, 2). The
symptoms of it are said to be itching, roughness of the skin, and small
eruptions attacking the patient during the night.

Thucydides, Hippocrates, and Galen mention exanthemata as a common
symptom of the plague.

We may take the present occasion to mention that none of the Greek or
Latin authorities has given any distinct account of _purpura_. Avicenna
has briefly described it in its chronic form. (iv, 3, 1, 8).


SECT. IX.—ON EPINYCTIDES.

Epinyctides are small ulcers breaking out spontaneously on the skin, in
the form of bullæ, reddish, and when broken, discharging a bloody ichor.
These are not very troublesome during the day, but at night, they are
more painful than the smallness of the ulcer would bespeak. Wherefore,
having dissolved the juice of laserwort in water, apply it; for it is
desiccative without being pungent; or, having levigated hemlock, apply
it; or crude cabbage with water, or triturate parsley with polenta, and
apply; or, triturate the leaves of henbane with honey, and apply; or,
strychnos by itself, and with the green coriander; or, use the leaves of
olives boiled with water; or, having triturated raisins deprived of their
stones, and spread them upon a splenium or oblong pledget, apply; or
triturate maiden-hair with honey. They must avoid all acrid, acid, and
saltish things, also fomentations, baths, and insolation.

       *       *       *       *       *

COMMENTARY. Celsus (v, 28); Aëtius (xiv, 61); Oribasius (Morb. Curat.
iii, 54); Actuarius (Meth. Med. ii, 11; vi, 8); Pollux (Onomasticon iv,
24); Avicenna (iv, 3, 1, 13); Serapion (v, 8); Haly Abbas (Theor. viii,
17); Pract. (iv, 8); Rhases (Divis. i, 122.)

Celsus describes the epinyctis as a bad species of pustule, somewhat
livid or red, about the size of a bean, very painful and inflamed, and
coming on principally at night, whence it derives its name. Persons of
all ages, even infants at the breast, are subject to it, and in treating
them he directs the regimen of the nurse to be properly attended to. In
laying down the rules of treatment he puts particular stress upon the hot
bath.

Aëtius, Oribasius, and Actuarius treat of it as our author. Pollux
defines it to be a vesicle of a palish colour, somewhat humid and bloody,
and forming about the legs and feet in the night.

The Arabians give a similar account of epinyctis, under the names of
Sare, Serie, and Essere. Thus Serapion recommends bleeding if required by
the general symptoms, purging with myrobalans and prunes; and external
applications, containing sumach, savin, &c. Haly Abbas, who describes
it as one of his serie, approves of much the same treatment. Avicenna
and Rhases in like manner recommend bleeding, gentle purgatives, cooling
lotions, and the tepid bath. Rhases, in his ‘Continens,’ applies the
directions given in this chapter by Paulus to the treatment of the
cutaneous disease, which he calls sera. This establishes their identity
(xxxvi, 6.) As stated in the preceding chapter, the epinyctis is also the
“benat noctis,” i. e. “filia noctis” of the Arabians. Marcus Aurelius
Severinus, therefore, is mistaken in distinguishing between the epinyctis
and the benat noctis. Ingrassius admits their identity.

Fracastorius gives the following account of this affection: “Si
inflammata et accensa sit cholera, pustulam illam facit, quæ ἐπινυκτις
vocatur, quod sæpissime noctu nascatur, Arabes Essere appellant.” (De
Morb. Cont. ii, 15.) Both Lorry and Rayer confess themselves unable to
determine what the epinyctis of the ancients was. It would appear to
have been some peculiar species of eczema, now extinct. It must have been
a more formidable disease than the nettle-rash, which certain modern
authorities have taken for the _epinyctis_ of the ancients.


SECT. X.—ON PHLYCTÆNÆ OR BULLÆ.

As Bullæ when they burst spontaneously are attended with acute pain, it
is proper to perforate at their under part with a sharp needle, and then
to squeeze out the humour gently, suffering the skin which covers it to
remain. And if the wound should close up and the bullæ fill up, it is to
be evacuated again in like manner, and pressed out; and the incumbent
skin is to be kept pressed down until the ulcer below be healed. Before
the bullæ break, apply boiled lentils triturated with water; or, the
shoots of pomegranate, having been warmed upon hot coals, are to be
applied, so as to burn the parts. But if they burst and form an ulcer,
having melted axunge, and mixed levigated litharge, put into a linen
cloth, and apply; or, having boiled the root of lily in water, triturate
it with cerate, and apply.

_For epinyctis and phlyctæna._ Having triturated equal portions of
litharge and sulphur vivum with vinegar and myrtle-oil, until it become
of the thickness of the sordes of baths, rub with oil and wine. For hot
eruptions, warm papulæ, achores, incipient furunculus, and burns, the
composition of plumbago, and that from eggs is applicable.

       *       *       *       *       *

COMMENTARY. See Aëtius (xiv, 63); Oribasius (Morb. Curat. iii, 23);
Actuarius (Meth. Med. vi, 8); Avicenna (iii, 3, 1, 11.)

This appears to be the pompholyx of Drs. Willan and Bateman. Aëtius
remarks, that the disease principally attacks women whose menses
are obstructed. (Bateman says, “it seems to affect only women.”) He
recommends emmenagogues, laxatives, and diuretics, and forbids all acrid
things.

Our author copies the whole from Oribasius. Actuarius recommends nearly
the same applications.

Celsus describes the phlyctænæ as a variety of the pustulæ. There is
nothing particular in the treatment recommended by Avicenna.

Thucydides mentions small phlyctænæ and ulcers among the symptoms of the
plague of Athens. (De Bello Pelopon. ii.) Hippocrates gives the name of
_pemphyx_ to the cutaneous eruption, by which the plague of Athens was
distinguished. (Epidem. vi.) See Galen’s Comment. (v, 453, ed. Basil.)
Procopius also takes notice of black phlyctænæ among the symptoms of
the great plague which raged in the reign of Justinian (Pers. ii.) See
also Diodorus Siculus (Biblioth. xiv.) Some suppose, however, that by
phlyctænæ were meant petechie. See Prælect. Marc. p. 301.


SECT. XI.—ON BURNS.

Burnt parts require applications which are moderately detergent, without
being decidedly heating or cooling. Wherefore, Chian, Cimolian, Cretan,
and every light earth, when rubbed in with vinegar not very acrid, or
mixed with water, are excellent applications, and prevent blisters
from forming; also a whole raw egg immediately applied upon soft wool,
for it cools moderately, and dries without being stimulant. And anoint
the part with black ink, or with frankincense dissolved in water, or
use a cataplasm of boiled lentils, or of tares. For burning with hot
water, before blisters arise, pour frequently on the part the brine of
pickled olives, or apply olives themselves triturated with polenta;
or, triturate stone-alum with vinegar, and rub it in; or, anoint with
bull’s gall dissolved with much water; or, pour on the part strained
ley with sauce of pickles, or brine; or, triturate the bulbous roots of
lilies, hyacinths, or narcissi with rose-oil, and having made it of the
consistence of the sordes of oil in baths, anoint with it. But Marcellus
gives the following composition: having smeared a rag with honey, and
wrapped it around barley, burn it, and mix of the ashes, dr. viij; of
ceruse, dr. iv; of butter, dr. viij; of wax, dr. xvj; of goat’s fat, dr.
xvj; of rose-oil, dr. xvj. For burnt parts already blistered, having
triturated sumach and polenta with vinegar, apply it; or, mix quicklime
with cerate, put it on a rag, and apply. And the medicine called
Sphæria is applicable in such cases. The parts which are ulcerated, may
be covered with pounded leeks; or, triturate purslain with polenta, and
apply; or, put pigeon’s dung into a rag of linen, burn it, and mix the
ashes with oil, and use; (this is an excellent application:) also the
bark of pine and of spruce fir, or dried maiden-hair levigated, or the
burnt leaves of myrtle, are to be triturated and sprinkled upon the part.
Each of these things answers well, when applied with cerate. But a good
application is formed by triturating together of the dried roots of the
red alkanet, oz. iv; of white wax, oz. ix; of rose-oil, oz. xviij; and
also that made of ceruse, with a small quantity of stag’s marrow.

       *       *       *       *       *

COMMENTARY. See Hippocrates (de Ulceribus.) Celsus (v, 27); Galen (de
Simpl. Med. et alibi.) Aëtius (xiv, 64); Pseudo-Dioscor. (Euporist. i,
178); Actuarius (Meth. Med. vi, 6, 8); Nonnus (240); Serapion (v, 11);
Avicenna (iv, 4, 2, 12); Haly Abbas (Pract. 4, 25); Alsaharavius (xxix,
2, 8); Rhases (Antid. i, 27); (ad Mansor. vii, 18); (Div. i, 136.) The
author of the Hippocratic treatise referred to above, recommends various
applications to burns, such as old axunge rubbed into the part, and the
root of squills applied above; or a mixture of old axunge, rosin, and
bitumen, spread upon a rag and heated at the fire; or the roots of the
ilex boiled in white wine at a gentle fire until it be of the consistence
of a liniment.

Dioscorides, Avicenna, and Galen, agree in praising Cimolian earth as
an application to recent burns. Galen says that copperas, especially
when dissolved in vinegar, forms an excellent application for the ulcers
occasioned by burning.

Aëtius treats burns upon nearly the same principles as our author.
When blisters rise he forbids an early opening to be made in them. As
an application to them he recommends alum with water and the white of
an egg. Some of his applications can only be supposed proper for the
foul ulcers left by burning. Such is that consisting of verdigris and
litharge, pounded with wine and oil. For healing ulcers he recommends a
composition containing ceruse, litharge, toasted barley pounded, wax, and
rose or myrtle oil.

In the ‘Euporista’ Cimolian earth, litharge and oil, and many other
applications are recommended.

Actuarius recommends a composition of litharge, ceruse, wax, turpentine,
and some other articles of less importance. We need scarcely mention
how much the oil of turpentine has been used of late in such cases. He
praises such things as are moderately astringent, such as alum dissolved
in vinegar, &c.

Celsus recommends at first such things as are, “mediocriter exedentia
reprimentiaque,” and afterwards articles of a soothing nature. To the
former class belong the farina of lentils and honey; myrrh with urine,
or the Cimolian chalk, with the bark of frankincense; and to the latter
belong all fatty applications, and such things as contain the dross of
lead and the yelks of eggs. He also mentions turpentine rosin, as an
application to foul ulcers from burning.

Serapion, like our author, recommends applications which are moderately
detergent, and neither very calefacient nor refrigerant. He gives the
following directions for making a preparation from lime. Take of lime,
seven times washed in sweet water and dried, oz. viij; of wax, oz. ij;
of oil of roses, oz. vj: let the wax be melted along with the oil,
and well mixed with lime. This is to be rubbed into the part. He also
gives a prescription for preparing a mixture of lime-water and oil,
exactly similar to that which is now used in cases of burns. (vii, 28.)
Avicenna, with his usual accuracy, lays down very particular rules for
the treatment of burns. To prevent blisters from rising he recommends
cooling things; when the burning is occasioned by hot water, he directs
us to apply sandals, rose-water, and camphor: or a cloth dipped in
congealed water is to be kept constantly applied, and it will prevent
blisters from rising. Most of the applications recommended by our author
are also mentioned by him. Haly Abbas directs us to apply a cloth cooled
in rose-water. He also speaks of the ointment of lime and rose-oil,
mentioned above. When the burning is not severe, Alsaharavius directs us
in the first place to wash the part with vinegar and salt, and then to
sprinkle upon it the flour of barley or of oats. Then if blisters do not
rise, but there is a sensation of burning in the part, he recommends us
to apply cloths dipped in cold water, rose-water, or snow-water, which
are to be changed frequently. Afterwards some emollient applications,
such as the white of an egg, with gum arabic is to be used. When the
burning is more severe, he recommends us to bleed and use a cooling
application, such as the brain of a sheep, the white of an egg mixed
with rose-oil, or an ointment made of white wax and rose-oil. He also
makes mention of the application from lime. Rhases recommends an ointment
containing ceruse, camphor, opium, &c. Like Avicenna, he directs us to
apply at first a cloth wetted in cold water, or in rose-water, which
has been cooled with snow. If the burning be extensive he recommends
venesection, with a cooling and attenuant diet. When the pain is great
he directs us to apply the yelks of eggs mixed with rose-oil. When a
large ulcer is formed, he directs us to dress it with the ointment of
lime, described above. He also approves of a white ointment, consisting
of ceruse, oil of roses, and wax. In his ‘Continens,’ he relates a case
of severe burning, which he treated with liniments composed of sandals,
camphor, and roses; a cloth wetted in snow-water being applied externally
to it. He approves of opening the blisters. To prevent them from forming,
he recommends strongly an astringent collyrium of galls. Like many of
the other authorities, he recommends Cimolian earth very much. The
applications recommended by Haly Abbas are of a refrigerant and cooling
nature, such as Armenian earth in vinegar, the white of an egg, ceruse,
&c.

The earlier modern authors treat burns upon the plan laid down by the
ancients, more especially the Arabians. Thus Guy, of Cauliac, recommends
us in cases of extensive burning to have recourse to venesection,
along with a cooling and attenuant regimen. As a local application, he
recommends a cloth wetted in rose-oil congealed in snow, and afterwards
cooling ointments containing ceruse, litharge, and the like. He approves
of opening the blisters, of afterwards dressing the part with desiccative
remedies, such as the ointment of lime, seven times slaked. (Tr. vi,
Doct. C. 6.)


SECT. XII.—FOR THOSE BEATEN WITH SCOURGES.

Take of ceruse and litharge equal parts, of wax four parts, use as a
plaster with the oleum susinum, or rose-oil; but on the first day use
the susinum separately; or, of saffron, dr. j; of tragacanth, dr. j;
unite with them a whole egg, without the shell, and use. For those who
have been scourged, the skin of a sheep newly taken off, when applied
while yet warm, of all remedies cures the soonest, effecting this purpose
in a day and a night.

       *       *       *       *       *

COMMENTARY. See Aëtius (xiv, 62); Avicenna (iv, 4, 2, 7); Haly Abbas
(Pract. iv, 26); Alsaharavius (Pract. xxxi, 2, 1); Rhases (Contin.
xxviii.)

Aëtius gives similar directions. The following is said to be an excellent
application for the stripes of a whip: mix washed lime with raw eggs,
and add some rose cerate. Aëtius, Galen, Nonnus, Avicenna, Rhases, Haly
Abbas, and Alsaharavius join our author in recommending the fresh skin
of a newly-killed sheep as an application in such cases. Alsaharavius
recommends an ointment containing white wax, rose-oil, and ceruse,
when the wounds are deep; when there is any apprehension of heat and
inflammation, and more especially if the patient be plethoric, he
approves of venesection. When on the other hand the patient is weak, and
is in danger of falling into a state of syncope, he recommends musk and
wine to be administered. When there is much appearance of ecchymosis he
speaks of scarifying the part after the heat is gone. Rhases recommends
a composition of ceruse, litharge, wax, and rose-oil, as a general
application.

Most of the applications recommended by Bertapalia contain litharge,
ceruse, tutty, wax, and oil. (De Ulceribus, 16.) The other earlier
medical authors of modern times likewise follow the ancients in this case.


SECT. XIII.—TO MAKE HAIRS GROW ON A PART THAT HAS BEEN BURNT.

Hairs grow on a burnt part if you apply fig leaves boiled in a pot
with cerate, in the form of a plaster; or, of dried fig, dr. viij; of
marjoram, dr. j; triturate with oil to the thickness of a cerate, and
use; or, of gypsum, dr. _c_; of squama æris, dr. j; form trochisks with
water, and keep. When going to use, mix one part with eight parts of
cerate.

       *       *       *       *       *

COMMENTARY. The Arabians mention various things which were supposed to
be possessed of the property of making hairs grow; such as turpentine,
spikenard, thapsia, &c.


SECT. XIV.—FOR EXCORIATIONS.

For excoriated surfaces and superficial ulcers, at first use astringents,
such as wine, or vinegar and brine, and afterwards such plasters as
contain fat and promote cicatrization, and the most delicate of the white
plasters. This is particularly applicable: of ceruse, p. j; of ammoniac,
p. ss; of myrtle-oil, q. s; having triturated the ammoniac in water, mix
the ceruse, adding the myrtle-oil, and use in an oily state: or, mix the
squama æris with gypsum, and having triturated with myrtle-oil, use: or,
having triturated Cimolian earth and litharge with wine, and the oleum
ricini, or myrtle-oil, use.

_For excoriations, intertrigo, chronic ulcers, and old and tender skin._
Of golden-coloured litharge, dr. lx; of wax, dr. xx; of dried pitch
rosin, dr. xij; of oil, iss cyathus: having boiled the litharge and the
oil, add the other things, and having agitated it with a spatula, or
softened it in a mortar, use. Skin which has been torn away, ought not
to be cut from the sores, but it ought to be laid on, and the medicine
applied; for thus they coalesce, even if it is black. When stripped of
the skin, the cicatrization is difficult, the ulcer being irritated and
rendered foul. Excoriated parts are preserved from inflammation by the
application of red sumach, triturated with honey, or with the hair of
sweet flag burnt and applied with honey.

_An anodyne for excoriations, sores from stripes, and contusions of the
joints._ Of litharge, of ceruse, of each, oz. j; of wax, oz. vj; of pure
oil or rose-oil, lb. iss; of starch, oz. ij. The composition called
pelarium, from the dross of silver, produces the same effects, and that
from eggs in like manner.

       *       *       *       *       *

COMMENTARY. See Oribasius (Morb. Curat. iii, 18); Aëtius (xiv, 66, 67);
Scribonius Largus (88); Marcellus (De Med.); Avicenna (iv, 4, 2, 9);
Haly Abbas (Pract. iv, 10); Rhases (ad Mansor. vi, 18.)

Our author copies closely from Oribasius.

Aëtius recommends as a good application for intertrigo occasioned by the
friction of shoes, the warm liver of a pig or lamb, or unwashed wool.
Here he follows Dioscorides (ii, 37.) He also makes mention of several
cooling applications, containing ceruse, litharge, the dross of lead, &c.

Scribonius Largus recommends an ointment containing litharge, ceruse, the
flour of frankincense, alum, axunge, old austere wine, roses, and sour
oil.

Marcellus also recommends litharge for intertrigo.

The Arabians treat these cases similarly. Thus Avicenna agrees with
Aëtius in recommending the liver, and the ointment containing ceruse, &c.
For bruised parts he recommends astringents; such as galls, acacia, &c.

To relieve the heat and irritation occasioned by riding, or any such
cause, Rhases directs us to apply a cloth dipped in rose-water properly
cooled, he means, perhaps, with ice. After the heat and pain have been
removed, an ointment of ceruse, or litharge is to be applied. Blisters
produced by walking are to be opened and then washed with rose-water;
and afterwards they are to be dressed with an astringent application,
containing Armenian bole, galls, pomegranate flowers, or the like.


SECT. XV.—FOR MYRMECIA AND ACROCHORDON.

Each of these is a small rising of the skin, of a callous nature, and
for the most part circular; but the myrmecia have a broad base, and when
rubbed, convey a sensation like the bites of ants. But the acrochordon
has a narrow base so as to seem to hang, resembling the extremity of
a cord. Wherefore, elaterium with salts, when applied, removes these
swellings; and frankincense with vinegar, green figs with vinegar, flour
and natron, the juice of the fig rubbed in, and in like manner, that
of the spurge, the pickled head of picarel burnt, verdigris burnt with
sulphur vivum, the leaves of basil with copperas; that which flows from
green vine shoots when burning, sheep’s dung with vinegar, a buck-goat’s
gall when rubbed in, the fruit of the large sun-flower, when applied
with wine, rue with natron and pepper, natron with the urine of a youth
not come to puberty, the dung of an ox of the herd in vinegar.

       *       *       *       *       *

COMMENTARY. See Celsus (v, 28); Galen (Meth. Med. xiv); Aëtius (xiv, 4);
Oribasius (Morb. Curat. iii, 55); Actuarius (Meth. Med. vi, 8); Pollux
(Onomast. iv); Avicenna (iv, 3, 1, 6); Rhases (Divis i, 131, _et seq._;
ad Mansor. vii, 15, 16.)

Celsus defines these tumours in the following terms: “Ἀκροχορδόνα Græci
vocant, ubi sub cute coit aliquid durius, et interdum paulo asperius,
coloris ejusdem: infra tenue, ad cutem latius: idque modicum est quia
raro fabæ magnitudinem excedunt. Vix unum tantum eodem tempore nascitur;
sed fere plura, maximeque in pueris; eaque nonnunquam subito desinunt;
nonnunquam mediocrem inflammationem excitant; sub quâ etiam in pus
convertuntur.” He then describes the θύμιον to be about the size of an
Ægyptian bean, and of the colour of thyme. He adds: “Μυρμήκια autem
vocantur humiliora thymio durioraque: quæ radices altius exigunt,
majoremque dolorem movent: infra lata, supra autem tenuia; minus
sanguinis mittunt; magnitudine vix unquam lupini modum excedunt.
Nascuntur ea quoque aut in palmis aut in inferioribus partibus pedum.”
The acrochordon, he says, if cut out, leaves no roots, and does not grow
again. This is not the case with the myrmecia. For it he recommends an
application consisting of alum and red arsenic.

Galen describes minutely the method of extracting these tumours; but that
belongs more properly to the surgical part of this work.

Applications containing arsenic, chalcitis, quicklime, elaterium,
sulphur, and alum are mentioned by Oribasius and Aëtius. See in like
manner the ‘Euporista’ of the Pseudo-Dioscorides.

The myrmecia is generally rendered _formicaria_ by the Latin translators
of the Greek medical authors, and _formica miliaris_ by those of the
Arabians. Avicenna seems to confound the myrmecia with the herpes.

Pollux defines the thymus, or thymium, to be an excrescence about the
pudenda, anus, fingers, or face, of a red colour, rough, bloody, and not
difficult to remove. The acrochordon, he says, is white at the root, and
it gets enlarged at the extremity. The myrmecia he defines to be a hard,
rough excrescence of a callous nature, but bloody at its extremity.

The acrochordon is thus described by an intelligent modern author:
“Est verruca subcutanea durior et asperior, callosa, atque plerumque
teres, cute concolor, in basi tenuis, summitatis vero latioris, fabæ
magnitudinem raro excedens, juniores maxime infestans.” (Mangeti Bibl.
Chirurg. i, 72.) The terms thymus, myrmecia, and acrochordon, have now
fallen into disuse.


SECT. XVI.—ON GANGLION.

Ganglion is a round tumour of a nerve (tendon?) arising from a blow or
pressure, in many parts of the body, but particularly in those parts
which are moved, such as the extremities of the hands and feet. In this
case, says Archigenes, apply quick lime with the grease of geese and
turpentine. But Poles uses the medicine from agate stone, and Oribasius
the following: of ceruse, of pine rosin, of old oil, of each, oz. j; of
ammoniac perfume, of galbanum, of each, oz. j; of wax, oz. iv; or, he
says, apply a thick plate of lead, like the vertebræ, and larger than the
ganglion, and bind it on; for by its weight this dissolves it in process
of time. This we have used.

       *       *       *       *       *

COMMENTARY. See Hippocrates (De Artic. xxvi); Galen (Comment., de Med.
Simpl. ix); Celsus (vii, 6); Oribasius (De Virt. simpl. ii, in voce
Plumbum); Aëtius (xv, 9); Actuarius (Meth. Med. ii, 11); Avicenna (iv, 3,
2, 6); Albucasis (Chirurg. ii, 50); Rhases (ad Mansor. vii, 15: Contin.
xxviii.)

Hippocrates points out the danger of opening these tumours
indiscriminately. They consist, as Galen remarks, of a viscid and mucous
fluid. Galen and Oribasius agree with our author in directing a piece of
lead to be bound upon the ganglion. Nearly the same plan of treatment is
recommended by Aëtius, who directs us to bind a piece of lead upon the
tumour, and after some days to remove it, when the ganglion will be found
much softened; it is then to be squeezed firmly between the thumb and the
fingers, by which means it will be speedily dissolved. Albucasis approves
of extirpating the tumour, unless it be seated near a joint. Rhases as
usual collects the opinions of all preceding authorities. Antyllus, he
says, directed the surgeon to break the sack, or to bind a heavy plate
over it, or to extract it by the knife. When an operation is attempted,
he recommends that the surgeon be sure that he has removed the whole sac.
He relates a case in which the swelling was dissolved by an application
containing mustard.


SECT. XVII.—ON PHLEGMON.

In general, we call all those swellings phlegmons which are red and
painful, and accompanied with heat; some diversity of their nature
arising from the cause which occasions them. For when good blood and
of moderate consistence rushes abundantly to a part and from its
quantity becomes seated in it, the disease is that which is properly
called phlegmon; but when yellow bile is seated in a part, it is called
herpes; and when blood and yellow bile together are collected in a part,
erysipelas is formed; but when in this case the blood is hot and thick,
it usually gives rise to carbuncle. Wherefore, we shall begin with
what is properly called phlegmon, which occurs in many cases, being a
swelling which is red, painful, elastic, and hot, deriving its origin,
as I said, from good blood which is sometimes collected from the whole
body, and sometimes is formed abundantly in the part itself, so that it
cannot be contained in the vessels, but escapes from them in the form of
vapour into the surrounding cavities. And this affection supervenes upon
wounds, fractures, ulcers, and many other causes. When therefore a part
becomes inflamed without any obvious cause preceding it, the whole body
sending a defluxion to the part, we must evacuate the general system by
venesection, and apply to the part embrocations and cataplasms, not such
as are of a heating and moistening nature, but such as are calculated to
repel the fluid, which is flowing to the part, and evacuate that which
is already contained in it. Apply, therefore, a cataplasm of house-leek,
and of the bark of the pomegranate tree boiled in wine, with sumach and
polenta: when the pain is not violent, this or such like applications are
to be used; but when there is a defluxion to the part with greater pain,
then cataplasms of hot water and oil, or of polenta, must not be applied
(for all these are inimical to such defluxions); but the vehemence of the
pain is to be allayed by that which is composed from musk, rose-oil, and
a little wax, with unwashed wool containing much grease: these things are
to be prepared and applied cold in summer, but tepid if in winter, so
that the parts above the affected places be covered with a sponge soaked
in austere wine or cold oxycrate. But we must add to the cataplasms such
herbs as are proper for the purpose required. Pellitory of the wall,
therefore, is applicable to every phlegmon at the commencement, and
while on the increase; and in like manner, horned poppy, orach, mallows,
lettuce, and gourd, when applied on hot parts. Both kinds of caltrops
(tribuli) are applicable to inflammatory defluxions, and the cabbage to
such as are hard. When a change is thereby effected, and no pus falls
into the part, you may accomplish the cure by means of the plaster from
chalcitis, or some of those plasters of a similar nature, which apply to
defluxions; but clean wool soaked in austere wine is to be put externally
to the medicine. In this manner you may cure phlegmons from defluxion.
But such as are occasioned by any external cause will not be injured by
moistening and heating applications, and if necessity require, you may
scarify them with advantage. But in phlegmons arising from defluxion,
scarification, more especially at the commencement, may become the cause
of much mischief to the patient.

       *       *       *       *       *

COMMENTARY. See Galen (ad Glauc. ii); de Different. Morb. (12); Meth.
Med. (xiii, 2); Celsus (iii, 10); Oribasius (Morb. Curat. iii. 41);
Aëtius (xiv. 31); Leo (vii, 4); Actuarius (Meth. Med. ii, 12); Avicenna
(iv, 3, 1, 2); Serapion (v, 22); Haly Abbas (Theor. viii, 9; Pract. iii,
27); Alsaharavius (Pract. xxix, 2); Rhases (Divis. 126, and Contin.
xxvii.)

Galen explains that the term _phlegmone_ is used either to signify
inflammations in general, or a red, resisting, and painful tumour in
particular. It is here used in the latter acceptation. He says, when a
defluxion of blood of good quality and of moderate consistence takes
place to a part, and from its quantity becomes fixed in it, the person
is seized with a violent pain, unless the part be very insensible; it is
also accompanied with a deep-seated throbbing; it seems stretched and
broken; there is a sensation of increased heat, so that the part feels
as if it were burnt and desires cooling; there is a florid redness as in
those who have been in the bath, or have been warmed at the fire, and
by other means. This affection, he says, gets the generic appellation
of phlegmone, or inflammation. He enumerates many causes of it, such as
bruises, fractures, and dislocations; but even without these, he adds,
it may arise from the veins being immoderately distended with humours,
and the superfluity being cast off upon a part fitted to receive them at
the time. Such a part, from some cause or other, happens to be weaker,
or more lax, or more calculated to attract, or is more inactive than
the other parts of the body. He lays it down as a general principle,
that the cure of such affections is to be accomplished by evacuation.
Reason and experience, he adds, teach us that the general system is to be
evacuated by the suitable means, and the inflamed part by embrocations
and cataplasms of a repellent nature, and such as are calculated to give
tone and strength to it. Such are his general principles of treatment.
His particular remedies we need not mention, as in fact our author’s are
entirely borrowed from him. Oribasius, Aëtius, Actuarius, and Nonnus,
in like manner, borrow from him everything which they advance upon this
subject.

Celsus does not treat of phlegmon in particular, but he has given
an excellent account of inflammation in general. His definition of
inflammation is singularly appropriate: “Notæ inflammationis sunt
quatuor, rubor, et tumor, cum calore et dolore.” Isidorus attempts the
same not so successfully: “Phlegmone est fervor cum extensione et dolore;
sive est inquietudo cum rubore, et dolore, et extensione, et duritie, et
vastitate: quæ quum cæperit fieri, inquietudo et febris insequitur.”

Avicenna gives a clear and comprehensive exposition of the doctrines of
the Greeks, but supplies no new information. He is at pains to explain
that the term phlegmon applies generally to every inflamed part; and also
to a hot aposteme in particular. He joins Galen in recommending a free
incision when it is apprehended that the member in which it is seated
will become corrupted. Serapion’s treatment is nowise dissimilar. A
phlegmon, says Haly Abbas, is a sanguineous collection, arising either
from an external cause, such as a bruise, a blow, a wound, or the
like, or from an internal cause, namely, a defluxion upon the part. He
attributes the collection which takes place in a part to its debility,
which makes it unable to cast off the load which is thrown upon it.
When seated in a vascular part, phlegmon, he says, is attended with a
throbbing pain. He approves of free and bold incisions. Alsaharavius
treats of phlegmon at great length, but there is nothing original in his
views. Rhases recommends at first bleeding, purging, and applications
of a cooling and astringent nature. But when suppuration has commenced
he properly forbids depletion, lest it only protract this process. He
remarks that phlegmons are often occasioned by disorder of the stomach,
and the use of too much food and drink. He recommends in general
maturative applications, to which, if necessary, narcotics may be added.


SECT. XVIII.—ON EXTERNAL ABSCESSES.

If it appear to you impossible to prevent suppuration, boil bread in
water and oil, and apply it as a cataplasm; or apply barley flour
prepared in like manner; and bathe the part with an infusion of
marshmallows. But when the swelling is difficult, either to convert into
pus or to dissipate, you may use a cataplasm of dried figs. But sweet
and fat figs are to be dissolved by boiling in water, and made like thin
honey, and barley flour added to it. And if the swelling is resolved
but imperfectly, you may boil with the figs hyssop or marjoram; or, if
you wish to increase its strength, add salts to the decoction. But you
must attend that the part be not dried too much, for thus will it be
rendered hard. If you perceive any such thing, you must boil with the
water the root of wild cucumber, or of marshmallows, or of bryony. But
the root of the dracunculus is stronger than these and more discutient;
and the medicine formed from the dracunculus itself is very discutient.
Sometimes, therefore, you may apply decoctions of these things alone; but
at other times you may add dried figs, and mix polenta with fat. And the
oil of dill is discutient, and adapted for concocting crude humours, and
unconcocted swellings. And pitch, more especially the liquid, concocts
all hard and unconcocted swellings, when added to the cataplasms. A
compound medicine for procuring the discharge of the concocted matter
of abscesses, so that often the pus is found on the pledget; and for
thoroughly discussing what is not concocted: of pyrites, of levigated
ammoniac, of each, dr. xij; of the flour of beans, dr. vj; add to liquid
pitch, and spread upon skin, and apply. But do not take away the pledget
until it fall off spontaneously. The medicine must not be prepared long
beforehand, as it soon becomes dry. When the tumour is no wise dissipated
by these means, and matter falls into it, it is to be opened, and the
matter evacuated, taking care not to apply to it water or oil; or, if
it be necessary to clean the sore, it must be done with honied water,
oxycrate, wine, and wine and honey; and if it become inflamed, the
cataplasm of lentils is to be applied; but if it is not inflamed, we may
use some of the plasters to such openings, more especially that from
chalcitis; but apply to them sponge or wool soaked in austere wine. But
to the wound itself, do not apply any of the oily ointments, such as the
tetrapharmacon, for it stands much in need of being dried.

_Those things which open abscesses._ Since some persons will not endure
to have abscesses opened with iron, we must endeavour to have recourse to
epispastic medicines. Having triturated the root of narcissus in honied
water, boil it with oil of iris, and apply; or, having triturated the
tender root of calamus, and if it be hard, boil it in honied water, and
apply; or, use a cataplasm of birthwort and honey. But equal parts of dry
pitch and Cretan bee-glue, produce the rupture of abscesses and promote
cicatrization.

_The Dionysian plaster, a wonderful epispastic application for abscesses,
to the breasts and to buboes, dissipating by the insensible pores._
Of old oil, of water, of each, lb. j; having boiled the oil and water
for a little time, add of aphronitrum, oz. vj; of misy, oz. j or ij;
and boil until it does not stain the finger; then add of the manna of
frankincense, of wax, of turpentine, of each, oz. vj.

_For abscesses of the nervous parts._ Of wax, of colophonian rosin, of
butter, of each, lb. j; of dry pitch, of honey, of each, lb. ij, oz. vj;
of verdigris, oz. iij; of bird lime, q. s.—_Another_, an epispastic:
Of ammoniac perfume, oz. vj; of wax, of turpentine, of each, oz. iv; of
sulphur vivum, oz. iij; of natron, oz. iij; and the application called
smilium, and that from garlic are strongly calculated to promote the
breaking of abscesses already formed. But that which consists of the
juice of linseed dissipates, changes, and bursts abscesses most aptly.
For the milder sorts of abscesses, those also which were mentioned for
parotis will apply. These observations apply to an abscess following
phlegmon. But, Galen says, that an abscess will sometimes take place
without being preceded by inflammation, in which case, it has its
origin from good blood. For at the commencement, he says, owing to some
humour, excoriation takes place, and in process of time, the containing
parts are separated from those below. And, therefore, when opened, they
appear to contain within them all kinds of fluid and solid bodies.
For, bodies resembling dung, urine, thrombus, a honey or mucus-like
humour, bones, nails, and hairs, have been found in abscesses. And even
animals have been found very like to those which derive their origin
from putrefaction. Nay, they affirm that, more particularly in chronic
abscesses from metastasis, bodies have been formed resembling stones,
sand, shells, wood, coals, clay, the sordes of the oil of baths, the
lees of oil, and the lees of wine. Wherefore, we shall now give a
succinct account of abscesses, more especially such as are seated in the
external parts of the body, and those which do not admit of resolution
by medicines. An abscess, then, is a corruption and change of the flesh
or fleshy parts, such as muscles, veins, and arteries. Of them, some are
contained in a cyst, as atheroma, steatoma, and meliceris, and others are
formed without a cyst, and are properly called by the generic name, and
of them we have now to treat. The formation of an abscess then is most
commonly preceded by inflammation, as we have stated, but sometimes it
arises at once originally, as we have just now mentioned. An abscess,
then, is attended with strong heat of the place, the swelling becomes
greater and more red than formerly, and is hard, with a pungent pain,
throbbing, and weight, so that it seems as if something were suspended
from the part. And if the part be a vital one, fever supervenes with
irregular rigors, and the pain and fever are greatest at night. Sometimes
too a bubo is formed in the neighbouring glands. When the abscess is
fairly formed, the most of these symptoms are diminished, the pungent
pain becomes itchy and somewhat dull, the swelling is more sharpened into
an acute point, is soft and yielding to the touch, and the skin at the
top is separated; I speak with regard to those that burst externally. If
therefore, it has burst spontaneously, or from medicines, it is to be
cured by means of pledgets spread with ointment, the pus being evacuated
by degrees; but if not, it is to be opened in the manner to be described
in the surgical part of the work.

       *       *       *       *       *

COMMENTARY. All the writers referred to in the last Chapter may be
consulted on the treatment of abscesses. See especially Aëtius. He
recommends when suppuration is not taking place properly to apply barley
meal, or bread boiled in the decoction of figs, to which if necessary
may be added nitre, turpentine, or the like. When suppuration takes
place, the abscess is to be opened where the skin is thinnest. (See
Book 6.) The incision is to be made long and narrow, and if any putrid
substance appear it is to be cut out. The opening is to be sprinkled
with frankincense and suitable pledgets applied. When the neighbouring
parts are inflamed a cataplasm will be the most proper application. When
the ulcer is foul, turpentine and honey will serve for cleaning it; or
applications containing verdigris may be used for the same purpose. After
the ulcer is cleaned, first incarnants and afterwards incrassants are to
be applied. For producing rupture of the abscess, he recommends various
applications, such as ammoniac, and nitre triturated with vinegar, and
the like. This account, however, is mostly taken from Galen.

The treatment recommended by Celsus is nearly the same in principle.
At first if the part be soft he recommends applications of a repellent
and cooling nature: but if it is hard he directs us to use applications
which digest and produce resolution, such as dried figs pounded. To
such applications may be added equal proportions of ammoniac, galbanum,
bees-glue, and birdlime, with somewhat less than one half of myrrh. The
plasters and malagmata for this purpose are likewise to be applied. When
these applications do not produce resolution, we must conclude, he says,
that the abscess will ripen. The symptoms of an unripe abscess are
strong motion of the arteries, weight, distension, pain, redness, and
hardness; to which are to be added horror and fever if the abscess be
large. When there is a remission of these symptoms, and the part becomes
itchy, and somewhat livid or white, the suppuration is ripe, and the
matter is to be let out by medicines or iron. Unless the opening be large
he properly forbids tents or pledgets to be put into it. When these are
used, however, lentils and honey, or pomegranate rind boiled in wine are
to be applied over them. Whatever is applied must not be tightly bound.

The Arabians mention a variety of applications for producing the rupture
of abscesses. (See in particular Avicenna and Rhases.) Thus, they
recommend a plaster consisting of cantharides and old oil. Some of their
applications contain nitre, quicklime, and arsenic. Such a composition,
by producing a slough, would no doubt effect the purpose for which it
was intended. Haly Abbas recommends a poultice made of leaven, boiled
figs, and the seeds of rosemary. He speaks of onions as an application to
indolent abscesses. Alsaharavius treats of abscesses at great length.

By abscesses of the nervous parts it will be readily understood that
our author does not mean that they are seated in what are now properly
called nerves, but in tendinous and membranous parts, for all these were
comprehended under the name of nerves by the older writers, namely,
Hippocrates, Plato, and Aristotle. Galen pointed out clearly the
distinction between these parts, but the term is often used in its old
and popular acceptation by the writers subsequent to him.

The account which our author gives of deep-seated abscesses is highly
interesting, but is mostly borrowed from Galen (ad Glauc. ii.) Rhases,
in his ‘Continens’ (xxvii), gives an interesting outline of the opinions
of all preceding authorities, with some ingenious observations of his
own. When there is any hope of producing resolution he approves of
scarifications. When the pain is violent he recommends hot and humid
applications with the addition of narcotics. After the abscess has
been opened with the knife, he says that desiccative applications are
indicated, and not ointments containing wax or oil. He describes the
leaven cataplasm, and others of a similar nature. He gives Antyllus’
directions for opening abscesses. Abscesses in the limbs are to be
opened by a straight incision, but those about the ancles by a circular,
as they are apt to terminate in fistulæ. He recommends it to be made
at the lower part of the abscess, but mentions that Galen prefers the
thinnest part.


SECT. XIX.—ON GANGRENE AND SPHACELUS.

When the inflammation is neither resolved nor converted into pus, it
often passes into gangrene and sphacelus, of which we shall now treat.
Wherefore, we give the name of gangrene to mortifications arising from
the violence of the inflammation, when they are not yet formed but
forming; and if such a state is not speedily cured, the affected part
readily dies, and the disease seizing upon the surrounding parts, kills
the person. But when the parts thus affected become totally insensible,
the affection is no longer called gangrene, but sphacelus. This affection
happens also to the bones when the flesh that surrounds them engendering
noxious humours impregnates the bones therewith, and causes them to
putrefy. When, therefore, the part is completely mortified, it must be
speedily cut away, where it joins the sound part. Gangrene is to be cured
by evacuating as much as possible of the blood in the affected part; and
we may either procure the discharge of the corrupted blood by opening a
vein, when the vein of the part is large, or we may divide the whole skin
by many and deep incisions, so that the blood may be permitted to escape;
and we may apply some of the medicines suitable to mortifications. These
are, the flour of tares, or of darnels, or of beans with oxymel. When
wishing to apply stronger ones we may add salts, or use the trochisk of
Andron, or the like. Old walnuts are good applications for gangrene.
The nettle also cleans them, and the juice of spurge, when applied in
season and in proper quantity. The decoction of bitter lupines, poured on
the part, is also beneficial. Some after the incision, for the sake of
security, apply the cautery, in which cases we must use salt with leeks:
afterwards, in order to remove the eschar, we may apply a cataplasm of
bread, or of barley, or of wheaten flour boiled in water and oil; or the
dry cephalic powder with honey, and the tetrapharmacon; and that called
the Macedonian may be used. The eschars may be properly removed by bread
triturated with parsley, or basil, or by iris, panacea, or birthwort, or
by the sweet-flag with honey, or by frankincense. And the medicine of
Machærion takes away the eschars in a proper manner, and the iris spread
upon pledgets with honey; but in soft bodies the flour of tares, with
honey, is sufficient.

_From the works of Oribasius, for gangrene._ Of scraped verdigris, of
vermilion, of stone alum, equal parts; triturate in water and anoint. The
flour of darnel, with radish and salts, and sometimes with vinegar, will,
when applied as a cataplasm, be proper for the scarified parts; also
dried grapes deprived of their stones with the bark, and with salts and
oxymel; the inner parts of walnuts, and myrtle leaves boiled in wine and
triturated with honey. Radish, with vinegar, breaks the eschars even to
the bone.

       *       *       *       *       *

COMMENTARY. See the authors referred to in the 17th Section.

Paulus copies freely from Oribasius (Synops. vii, 27.) Upon comparing
Oribasius with our author we have ventured to give an interpretation of
the last sentence not justified by the text as it now stands, and at
variance with the translation of Cornarius. Oribasius does not say that
the flour of darnel will scarify the parts (how could he?) but that it
will be a proper application after the parts are scarified.

Galen (ad Glauc. and Comment. in Hippocr. App. vii. 50,) is the great
ancient authority on mortification, and from him Oribasius, Aëtius,
Paulus, and all the subsequent writers on this subject have copied. He
lays it down as the great rule of treatment, to evacuate the blood which
is impacted in the part and prevents the diastole of the arteries. To
accomplish this end he directs free incisions to be made, after which the
actual cautery is to be applied, at the line of separation between the
sound and diseased parts.

Celsus is a strong advocate for this practice, which has been revived
lately and is much used in France. (See Encyclopédie Méthiodique, art.
Gangrène, and Cross’s Sketches of the Medical Schools in Paris.) He
states, however, that when the disease goes on spreading, amputation
of the mortified limb is the “auxilium unicum.” At the commencement he
approves of venesection, if the strength permit, and of a restricted
diet; and, afterwards, astringent food and drink are to be given. He also
recommends, for gangrene, applications containing arsenic, quicklime,
chalcitis, and the like (v, 22.)

The practice of the Arabians is little or nothing different from that
of the Greeks. Avicenna at the commencement approves of Armenian bole
and terra sigillata with vinegar; but if these have not the effect he
directs us to empty the part by scarifications, leeches, or opening the
veins which lead to it. He then recommends us to apply the flour of
beans and the other remedies mentioned by the Greeks. When the disease
proceeds, free incisions and the actual cautery must be had recourse to.
Alsaharavius recommends us to bleed at first, if the strength permit;
then to use powerful caustics and escharotics such as arsenic, quicklime,
and sublimed quicksilver; or if these do not succeed, the actual cautery.
He approves of early incisions, and of amputation, if the mortification
spread. He describes a species of gangrene which seizes the hand and
spreads upwards; and relates a case of it in which he refused to amputate
for fear of hemorrhage. The same case is related by Albucasis, which
certainly amounts to a strong presumptive proof that Alsaharavius was the
same person as Albucasis. Rhases inculcates in the strongest terms that
when an inflammation threatens to terminate in mortification, it is to be
treated by scarifications, stimulant applications, and the cautery.

The earlier modern surgeons followed the ancient practice of applying the
cautery in cases of gangrene.


SECT. XX.—ON HERPES.

When yellow bile, unmixed with any other humour is fixed in a part, the
affection is called herpes: but if it is thicker and rather acrid it
ulcerates the whole skin as far as the subjacent flesh, and is called
herpes exedens; but if it is thin, less acrid and hot, it raises small
blisters on the surface of the skin like millet-seeds, and hence has been
called herpes miliaris. According to Oribasius, a mixture of phlegm, with
yellow bile, produces the herpes miliaris. Wherefore we may evacuate the
whole body with cholagogue medicines, and apply cooling and desiccant
things to the affected part. At the commencement, therefore, we may apply
cataplasms from vine shoots, bramble, and plantain; but afterwards we may
add lentil to them, sometimes with honey and polenta. And the cataplasm
recommended for phlegmons from defluxion may be applied without the
house-leek. But ulcerated parts are to be rubbed with trochisks dissolved
in must, or in a thin and austere wine, not very old, or in a watery
oxycrate. Administer also horned poppy, and similar things in water;
and when these do not prove effectual, vinegar may be added. But wine
diluted with the juice of plantain or strychnos is of great service, or
linseed bruised and boiled in wine and oil may be applied; or Cimolian
earth, mixed with the juice of strychnos may be applied by anointing: and
take of litharge, oz. iv; of the juice of leeks, vij cyathi, and of the
juice of beet an equal quantity, triturate and anoint. But when these
ulcers have become chronic, the trochisk of Musa and that of Andron will
be convenient applications.—_Another_: For herpes phlyctænodes: having
triturated the dross of lead in austere wine and anointed with it, apply
above it beet leaves boiled in wine, or of wax, oz. iv; of myrtle oil,
oz. xvj; of the dross of lead, oz. iv; anoint with one half of wine. When
it has stopped from spreading, use the cerate from the dross; or apply
boiled lentil with honey. For herpes, under the skin, mix the dross of
lead with the juice of levigated rue, or myrtle cerate, instead of the
rue.—_Another_: Of old unwashed wool wrapped round a dead pine and burnt,
dr. xij ss; of wax, dr. xxv; of the dross of lead half an acetabulum; of
goat’s tallow cured and washed in water, dr. xxxj; of myrtle oil, oz.
v.—_Another_: To those which spread rapidly: of the rind of the sweet
pomegranate, dr. vj; of litharge, dr. vj; of unwashed wool about a dead
pine and burnt, dr. iij; of wax, dr. xij; of ceruse, dr. viij; of fissile
alum, dr. j; add to wine and myrtle oil.

       *       *       *       *       *

COMMENTARY. The writers on phlegmon treat immediately afterwards of
herpes and erysipelas. Fabricius ab Aquapendente, Dr. Bateman, and most
of our modern authorities on this subject, are of opinion that the _ignis
sacer_ of Celsus and the other Latin authors was herpes. Scribonius
Largus, however, distinguishes the ignis sacer from zona, which, he says,
was called herpes by the Greeks. The ignis sacer of Octavius Horatianus
likewise appears to be erysipelas. And Isidorus states decidedly that the
ignis sacer was erysipelas:—“Erysipelas est quam Latini _sacrum ignem_
appellant, id est, _execrandum_, per antiphrasin. Siquidem in superficie
rubore flammeo cutes rubescunt. Tunc mutuo rubore quasi ab igne vicina
invaduntur loca ita est etiam febris excitatur.” (See a learned
dissertation on the ignus sacer in Burman’s edition of Serenus Samonicus,
‘Poet. Latini Minores.’ ii, 335.) Having thus stated the doubts which
prevail respecting the ignis sacer of the ancients, we shall return to
Celsus’s account of it, which certainly, as already mentioned, seems to
apply to herpes. He describes two varieties of it. The first is reddish,
or a mixture of redness and paleness, and in it the skin is covered with
a great number of small pustules. The disease spreads, the part first
affected either healing, or becoming ulcerated from the rupture of the
pustules and discharging a humour intermediate between sanies and pus.
The breast and sides are mentioned as being frequently the seat of this
complaint, and hence Bateman concludes that it is the herpes zoster. The
second variety is described as consisting of a superficial ulceration of
the skin, broad, somewhat livid, but unequal; the middle part healing as
the extremities spread, and the part about to become affected becoming
swelled, hard, and of a colour compounded of black and red. It affects
principally old and cachectic persons, especially their legs. We cannot
understand what could have led Dr. Bateman to think that this is the same
as the herpes circinatus of his arrangement. Rayer rather supposes it
to be the _dartre squameuse centrifuge_ Alibert. His general treatment
consists of abstinence, opening the belly, food intermediate between the
glutinous and saltish, and if there is no fever, exercise, austere wine,
and the like. The ulcers (vesicles?) are to be washed with hot water, or,
if they spread, with hot wine; they are then to be opened with a needle,
and dressed with applications for eating away putrid flesh. When the sore
is cleaned, gentle applications are to be used.

For the zona or herpes, Scribonius Largus recommends applications
containing alum, galls, chalcitis, misy, quicklime, &c.

Pollux defines herpes to be inflammatory and pungent pustules, which
spread most commonly about the neck, but sometimes affect also the hands
and feet.

Galen gives a very full account of the nature and treatment of herpes.
According to him the complaint arises from yellow bile separated from
the blood and fixed in a part. When it is thickish it ulcerates the
skin down to the bone, and forms the disease called by Hippocrates
_herpes exedens_. But if thinner, it only burns as it were the surface,
when it is called by the generic term of herpes. Of the other two
varieties, the one, as has been said, is called _exedens_, and the other
_miliaris_, because it is attended with many small bullæ (phlyctænæ)
like millet-seeds. As our author’s treatment is entirely derived from
him we shall not enter into any detailed exposition of his practice.
We may mention, however, that he decidedly recommends purgatives for
proper herpes. When the ulceration is of a malignant nature and attended
with putridity it requires the most acrid medicines, and such as in
power resemble fire, namely, misy, chalcitis, arsenic, quicklime, and
sandarach. For, he adds, these medicines burn like fire, and often when
they fail, we must have recourse to fire itself.

Aëtius gives an accurate account of herpes, but it is professedly
borrowed from Galen. Like him he divides the disease into three
varieties, the herpes proprius, the herpes exedens, and the herpes
miliaris, the last being characterized by an eruption of vesicles
(phlyctænæ). We shall here notice what Dr. Bateman says respecting
this division of herpes:—“The ancient division of herpes into three
varieties, miliary (κεγχρίας), vesicular (φλυκταινώδης), and eroding
(ἐσθιόμενος), may be properly discarded, for there appears to be no
essential difference between the first two, which differ only in respect
to the size of the vesicles.” This is evidently an incorrect account of
the ancient division, in which no distinction was made between the herpes
miliaris and the herpes phlyctænodes.

Palladius makes mention of only two varieties of the disease, namely, the
proper, and the eroding herpes. (De Febribus 2.)

Leo briefly refers to Galen’s account of the disease (vii, 3.)

Actuarius mentions only the proper herpes, and the herpes miliaris. This
is, perhaps the best division of any, as the herpes exedens is evidently
a disease of a very different nature from the other varieties.

The Pseudo-Dioscorides recommends strong stimulant applications
containing sori, misy, sulphur, onions, &c.

Avicenna seems to confound herpes with myrmecia, which detracts from the
value of his account of it. (iv, 3, 1, 7.)

Rhases describes separately the formica miliaris or herpes miliaris,
and the herpes esthiomenos or exedens. For the former he recommends
astringent applications, for the latter strong caustics. In his
‘Continens’ he directs the herpes miliaris to be treated with cholagogues
and astringent applications.

Serapion in like manner describes two varieties of the disease, but his
account of it contains nothing particularly interesting.

Haly Abbas adopts the division laid down by Galen (Theor. viii, 10.) His
treatment also is quite similar (Pract. iii, 29.)

In the translation of Alsaharavius the three varieties are described by
the names of formica or erysipelas muscina, formica corrosiva (herpes
exedens?), and formica miliaris. He describes the formica corrosiva as
being a dangerous complaint, spreading deeper and deeper. His treatment,
although amply detailed, contains nothing remarkable (Pract. xxix, 9.)

The earlier modern writers on medicine being the servile copyists of the
Arabians, describe herpes by the name of formica, as a disease nearly
allied to erysipelas, and like it arising from corrupted bile. See Guy of
Cauliac (ii, 1), and Theoderic (iii, 16). For the herpes esthiomenos or
lupus they recommend the application of arsenic or the actual cautery.


SECT. XXI.—FOR ERYSIPELAS.

Galen, giving the name of erysipelas, more especially to the swelling
formed of a hot and thin blood, to that which is formed of both blood
and bile, he applies an appellation from the prevailing humour, calling
it erysipelatous inflammation when blood prevails, and inflammatory
erysipelas when yellow bile prevails. But in general the swelling formed
of hot blood and bile is called by him erysipelas. Whatever division
we adopt, it will make no great difference as to the treatment. But it
is proper to know that erysipelas is a most dangerous disease, more
particularly about the head; so that if active treatment be not resorted
to, it will sometimes prove fatal to the patients by suffocation. At
its first appearance then we must open a vein at the elbow, especially
the humeral, or, if it cannot be seen, any one that appears. But if
any thing prohibit venesection we must have recourse to purging by
cholagogue medicines. The same treatment may be applied to erysipelas
of other parts, or we may administer strong clysters. And we are to rub
the parts affected by erysipelas with cooling things, in order to repel
the defluxion, and with moderately heating and moistening things so as
to dissipate that which is collected, before the parts become livid
or black; but the parts which are anointed are to be kept constantly
in a wet state, by frequently changing the applications, which may
be done by cleansing them with soaked sponges: for the heat of the
part by converting them into vapour soon renders it dry. As I have
said, erysipelas at the beginning requires such things as are cooling
and moistening, without astringency; such as house-leek, purslain,
and fleawort; the marsh lentil, endive, and gourd; the nightshade,
henbane, lettuce, and horned poppy. And parsley, and the leaves of
rhamnus by themselves, and made into a cataplasm with bread, are proper
applications; also cerates used with very cold water; but we may mix with
them some opium, the juice of poppy, cicuta, and mandragora, and thus
form them into compound applications. And a cerate may be made of white
wax mixed with four parts of rose-oil, prepared from the oil of unripe
olives without salts, the ingredients being pounded in a mortar, and as
much cold water poured in as it can receive. But if you add a little
thin and transparent vinegar, you will render the medicine still better:
but polenta, with some of the aforementioned cooling herbs, cool very
properly, and fat dates with any of them. And the part may be anointed
with ceruse, Cimolian, or potter’s earth, with the juice of strychnos, or
litharge with rose-oil, or chalcitis with oil and must; or ceruse, with
vinegar and buckthorn; or acacia, with vinegar. When the effervescence
subsides we may use these simple applications, native sulphur and mint,
with vinegar and rose-oil; or rue with worm-wood; vinegar and oil, or
litharge with the juice of leeks and beet; or compound ones, as this
trochisk, more especially to the head: of litharge, of ceruse, of
saffron, of native sulphur, of opium with must; and in common, for all
parts, of Sinopic vermilion, of chalcitis, of roasted misy, of verdigris,
of copperas, of fissile alum equal parts, use with vinegar.—_Another_:
Of native sulphur, of ceruse, of opium, of acacia equal parts; use with
vinegar. A cataplasm for erysipelas, herpes, abscess, parotis, and
burning: of the tender leaves of fresh marsh-mallows, lb. j; having
boiled in water and oil, triturate properly, and adding of rose-oil,
oz. iv; of litharge, of ceruse, of each, oz. iiss; triturate again with
the juice of coriander, or of house-leek, or of strychnos, then adding
crumbs of bread so as to form a plaster, apply it. And use this plaster:
of oleum cicinum, i. e. castor-oil, lb. j; of oil of myrrh, lb. j; of
wax, oz. v; of litharge, oz. iv; of scraped verdigris, oz. ij; the
verdigris and litharge are to be triturated with vinegar. A cerate for
erysipelas and burns: of white wax, oz. iv; of rose-oil, oz. iij; six
eggs, of pellitory of the wall, oz. iv. When the inflammation ceases or
becomes chronic, before the part becomes livid, apply a cataplasm of raw
barley-meal; but if it has already become livid, incisions must be made
in the part, and cataplasms moreover applied, and hot sweet water poured
on it, and sometimes sea-water or brine; and sometimes these ingredients
are to be mixed with the cataplasm, and then we must use the aforesaid
compound medicines with caution: for should these symptoms continue, a
transition to suppuration or mortification takes place.

       *       *       *       *       *

COMMENTARY. Hippocrates in his ‘Prognostics’ has stated the danger of
an erysipelas being translated to an internal part. He also states that
gangrene supervening upon erysipelas is dangerous. He has not, however,
given any very particular account of the disease. In one of his aphorisms
he states that cold is useful in erysipelas when not ulcerated, but
prejudicial when it is ulcerated. His commentators, Theophilus and
Damascius, confirm this statement. (Scholia in Hip. et Galen, ii, 456).

Celsus recommends bleeding if the strength permit, and then repellent and
refrigerant applications, especially ceruse with the juice of solanum
(nightshade), or Cimolian earth with river water, and the like. When
refrigerants fail to produce the effect, sulphur, ceruse, and saffron are
to be pounded with wine and applied. If the part become putrid he directs
us to use corrosive applications or the actual cautery. Afterwards the
sore is to be cleansed with honey and rosin, and treated upon general
principles.

We have stated in the preceding Section that the ignis sacer of
Scribonius Largus is not herpes. That it was erysipelas seems probable
from the similarity between his applications for it and those which
Celsus and the other authorities recommend for erysipelas. Thus for ignis
sacer he recommends Cimolian chalk, diluted with the juice of solanum,
or the solanum by itself, or with bread; or a mixture of sulphur vivum,
ceruse, and litharge.

We may remark further in this place that the _ignis sacer_, or St.
Anthony’s fire of the middle ages, would appear to have been some variety
of erysipelas.

Galen’s account of erysipelas is particularly deserving of attention. In
the 14th Book of his ‘Meth. Med.,’ he is at pains to state the nature
of the disease, and the difference between it and phlegmon. The common
symptoms of both are heat and swelling. But they differ, first and
principally in colour, which is red in phlegmon, but pale or yellow, or
a compound of both, in erysipelas. Throbbing is also a characteristic
symptom of a great phlegmon, for it is deep-seated, whereas erysipelas is
rather in the skin. Erysipelas, he pointedly inculcates, is occasioned
by a bilious humour. This humour being thin, readily passes the fleshy
and rare parts, and flows to the skin, where, unless it be particularly
watery, it is unable to pass the pores, and, consequently, is retained.
When things, indeed, are in their natural state, this bitter bile passes
through the pores of the skin by the insensible perspiration, but when
it is either too abundant or thicker than usual, it is retained by
the skin, which it inflames and causes to swell: hence the reason why
erysipelas chiefly affects the skin or the prolongation of it which
lines the internal cavities. He states that the great indication of
cure is refrigeration or cooling, but that there is danger of carrying
this plan too far, lest the humour should be driven to some vital part:
wherefore cooling applications are to be used until the part change its
colour, but are not to be continued until it become black or livid. It is
necessary, therefore, as soon as a change of colour in the affected part
is remarked, to exchange them for those of a contrary nature. His cooling
applications consist of strychnos (solanum?) and the other articles
mentioned by our author. When the part becomes livid, he directs us to
make incisions, and afterwards to apply cataplasms and fomentations with
hot water, to which salt or vinegar may sometimes be added. It is only
at this time that quicklime may safely be added to the applications;
for it would prove highly prejudicial at first. With respect to the
general treatment, he approves strongly of cholagogues, but does not
think bleeding necessary in ordinary cases. When erysipelas arises from
ulcers or any obvious causes, he recommends scarifications and cataplasms
of barley flour. He recommends much the same plan of treatment in his
‘Therapeut. ad Glauc.’ ii. He speaks highly of early incisions.

Aëtius, as he professes, merely copies from Galen.

Oribasius recommends, at first, such things as are cooling without
astringency; namely, henbane, nightshade, &c. When the inflammation
subsides, he directs us, before the part becomes livid, to apply a
cataplasm of barley flour; but when it does become livid, he recommends
free incisions, and afterwards cataplasms and fomentations with fresh
water, or water with salt and brine.

Actuarius states the danger of carrying refrigerant and repellent
applications too far, and recommends something discutient to be added to
them.

Octavius Horatianus approves of bleeding (unless contra-indicated by
the want of strength), and of cholagogues, with free incisions and
fomentations.

Avicenna states that bleeding in general does no good, unless the humour
be seated between the two skins. He approves most of cholagogues and of
applications strongly refrigerant; only he cautions us not to carry this
plan too far, lest the disease be determined to an internal part, or
terminate in gangrene.

Serapion treats of the disease very accurately by the name of _al
massire_, but in nearly the same terms as Galen. He approves decidedly
of cooling and repellent applications at the commencement. Serapion and
Avicenna notice the eruption of bullæ in erysipelas.

Haly Abbas directs us, when erysipelas is not attended with swelling, to
use cooling and repellent applications to the part, and to administer
gentle cholagogues, such as myrobalans, tamarinds, and prunes. But
if swelling be present, and if there is nothing to contra-indicate
venesection, he recommends us to bleed and apply cataplasms.

Alsaharavius describes three varieties of erysipelas; namely, the
erysipelas properly so called, the ignis Persicus, and the erysipelas
inflativa. The first variety, he says, is attended solely with redness
of the cuticle. It is to be treated by bleeding, purging, and local
applications of a cooling and humid nature. In the ignis Persicus, the
heat and redness are strong, and black blisters rise on the part. It is
to be treated by bleeding at the commencement, and scarifications. The
erysipelas inflativa arises with a sudden swelling, and blisters, like
those produced by fire. It is to be treated by bleeding and cooling
applications, containing ceruse, litharge, &c. The _ignis Persicus_ would
appear to have been some variety of anthrax, or the malignant pustule.

None of the ancient authorities express themselves so decidedly favorable
to bleeding as Rhases. Like the others, he attributes it to heated bile.
He, and most of the authors quoted by him in his ‘Continens,’ approve of
cooling applications, but he cautions against carrying this practice too
far. He remarks that vesicles like those from burning often arise on the
part.

Fabricius ab Aquapendente is a strong advocate for the ancient theory,
of which he gives a full explanation. The system, he says, being loaded
with vitiated bile, the more important organs cast it off: it is,
therefore, sent outwardly, and is detained by the cuticle when its pores
are obstructed. He attempts to reconcile the contrary opinions of the
ancients with regard to venesection. He himself approves decidedly of
bleeding when the disease is seated in the head or neck.

None of the ancient authorities seem to have entertained the same
apprehensions as most of the moderns do against liquid applications in
cases of erysipelas. When this prejudice became general we do not exactly
know. Heister mentions that, in his days, some surgeons disapproved
of liquid applications, but, as he thought, without any good reason.
He himself recommends camphorated spirit of wine. The earlier modern
surgeons, as, for example, Brunus and Theodoricus, decidedly recommend
cold applications at the commencement. When the disease is not thereby
resolved, they direct us to have recourse to leeches and scarifications.
They approve much of cholagogue purgatives, but do not recommend bleeding
unless inflammatory symptoms run high.


SECT. XXII.—ON PHYMA, BUBO, AND PHYGETHLON.

According to Galen, phyma, bubo, and phygethlon, are affections of
the glands: bubo being an inflammation of a gland; phygethlon, an
inflammatory erysipelas, or an erysipelatous inflammation of a gland;
and phyma, an inflammation of a gland passing rapidly into suppuration.
But, according to others, all tumours of the nature of apostemes, which
arise in any part of the body, are called phymata. For Hippocrates says,
“Those in whose urethra phymata form are relieved when they suppurate and
burst.” Wherefore those buboes which are occasioned by accidents, either
ulcers or pains, are not dangerous; but those which occur in fevers, more
especially in the pestilential, are of a very bad description, whether
they are formed in the groins, the armpits, or neck. But those of the
first kind, as is the case in every other inflammation, we must endeavour
to put back with cooling and astringent applications, either applying
a sponge out of oxycrate, or wool out of wine and raw oil, or oil of
roses, or oil of apples, or oil of lentisk, or oil of myrtles; and then
we are to apply diaphoretics. But if the whole body is plethoric, it is
to be evacuated. If free from superfluities, we must manage the ulcer
arising from it in the manner to be described when treating of ulcers.
When the gland is in a state of inflammation, it is to be mitigated by
wool soaked in some of the emollient oils, and the whole limb is to be
wrapped therewith. When the tumour has suppurated, we must not be in
haste to open it, but endeavour to dissipate it by the medicines in the
form of cerates, such as that prepared from apyranon, and that from
herbs called botanica. When resolution is not thereby accomplished,
we must forward the rupture as in the other abscesses, and cure it in
like manner as them. In those buboes which arise in fevers or from a
collection of humours, we must abstain from all repellents, lest the
matter should be repelled and regurgitate to the deep-seated parts; but
we must begin at once with discutients. When nothing prohibits, such as
the age or strength of the patient, venesection from the arm is to be
had recourse to, and fomentations applied to the part, either from the
decoction of camomile, or of dill, or of some such; but the materials
of the other applications may be transferred from our account, in the
Third Book, concerning parotis, and from what has been lately delivered,
more especially respecting phlegmons. And in like manner the cure of
phygethlon may be learned from what has been stated respecting them and
erysipelas. But the herb aster atticus, which, on this account, they call
bubonium, not only in the form of a cataplasm, but also when bound round
the part as an amulet, is believed to be of use for buboes. Phymata may
be discussed by the following applications in particular: maiden-hair;
orache; pellitory of the wall; the root of marsh-mallows, boiled in wine;
ammoniac, softened with honey, and applied; birdlime, with the rosin
cerate. But bee-glue, bitter lupins applied with vinegar, the root of the
wild cucumber added to turpentine, and in like manner root of capers, and
nitre with leaven, or figs, promote the rupture of these tumours.

       *       *       *       *       *

COMMENTARY. The account here given of these glandular inflammations is
taken from Galen (ad Glauc. ii.) See also ‘de Tumoribus’ and ‘Comment. in
Hippocrat. Epid.’ vi.

Celsus describes phyma as resembling furunculus, but as being larger,
and turning to pus. According to Rayer, his description of phyma applies
better to the boil than his account of anthrax. (Malad. de la Peau, p.
229.) The phygethlon, he says, is a tumour not high, but broad, and
containing something resembling a pustule. It occurs mostly in the
armpits, neck, or groins. He proposes applications of a repellent and
refrigerant nature; but if the swelling is hard, digestives must be
had recourse to, such as dried figs bruised, &c. He also recommends a
composition of sal ammoniac, galbanum, bee-glue, and mistletoe, with a
small proportion of myrrh. His treatment is considerably different from
our author’s. When matter is formed, he directs us to let it out by
medicines or the lancet, but he decidedly forbids the use of cerates. In
another place, however, he recommends an application containing lime,
spuma nitri, round pepper, galbanum, and salt mixed with rose cerate.

Scribonius Largus recommends a malagma containing pitch, aphronitum,
pine-rosin, wax, bay-berries, axunge, ammoniac, Illyrian iris, galbanum,
and white pepper, for discussing phygethlon.

Oribasius and Actuarius mark the distinction between these affections
in the same terms as Galen, and direct us to treat them with emollient,
concoctive, and discutient applications. For concocting phymata, the
Pseudo-Dioscorides recommends southernwood, boiled with raw barley
flour; figs, boiled with yeast, &c.; and for breaking them, the juice of
thapsia, with sulphur; cantharides, mixed with turpentine, &c. (Euporist,
i, 156.)

Nonnus’ account is mostly abridged from our author’s. Thus, he recommends
at first venesection, and sponges squeezed out of oxycrate and the like;
then digestives are to be applied; and afterwards cataplasms and such
things as will favour the rupture of the abscess, namely, compositions
containing bee-glue, bitter lupins, vinegar, nitre, yeast, or figs and
pitch.

Avicenna describes these affections by the name of _althaum_. It is
remarked by his translator that the Arabian recommends the same medicines
as Paulus, but neglects the distinction which the latter properly makes
between the bubo when attended with pestilential fever and when without
it.

The phyma seems to have been merely an acute inflammation of a gland,
terminating in suppuration. The phygethlon was an erysipelatous
inflammation of a gland. These complaints are well defined and described
by Fabricius ab Aquapendente (1, i, 23.) Dr. Willan uses the term phyma
in a different sense from that of our author. The term occurs in Marcus
Antoninus (ii, 16), where see the note of Gataker.


SECT. XXIII.—ON FURUNCULUS.

Furunculus is an apostematous swelling, formed of thick humours in the
fleshy parts of the body most especially; being mild when it is formed
in the skin only, but of a malignant character when it rises up from a
deep-seated part. Furunculus may be discussed and concocted by wheat,
chewed and applied; by Egyptian mastic; by raisins, deprived of their
stones, and triturated with salts, and applied—(this either discusses or
breaks the swelling); or apply dried figs boiled in hydromel; or rosin
may be mixed with the figs and applied; or the figs themselves, when they
are fat, may be split open and applied; or leaven with nitre; or linseed
with honey; or the leaves of henbane, triturated with butter: of compound
applications, that which is prepared from leaven and fine flour, and that
which is particularly named Dothienicon, are very applicable. Foment with
soft sponges frequently dipped in hot water, and then apply the medicines.

       *       *       *       *       *

COMMENTARY. In this and the two following Sections, see the authorities
on phlegmon.

The furunculus, according to Galen, is an inflammatory affection which is
of a malignant nature when deep-seated, and differs from phyma only in
hardness. (De Tumoribus.)

Furunculus, says Celsus, is an acute tubercle, attended with inflammation
and pain, more especially when converted into pus. After it has been
opened, and the pus discharged, there appears part of the flesh below
converted into pus and part corrupted, of a whitish or reddish colour,
which they call the ventricle or belly of the furunculus. He says that
the disease is not attended with danger, and that medicines are necessary
solely for removing it the more expeditiously. For this purpose he
particularly commends galbanum. If repellent applications do not succeed,
suppurative ones may be used; and, failing these, rosin or leaven. When
pus is formed, no further treatment is required. According to Rayer,
Celsus’ description of furunculus applies to the malignant pustule and
not to the boil. (Malad. de la Peau, 233.)

The simple remedies recommended by our author are borrowed from Oribasius.

It is to be remarked that Galen, Celsus, Pliny (Nat. Hist. xxiii, 7),
Octavius Horatianus, and Avicenna concur in recommending figs for
furunculus or the boil. It was with a lump of figs that the prophet
Isaiah cured Hezekiah’s boil.

Avicenna and Rhases treat furunculus judiciously by bleeding and purging,
which prevent the formation of a large abscess. When there is throbbing
in the tumour, they direct us to use maturative applications. When it
is ripe, and does not break readily, they recommend us to open it. Haly
Abbas says, that boils arise from gross and depraved humours. (Theor.
viii, 11.) Alsaharavius also ascribes them to a full and unwholesome
diet. He mentions that he often succeeded in stopping the formation of
the furunculus by cauterizing it with a piece of myrtle or any other
wood. When the pain is violent, he recommends an application of the
leaves of henbane and poppies with the yelk of an egg. When the boil is
indolent, he approves of a stimulant plaster. (Pract. xxix, 4.)


SECT. XXIV.—ON TERMINTHUS.

Oribasius says, that terminthus is a species of phyma, but that a dark
bulla lies over it, which having burst, the part below appears as if
excoriated, and when it is divided, the pus is found. But Dioscorides of
Alexandria says, “Terminthi are eminences formed in the skin, round, of
a dark green colour, like the fruit of turpentine.” These, therefore,
are to be cured like other phymatous swellings, by applying the remedies
there described.

       *       *       *       *       *

COMMENTARY. Aëtius gives the same account of terminthus, which is a
species of phyma. See Hippocrat. (Epidem. ii, 11; de Humor. xi, 1); Galen
(Comment. in Epidem.); Oribasius (Synops. vii, 136.) Avicenna describes
these affections by the name of _albothin_ (iv, 7, 3, 1.) He says that
they are ulcers produced by black bile; that they appear upon the leg,
and are of the same nature as varices.

The terminthus would appear to have been the cutaneous disease to which
Willan applied the name of ecthyma.


SECT. XXV.—ON CARBUNCLE OR ANTHRAX.

When the blood having become more melancholic than natural, ferments
and fixes in a part, the diseases called carbuncles are formed, which
are sloughy ulcers, for the most part beginning with bullæ, like burnt
parts, but sometimes without them; and the patients at first rub the
part for its itchiness, whether one bulla is formed or several small
ones, like millets, which, having burst, a sloughy ulcer takes place,
resembling those occasioned by cauteries, the eschar being sometimes of
a cineritious colour and sometimes black, along with its being fixed
to the base, and in a certain manner nailed to it, and it spreads at
the same time, the surrounding flesh is in a fiery state, black in the
colour, and shining like bitumen and pitch. Such is the true black bile.
But carbuncles that form in the flesh are speedily circumscribed; whereas
those which take place in membranes or nerves remain long, and affect
sympathetically the parts below, so as to give origin to erysipelatous
inflammations. Not a few terminate in suppuration, and most cases are
attended with fever.

Carbuncles also sometimes arise from epidemic causes. We must treat
them, unless they are very small, by venesection, carrying evacuation as
far as to occasion deliquium animi; and after venesection it will not
be improper to make deep scarifications in the part, on account of the
thickness of the humour. To the affected part we may apply such things
as are moderately repellent and discutient, as the cataplasm of plantain
and boiled lentil, receiving the tender part of bread baked in an earthen
pan, neither very fine nor foul; and above the ulcer we must put some of
the strong applications, such as those of Andron, of Polyides, and of
Pasion, mixing them with must, until they are of the consistence of the
sordes of oil in baths. And so also the dry Massaleotic powder, which may
be diluted in like manner. And the root of dracunculus, or of birthwort,
or the juice of laserwort, or the Cyrenaic juice may be properly rubbed
in, each of these with vinegar. Cases of an erysipelatous nature may be
anointed with the applications for erysipelas; but those parts which are
suspected of being sympathetically affected are to be wrapped in unwashed
wool, out of wine and oil. When the inflammation abates, we must apply
to the carbuncles the cephalic cerates spread upon pledgets. That from
herbs is an excellent one, and that from natron, and the dry application
for spreading ulcers, separately and with rose-oil. When the hardness
remains, we must use the one from apples ascribed to Serapion. But we
must hasten the suppuration of the carbuncles as much as possible, by
changing the cataplasms and medicines twice during the day, and once
during the night. In order to root out the carbuncles, and free them
from their attachments to the surrounding parts, having divided sour
pomegranates, boil in vinegar, and when softened, triturate, put into a
linen rag, and apply. When dried, let them be moistened with vinegar.
The carbuncle is made to suppurate and burst, by the inner part of old
walnuts, or even of that which is not old, and by the leaves and shoots
of cypress, or by its young and tender balls (pilulæ), with barley-flour;
by raisins deprived of their stones; by dried figs boiled in wine; by the
flowers of horned poppy; by the juice of laserwort, with rue and some
honey; by liquid pitch with raisins and axunge.

_An excellent application for carbuncles._ Of litharge, lb. j; of old
oil, lb. j; of arsenic, oz. j; boil the oil and litharge until they do
not stain, and taking them off the fire, add the arsenic, and then boil
it until it become black, and having levigated it in a mortar, use upon
pledgets.

_For gangrene, old ulcers, those called chironia, strumous ulcers, and
the gout: it is a most admirable application for carbuncle, particularly
in the eyelids._ Of opium, of acacia, of toasted misy, of flakes of
copper, of each, dr. ij; of copperas, dr. j; of the seed of henbane, dr.
j; triturate in water, and use. They say also that the ointment called
tetrapharmacon, having a fifth part of frankincense, is an excellent
application. But for carbuncles in the pudenda, take of chalcitis, of
copperas, of each, dr. viij; of aphronitrum, dr. ij; triturate with
water, and use. Sheep’s dung roasted with honey is also a good remedy. In
Alexandria they use the green serapias, which is also called orchis and
triorchis, with crumbs of bread, as a cataplasm for carbuncles and all
sloughy ulcers; and when the eschar falls off, they cure them as a common
ulcer.

       *       *       *       *       *

COMMENTARY. The carbuncle is briefly treated of by Hippocrates (Epidem.
ii, 1), and is frequently mentioned by him as a symptom of the
pestilential fever. (Epidem. iii.)

Celsus gives a very minute description of carbuncle. With regard to
the treatment, nothing, he says, answers so well as immediate burning,
which produces no pain, as the flesh is dead. The sore is to be treated
like other burnt parts. Under the use of eroding applications a crust
is formed, which, being removed from the living flesh, carries all the
corrupted parts along with it, and leaves a clean cavity, which is to
be filled up by incarnants. When the disease is superficial, corrosive
or caustic substances may be substituted, of such a degree of strength
as to produce a separation between the dead and sound flesh. But if
these applications fail, recourse must be had to burning. He recommends
abstinence from food and wine at the commencement, and directs water to
be given freely, especially if fever be present.

Pliny gives an indistinct account of an epidemical anthrax, which, he
says, prevailed in the province of Narbonne. (Nat. Hist. xxvi, 4.)

Galen ascribes the carbuncle to a defluxion of hot, black, and thick
blood, which gives rise to blisters, ulcers, and eschars. He directs us
to apply to the eschars those medicines the properties of which resemble
fire, such as misy, chalcitis, arsenic, quicklime, and sandarach. His
particular remedies are quite similar to our author’s. (Meth. Med. xiv),
and (ad Glauc. ii.) He mentions the carbuncle as a very unfavorable
symptom of the plague. (Epidem. iii, and de Diff. Febr. i, 6.)

The account of the carbuncle given by Aëtius is full and accurate, but
is entirely derived from Galen. Oribasius, Actuarius, and Nonnus also
repeat his doctrines. Actuarius says that the disease is occasioned by
melancholic blood overheated. This is much the same as Galen’s theory.

Octavius Horatianus recommends bleeding at the commencement, and external
applications of an acrid and caustic nature, or the actual cautery
itself. When danger is apprehended from a hot cautery, he directs us to
use a cold one.

In the Latin translation of Avicenna the carbuncle is described by the
names of pruna and ignis Persicus. It was called pruna from a black
slough which is formed in it, resembling a burnt coal. His account of
the disease is ample, but mostly copied from Galen and his successors.
Rhases approves of venesection at the beginning, and of the actual
cautery. He also recommends an application containing mustard and figs.
Alsaharavius describes the varieties of anthrax by the names of _alcubam_
and _alcoasat_. (Pract. xxix, 12.) At the commencement, he approves of
general bleeding and leeches, and afterwards of refrigerant and analeptic
medicines, to obviate the tendency to sinking. When these things do not
succeed, he directs us to use powerful caustics or the actual cautery.
Serapion, like Avicenna, describes it under the name of the ignis
Persicus.

Procopius mentions the anthrax as one of the symptoms of the great plague
which he describes. (Persica, ii.)

For the carbunculus or anthrax, Brunus and the other writers of that
age recommend, at first, bleeding and restricted diet, with maturative
applications, such as figs and mustard, or the yeast cataplasm, with oil
and salt. When the part becomes black, Theodoricus directs us to have
recourse to the actual cautery. (iii, 12.) Municks rather disapproves
both of purging and bleeding, but strongly commends the actual cautery,
which he greatly prefers to the potential. (Chirurg. i.) Vigierius,
however, prefers a paste made from quicklime and soap. V. Manget. (Bibl.
Chirurg. i, 374.) The learned Schelhammer speaks favorably both of the
potential and the actual cautery. (De Humoribus.)


SECT. XXVI.—ON CANCERS.

Cancer occurs in every part of the body; for it takes place in the eyes
and uterus (as we have stated when treating of those parts), and in most
other parts of the body; but it is more particularly frequent in the
breasts of women, because owing to their laxity, they readily admit the
thick humours which occasion it. For cancers are formed by black bile
overheated; and if particularly acrid, it is attended with ulceration.
On this account, they are darker than phlegmons, without being attended
with the same degree of heat. The veins are filled and stretched around
like the feet of the animal called cancer (crab), and hence the disease
has got its appellation. But some say that it is so called because it
adheres to any part which it seizes upon in an obstinate manner like the
crab. Owing to the thickness of the humour which occasions it, cancer is
an incurable disease, for it can neither be repelled nor discussed; not
yielding to purging of the whole body, resisting the milder applications,
and being exasperated by the stronger ones. It may be possible, however,
to prevent incipient cancers from increasing, by evacuating the
melancholic humour before it becomes fixed in the part. We may evacuate,
first, if nothing prohibit, by venesection, and afterwards by purging at
the commencement, with the simpler purgatives, such as giving dodder of
thyme to the amount of oz. ivss; in whey or honied water, and afterwards
hiera, containing the black hellebore.

The juice of strychnos may be applied to the ulcerated parts without
exciting pain, a linen rag being folded and wetted in it, and laid on;
but externally to this, we must apply soft wool, which also has been
soaked in the juice, and care must be taken that they do not become dry,
by frequently pouring on some of the juice. In all carcinomatous ulcers
of a chronic nature, one may use the preparation from pompholyx; and
those remedies which were mentioned in the Third Book for cancers in the
womb may be applied with advantage.

_For carcinomatous and malignant ulcers, for rugose ulcers on the
fundament, and for inflammations on the pudenda, testicles, and breasts._
In a leaden mortar, and with a leaden pestle, having triturated the
Lemnian earth with oxycrate and honied water or milk, so that it become
black, or having triturated rose-oil, or the oil of unripe olives, or
the juice of house-leek, or that of wall-pennywort, or of lettuce, or
of fleawort, or of unripe grapes in like manner, anoint with them. The
patient’s diet should consist principally of the juice of ptisan and the
whey of milk, and from among pot herbs, of mallows, orache, blite, and
gourd, of the fishes which live among rocks, and of all kinds of fowls,
except those that live in marshes.

_From Archigenes, for carcinomatous and malignant ulcers._ Levigate equal
parts of burnt river crabs and calamine, and sprinkle or apply the ashes
of crabs with cerate; or apply the seed of hedge mustard triturated with
honey.

       *       *       *       *       *

COMMENTARY. See Hippocrates (Epidem. v); Galen (de Tumoribus; Meth. Med.
xiv; Therap. ad Glauc. ii); Celsus (v, 28); Scribonius Largus; Aëtius
(xvi, 43); Oribasius (Morb. Curat. iii, 28); Actuarius (Meth. Med. iv,
16); Avicenna (iv, 3, 2, 15); Serapion (v, 24); Alsaharavius (Pract.
xxix, 1, 16); Avenzoar (ii, 7, 27); Haly Abbas (Pract. iii, 32); Rhases
(ad Mansor. vii, 9; Contin. xxvii.)

Hippocrates relates a fatal case of cancer in the breast, attended with a
sanious discharge, but he does not explain the nature of the treatment.

Our author’s description of cancer is abridged from Galen (de Tumor.
l. c.) The treatment is derived from the 14th Book of the ‘Meth. Med.’
He recommends melanogogues to remove the material cause of the disease.
In external applications he places little confidence, but prefers
those prepared from metallic substances which have been burnt and
washed. The only chance of a radical cure consists, he says, in making
a complete excision of the part; but in doing this he forbids us to
secure the arteries with ligatures, as they will occasion a recurrence
of the disease. The part, he says, is loaded with a thick, black, or
recrementitious blood. When the cancer is ulcerated, he disapproves of
cutting and burning.

Celsus describes carcinoma as an immovable and unequal tumour, attended
with swelling of the veins, which are pale or livid. His account of
the treatment is so important that it deserves to be given in his
own words: “Quidam usi sunt medicamentis adurentibus; quidam ferro
adusserunt; quidam scalpello exciderunt: neque ulla unquam medicina
profuit; sed adusta, protinus concitata sunt, et increverunt donec
occiderent; excisa, etiam post inductam cicatricem, tamen reverterunt,
et causam mortis attulerunt: cum interim plerique nullam vim adhibendo,
qua tollere id malum tentent, sed imponendo tantum lenia medicamenta
quæ quasi blandiantur, quo minus ad ultimam senectutem perveniant, non
prohibeantur.” In another place, however, he recommends compositions
containing arsenic, copperas, cantharides, galls, &c. (v, 22.) He makes
a distinction between the _cacoethes_, or malignant tumour, and the true
carcinoma, but says that the difference between them is to be recognized
only “tempore et experimento.” He marks the gradations of malignant
disease with singular precision: first, there is cacoethes; then
carcinoma without ulceration; and last, there is the fungated ulcer. (The
reading in the edition of Milligan is a great improvement.) In doubtful
cases he directs us, first to apply caustics or heating medicines, and,
if the disease is alleviated, to proceed to the scalpel or burning,
according to circumstances; but if it is exacerbated, we are to conclude
that it is of a carcinomatous nature, and must abstain from all acrid and
vehement applications.

Scribonius Largus recommends for all malignant ulcers, even such as are
cancerous, an application consisting of arsenic, p. vj; of squama æris,
p. iij; of elaterium, p. j; of burnt paper, p. iij.

Aëtius gives from Archigenes and Leonidas an interesting account of the
disease, which he divides into ulcerated cancer, and cancer without
ulceration. He describes the disease in the female breast as consisting
of a large tumour which is unequal and resisting, extending its roots
far, and being attended with varicose veins: its colour is either
cineritious, verging to redness or livid; it appears soft, but is in
reality very hard; is accompanied with a pungent pain, and gives rise to
malignant phlegmons in the armpits. The pains shoot to the clavicle and
scapula. An ulcerated cancer, he says, goes on corroding and spreading
deeper, nor can it be stopped; it discharges a sanies of an abominable
smell, and is aggravated by medicines and handling. The disease he
considers as generally incurable. His surgical treatment will be stated
in the Sixth Book. He recommends purging with hiera and the theric,
Mithridatic antidote, &c. Apparently, in order to mitigate the violence
of the pains, he directs us to make an application containing equal
portions of plantain, poppy heads, the seed of the wort, and other things
of the like kind. For ulcerated cancer he recommends emollient epithemes,
such as the one containing litharge, axunge, white wax, oil, and the
yelks of eggs.

Oribasius and Actuarius supply nothing of importance that is not to be
found in our author. Nonnus, according to Sprengel, is the only ancient
author who attributes cancerous ulcerations to acrimony of the bile. But
Nonnus merely copies the words of our author.

The Arabians agree with the Greeks in representing the disease as being
produced by black bile. They were, no doubt, led to form this opinion
from remarking that the blood in the part is thick and black, which they
considered owing to its not being properly purged of its recrementitious
sediment. The moderns deride this theory, but they have substituted
nothing satisfactory in its stead. Van Swieten thinks more favorably of
the ancient doctrines. (Comment. § 485.) Avicenna speaks highly of a milk
diet. Serapion likewise approves of milk deprived of its butter, and of
a vegetable diet. He speaks of no other treatment as being likely to
prove remediable, with the exception of excision and the cautery. Haly
Abbas rather approves of excision when the disease is seated in a part
which admits of this operation. However, like Galen, he disapproves of
tying the arteries. The characteristic symptoms of the disease, he says,
are a stony hardness and distension. The account given by Alsaharavius
is nothing different. Rhases has little confidence in excision. After
ulceration has taken place he approves of using a cooling application,
containing ceruse, tutty, rose-oil, the juice of nightshade, and some
other such things of a cold nature. He mentions a case of cancer of the
breast, in which the whole mamma was extirpated, but the disease returned
on the other side. One of his authorities, Antyllus, describes the
cancerous sore as having a tendency to spread inwards, its edges being
thick, large, and everted, and the discharge thin and acrid. When the
disease cannot be got completely extirpated, he forbids us to meddle with
it.

Theodoricus and all the earlier modern writers on medicine, call the
cancer by the name of apostema melancholicum, and recommend the same
treatment for it as the Greeks and Arabians.


SECT. XXVII.—ON ŒDEMA.

Having treated of swellings formed by hot humours, we shall now treat of
those from the opposite, beginning with the œdema. For as erysipelas is
formed by a bilious humour, so is œdema by a pituitous, being a loose
swelling devoid of pain. We are aware also, that œdematous swellings
occur in the feet, in dropsical affections, in phthisis, and in cachexia,
but in them the œdema is a symptom of the complaint under which the
person is labouring, and requires no very particular treatment; for it
will be sufficient in general to rub the limbs sometimes with vinegar and
rose-oil, and sometimes with oil and salts, or the salts may be added to
the vinegar and rose-oil. When the œdema is occasioned by a pituitous
humour being determined to the part, a sponge soaked in oxycrate may
be properly applied with a bandage loosely put on, beginning below and
terminating above. The sponge ought to be new, but if such a one is not
at hand, that which is may be cleaned with natron, or more especially
with what is called strained lye. If the swelling do not thereby subside,
we may mix some alum. And a very convenient application is a tender wick
of a lamp, soaked in such a fluid, and applied. A good remedy also is
horned poppy. When the œdema has become chronic, having first anointed
the part with oil, and then applied a sponge out of lye, bind it firmly,
and you will effect a cure. Every kind of earth discusses and represses
œdematous swellings, more especially the Ægyptian, and also the matured
woad.

       *       *       *       *       *

COMMENTARY. See Galen (ad Glauc. ii; de Tumoribus); Aëtius (xv, 1);
Oribasius (Morb. Curat. iii, 51); Leo. (vii, 5); Actuarius (Meth. Med.
iv, 16); Nonnus (251); Serapion (v, 23); Avicenna (iv, 3, 2); Haly Abbas
(Theor. viii, 11; Pract. iii, 30); Alsaharavius (xxix, 13); Rhases (ad
Mansor. vii, 12.)

Our author’s account of this disease is taken from Galen, Oribasius,
Aëtius, and, in fact, all the Greek, Latin, and Arabian authorities
adopt his views, without any material alteration. They all concur
in recommending cooling and astringent applications, with suitable
bandages; and, in certain cases, friction. Rhases recommends that the
limb should be buried in heated sand. He also approves of various
cooling and astringent applications with bandages. In the translation
of Alsaharavius, the œdema is described by the name of _apostema
flegmaticum_; in those of Avicenna, Haly Abbas, and Serapion, by that of
_undemia_. The celebrated Paracelsus used the term undemia for œdema. In
some late works we have seen it stated that the undemia was a species of
erysipelas, but this is evidently a mistake.


SECT. XXVIII.—ON EMPHYSEMA.

Emphysema is formed by a flatulent spirit, collected sometimes under the
skin, sometimes under the periosteum, or the membranes which surround
the muscles. And it is also sometimes collected in the stomach and
intestines, or between them and the peritoneum, in those kinds of dropsy
which are called tympanitic; and it differs from œdema in this, that the
parts do not pit upon pressure like it, and that it sounds like a drum.
The density of the body co-operates in preventing the flatus from being
dissipated, at the same time that the flatus also is of a thick nature.
Wherefore, the indication of cure is to rarefy the body, and attenuate
the thick air; which is to be accomplished by means of attenuant and
heating remedies. When the complaint is seated in the stomach and
intestines, this is to be brought about by a fine oil, having rue, cumin,
or parsley seed boiled in it. And sometimes a large cupping instrument
without scarificators, applied two or three times to the navel, will
discuss it. When the muscles from contusion are inflated, so as to
sound like an emphysema, the parts will not bear very heating and acrid
applications. Wherefore, at the commencement, we must use paregorics
liberally, and, when the disease is on the decline, discutients. Thus
we may use sodden must with a small quantity of oil, applying them warm
upon unwashed wool, or mixing the cerate of unwashed wool. And we must
take care that the heat be preserved, for it is not expedient that the
part be cooled. When the patient has been soothed, we are to mix vinegar
and nitre or aphronitrum, and afterwards some lye; and lastly, we may
use discutient plasters, for the removal of the complaint such as the
following: having boiled the sordes of the oil used in baths, strain it
first, so that it may become pure, and again throw it into the pot, and
having triturated slaked lime like flour, sprinkle until it become of the
consistence of clay, and use. A still more effectual application is the
compound medicine from sycomores.

       *       *       *       *       *

COMMENTARY. See Galen (Meth. Med. xiv); (Therap. ad Glauc. ii); Aëtius
(xv, 2); Oribasius (Synop. vii); Actuarius (Meth. Med. ii, 12); Nonnus
(252); Scribonius Largus (§ 119); Avicenna (iv, 3, 2, 20); Serapion (v,
23); Alsaharavius (Pract. xxix, § 1, 14); Rhases (Divis. 127, Cont.
xxvii.)

Our author has copied closely from Galen. The great indications of cure,
as laid down by him and acknowledged by all subsequent authorities, are
to rarefy the containing parts and attenuate the spirit. By _spirit_,
as we stated in another place, the ancients meant a thick air or gas.
The indications which we have mentioned are best fulfilled by friction
with oils, in which calefacient medicines, such as cumin, parsley,
anise, and the like, have been boiled. When, however, any inflammation
is suspected, he properly forbids us to use acrid or heating medicines.
When the pain of the bowels is violent in cases of tympanites, he allows
medicines containing opium, which are to be given by the mouth if the
small intestines be affected, but are to be administered in a clyster
if the large intestines be the seat of the disease. When the disease is
in a muscular part, he directs us to use a combination of attenuants
and emollients. In certain cases he recommends dry-cupping. Oribasius,
Aëtius, Actuarius, and Nonnus, adopt the views of Galen, without any
alteration.

For tympanites, Scribonius recommends cumin internally.

Avicenna, like our author, in ordinary cases recommends combinations of
attenuants and calefacients, dry-cupping and the like, for dispelling
the spirit; but when the disease arises from contusion of the muscles,
he directs us to use resolvents and paregorics. Serapion approves of
similar treatment. Alsaharavius recommends attenuant and calefacient
remedies externally and internally. In the translation of his works, the
disease is called inflatio. Rhases recommends friction with calefacient
oils; he remarks that the disease occurs most commonly in the stomach and
intestines. He calls it by the name of apostema inflatum.


SECT. XXIX.—FOR SPRAINS AND CONTUSIONS.

Sprains of the joints and contusions are remedied by unwashed wool, or
a sponge soaked in vinegar and oil, and applied; by the tender parts of
boiled bulbous roots with honey, by the leaves of the chaste tree, salts,
and roasted nitre, triturated with cerate. The affusion of sweet water,
or of hot sea water, may be used. But after the inflammation and pains
have subsided, apply rubbing to the sprained parts.

       *       *       *       *       *

COMMENTARY. See Aëtius (xiv, 71); Oribasius (Synops. vii, 14); Actuarius
(Meth. Med. ii, 35); Scribonius Largus (§ 209); Rhases (Divis. i, 140.)

Aëtius makes mention of all the remedies recommended by our author, with
the exception of the affusion of water; which, however, is a method
of treatment deserving of attention. Oribasius mentions particularly
the affusion of hot sea water. Scribonius Largus recommends a plaster
containing litharge, alum, ærugo, ammoniac, &c. Rhases directs us to use
attenuant ointments, sedative plasters, and loose bandages, with rest.


SECT. XXX.—ON CONTUSIONS OF THE FLESH AND ECCHYMOSIS.

The flesh being bruised by some weight falling upon it, and the small
veins in it being ruptured, blood is poured out from them by exhalation,
and collecting under the skin, is called ecchymoma. When the skin is
not divided, a soft yielding tumour is the consequence; it is pale,
and for the most part unattended with pain. Our object, therefore, is
to discuss the contained blood, and that quickly, before it become
black; and at first, astringents are to be mixed with the discutients,
because the bruised coats of the veins stand in need of condensation.
After these things, we must use those applications which are merely
discutient without astringency. And by scarifying the ecchymomata at the
commencement, we may thus apply the subsequent treatment. For chronic
cases of ecchymoma, radish in the form of a cataplasm is a suitable
remedy, but it must be taken away when it becomes pungent; or a cataplasm
of the juice of radish with crumbs of bread, may be applied. The diseases
called hypopion and hyposphagma, are species of ecchymosis, and also the
effusion of blood below the nail from a blow; of these, the first two are
treated of in their proper places in the Third Book; and the affection of
the nail will be handled in the Surgical part of the work.

       *       *       *       *       *

COMMENTARY. This is taken almost word for word from Oribasius (Synops.
vii, 14); Aëtius directs us to scarify the part affected with ecchymosis,
and then to apply to it the inside of citrons (xiv, 68.)

Avicenna approves of scarifications, provided the extravasated blood
cannot be got otherwise removed. (iv, 4, 2, 3.)


SECT. XXXI.—ON RUPTURE AND TEARING OF THE FLESH.

Rupture is altogether attended with ecchymosis. It is cured by medicines
which are moderately heating, as the acopon from black poplars, and
such as resemble it. But when the rupture is deep-seated, we must have
recourse to such remedies as are more acrid and cutting. The use of the
cupping instrument is likewise beneficial to them. Should therefore the
whole ecchymosis be discussed, the separated flesh readily unites; but
if it continue a long time, and sordes form under it, the ruptured flesh
can no longer unite; and we must only apply the lips together, so that a
small occasion may readily separate them, and that the intermediate space
may be filled with some moisture, and in a certain manner an ecchymosis
may be formed as at the commencement, except that it is sooner discussed,
as containing a thin humour, whereas that at the commencement was formed
of blood. Vulsion takes place when certain fibres are torn asunder, and
it only requires soothing applications until the pain is removed; for
they cannot be made to coalesce. Wherefore, the round birthwort, if any,
is a convenient application to ruptured and torn parts; and in like
manner, the root of the large centaury, and the juice of it, rhubarb,
costus, and bdellium, drunk with oxymel.

       *       *       *       *       *

COMMENTARY. These remarks are taken from Aëtius (xiv, 69, 70); or
Oribasius (Synops. vii, 14); and they are copied by Nonnus (Epit. 254);
and Actuarius (Meth. Med. iv, 16.)

The Arabians treat these accidents upon exactly the same principles. See
in particular Avicenna, as quoted in the preceding section.


SECT. XXXII.—ON SCIRRHUS.

Genuine scirrhus is a preternatural swelling, hard and devoid of
sensibility; but that which is not genuine is only attended with
diminished sensibility. That which is wholly insensible, then, is utterly
incurable; but that which is attended only with diminished sensibility
is not incurable, and yet it is not easily cured, for it is occasioned by
a viscid and thick humour, which is fixed in the hardened parts, so as
to be difficult to get discharged. Sometimes, then, the scirrhus is the
original complaint, and goes on to increase; but for the most part, it is
occasioned by the physicians applying too cooling and astringent remedies
to erysipelas and phlegmon.

If one, therefore, apply strongly discutient medicines to indurations of
the body, one will indeed produce a visible diminution of the scirrhus
in a short time, but will leave the remainder of the complaint in an
incurable state; for the thin moisture being dissipated, what remains
is rendered dry and hard as a stone. The discutient application, then,
ought to be in a certain degree emollient, without possessing manifestly
heating and desiccant qualities. Such are all kinds of marrow, more
especially that of a stag or of a calf, and the grease of a lion, of a
panther, or of bears, or of a bull, and among birds, that of geese, of
domestic fowls, or of pheasants: but that of bucks and he-goats is drier.
And to these may be added, ammoniac perfume, bdellium, more especially
the Scythian, the humid and fatty storax, and the Egyptian mastich. To
all other parts of the body, when in a scirrhous state, these things may
be applied singly, and in composition; but for tendons and ligaments, we
are to dissolve in the strongest vinegar some stone that has been heated
in the fire. If possible, the one to be used should be pyrites, or if
not it, the lapis molaris or millstone. In this, therefore, the affected
part is to be moved, so that it may receive the vapour which arises from
it; and afterwards, an emollient medicine is to be applied. A thin oil
then, and not water, is to be poured on the part, by all means once a
day, and sometimes one may boil in the oil the root of marshmallows, or
of wild cucumber. The patients ought to abstain from the use of the bath,
at least from the frequent use of it. But when the scirrhus is moderately
softened, the softest ammoniac is to be dissolved in very strong vinegar,
and the part rubbed with it for several days in succession; after which,
we must again have recourse to an emollient application, having the
fattest galbanum and opoponax added to it. Such are that from bacon,
that ascribed to Amythaon, and those which we are about to describe for
scrofula.

       *       *       *       *       *

COMMENTARY. See Galen (De Tumoribus; Meth. Med. xiv; Therap. ad Glauc.
ii); Oribasius (Synops. vii, 34); Aëtius (xv, 3, 4); Leo (vii, 4);
Actuarius (Meth. Med. iv, 16); Serapion (v, 23); Avicenna (iv, 3, 2, 12);
Haly Abbas (Pract. iii, 31); Alsaharavius (xxix, 1, 15); Rhases (Antid.
i, Cont. xxvii, Antidot. i.)

This section is entirely taken from Galen (Ther. ad Glauc. l. c.) Galen’s
account, however, is somewhat fuller than our author’s, and contains a
case treated upon the principles which he lays down. It was a case of
hard swelling in the thigh, arising from an erysipelas which had been
improperly treated by astringent and cooling applications. Galen informs
us that he began by pouring upon the limb an attenuant oil, namely, the
Sabine; after which he caused it to be rubbed with marrows and fats
medicated with bdellium, mastich, ammoniac perfume, and the like. After
this he bathed the whole limb with a solution of ammoniac in very acrid
vinegar. When the swelling had been lessened, but not completely removed
by these means, he afterwards applied one of the pitch medicines, and
at length effected a cure. In another place he states that scirrhus is
sometimes allied to cancer.

Oribasius likewise recommends a combination of emollients with
discutients; and Actuarius approves of the same practice.

Aëtius has a valuable chapter upon this subject. Besides the articles
mentioned by our author, he recommends various rosins, turpentine,
frankincense, and the like. He forbids the use of aluminous, sulphureous,
and chalybeate baths. For indurations of tendons he recommends things
possessed of attenuant and cutting properties combined with emollients,
such as ammoniac dissolved in vinegar with melons.

The Arabians treat of scirrhus in much the same terms as the Greeks.
Avicenna properly directs us to bleed when there is congestion of black
blood in the part, and afterwards to use applications of a solvent and
emollient nature. He and Serapion mention the same identical remedies
as those of Paulus. For dissolving hard tumours he recommends an oil
containing fenugreek, cyperus, and aromatic reed. Haly Abbas ascribes the
formation of scirrhus to the same causes as our author, and recommends
relaxant and emollient applications. Alsaharavius directs us to procure
evacuations of black bile, and gives prescriptions for various emollient
and discutient applications. When the usual remedies do not succeed, he
advises recourse to be had to the operation. Rhases divides scirrhus
into two varieties, that accompanied with sensibility, and that which is
insensible. He mentions that Antyllus approved of extirpation and the
actual cautery when the disease is of a corroding and cancerous nature.


SECT. XXXIII.—ON STRUMA OR SCROFULA.

Strumæ are indurated glands forming principally in the neck, armpits,
and groins. Their general treatment therefore is the same as that for
scirrhus, but in particular the flour of bitter lupines is to be boiled
in oxymel and applied (this also answers with phyma;) or apply cows’ dung
boiled in vinegar. This discusses all indurated swellings. But strumæ
may be properly discussed by means of quicklime mixed with honey, the
sordes of baths, oil, or axunge; or, equal parts of quicklime and natron,
and four times the quantity of cardamom and fenugreek may be boiled with
honey for an emollient ointment and applied. This one discusses hard
strumæ, and produces the rupture of suppurated swellings; the flour of
darnel boiled with pigeon’s dung, or linseed and wine: or, green olives,
either wild or cultivated; or, the white cardamus triturated with liquid
pitch and made into an emollient ointment may be applied; or, the ashes
of the dried root of the wild cucumber, and the burnt dried leaves of
the bay, may be mixed with turpentine and applied; or, equal parts of
stavesacre and of natron, with double the quantity of rocket may be
applied, with rosin; or, goats’ or cows’ dung boiled in vinegar; or, the
flour of bitter vetches soaked in the urine of a young person not come
to manhood, and added to melted pitch, wax and oil; or, a dead snake may
be thrown into a pot, and being covered over with gypsum, it is to be
put into a furnace, the ashes of it mixed with equal parts of fenugreek,
and then added to honey and used. And the composition from asps is an
admirable one, also that from fullers’ herb, that from the wild cucumber
and that from cedar rosin. The following one produces suppuration, or
resolution of strumæ: Of myrrh, dr. x; of ammoniac perfume, dr. ij; of
the mistletoe of oaks, dr. viij; of galbanum, dr. iv; of bee-glue, dr. j;
pound in a mortar.

_For strumæ and hardness of the breasts._ Of wrought birdlime, of dry
rosin, of wax, of each lb. j; of galbanum, oz. iij.

_For strumæ ulcerated and not ulcerated._ Of wax, of pine rosin, of
axunge not salted, of horehound, of scraped birdlime, of each oz. vj.

_An application for strumæ._ Of old oil, lb. ij; of wax, lb. j; of
colophonian rosin, oz. iv; of natron, oz. iv; the heads of garlic xij.
Take away the cloves (nuclei) of the garlic, macerate in oil for three
days, then having boiled until they are softened, throw them away, and
melt in the oil those ingredients which are soluble, and after they
are taken off the fire sprinkle on it levigated natron. It also breaks
apostemes.—_Another_: Of the ashes of figs, oz. ij; of fissile alum, oz.
j; of aphronitrum, oz. j; of liquid pitch, oz. vij.

_A septic application for scrofula._ Of fissile alum, of realgar,
of each, dr. iv; of the flakes of copper, dr. j; of orpiment, dr.
j; sprinkle the strumæ with it in a dry state; but if they are of a
cancerous nature, mix with rose oil and use twice a day.

       *       *       *       *       *

COMMENTARY. See Hippocrates (De Glandulis); Galen (Meth. Med. xiv, 11);
Oribasius (Synops. vii, 29); Aëtius (xv, 5); Actuarius (Meth. Med.
iv, 16); Nonnus (Epit. 124); Celsus (v, 18); Scribonius Largus (153);
Myrepsus (56); Marcellus (36); Serapion (v, 25); Avicenna (iv, 3, 2, 10);
Albucasis (Chirurg. ii, 42); Alsaharavius (Pract. xxix, 1, 23); Haly
Abbas (Pract. iii, 33); Rhases (ad Mansor. vii. 8; Cont. xxvii); Avenzoar
(i, 10, 10.)

Hippocrates mentions struma as being one of the worst diseases of the
neck, originating in inflammation, and being produced by a pituitous and
indolent defluxion.

Galen directs us when scrofulous glands are not situated near large
vessels to extract them with the knife, or consume them with septic
applications. In another place he relates a case in which an imprudent
surgeon, while removing a scrofulous gland of the neck, cut the recurrent
nerves, and thereby occasioned loss of speech. (De Loc. Aff. i, 6.) For
an account of the operation see the Sixth Book.

Part only of our author’s applications are derived from Oribasius.

A very minute account of these complaints is given by Aëtius. He divides
strumæ into the mild and the malignant. The mild are without inflammation
or pain, and are attended with a moderate degree of hardness; the
malignant are accompanied with inflammation, and a throbbing pain,
feel unequal, have enlarged veins, and are exacerbated by handling or
medicines. The latter are said to be incurable. He mentions, upon the
authority of Leonidas, the accident related by Galen. He approves,
however, of the operation in general. Incipient strumæ, he states, may be
discussed like scirrhi, by a combination of emollients with discutients.
He gives a long list of prescriptions for removing scrofulous tumours.
One of them contains arsenic mixed with the fat of a goat or ox. With
regard to the general treatment, he recommends laxatives, restricted
diet, emetics, and the theriac.

Actuarius and Nonnus, as usual, borrow from our author.

Celsus remarks that strumæ occur most frequently in the neck, armpits,
groins, sides, and the female breasts. He represents them as indolent
affections of the glands, which come slowly to maturity and prove very
troublesome to the physician. Some, he says, give white hellebore in
these cases, and use applications for bringing them forward or for
discussing them. Others have recourse to caustics, and when the eschar
is removed, they heal the ulcer upon general principles. When the sore
becomes clean he recommends exercise and a nourishing diet.

Scribonius Largus, Marcellus, and Myrepsus give nearly the same
prescriptions as our author. Arsenic is an ingredient in the septic
applications of Myrepsus.

Avicenna recommends emetics, phlegmagogues, bleeding in the arm,
attenuant food, and avoiding all gross things and repletion. As a
discutient he and Serapion commend the diachylon plaster. Haly Abbas
likewise mentions this application, and also directs the swellings to be
burnt with caustics. Alsaharavius briefly recommends excision or burning.
Serapion evidently copies from our author. Avenzoar gives a very full
account of scrofulous swellings, which, he says, are formed in general of
a gross and viscid phlegm. Except in very particular cases he disapproves
of bleeding. He approves in general of discutient applications; but when
the swelling tends to suppuration, he directs us to promote it; and
when pus is fairly formed he recommends us to let it out, but cautions
the surgeon not to attempt this operation unless he has a practical
acquaintance with anatomy, lest he wound any of the veins, arteries, or
nerves.

Rhases forbids the knife when the scrofula is in the neck or deep
seated. In certain cases he approves of destroying the tunic with septic
applications.

Brunus, and the other surgical writers of that age, in imitation of
the Arabian authorities, direct scrofulous tumours to be treated with
discutients, excision, or septics. A discutient ointment recommended by
Brunus consists of litharge, common oil, and the juice of melons and
fenugreek. His septic medicine is a mixture of arsenic and quicklime,
which is to be applied with honey. (Chirurg. Minor. 19.)


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

These things belong to the class of apostemes, as we said when treating
of them, and each receives its peculiar appellation from the substance
contained in the tumour. Thus one of them is like fat, another like
honey, and the third like pap. The indication of cure in them all is
to discuss the contents, produce the putrefaction of them, or to cut
them out. Some tumours fall under all these three indications of cure,
namely, those which contain a thin fluid, as the meliceris; others come
under two of them only, as the atheroma, for it can only be cured by
excision or putrefaction. But the steotoma admits of no cure except by a
surgical operation, for it can neither be discussed nor made to putrefy.
The diagnosis of each of these may be found in the Surgical part of
the work, while the materials of which the discutients are formed are
mentioned under the head of scrofula. This application is peculiarly
adapted for discussing meliceris: Twenty raisins without their stones;
of squama æris, dr. iij; having first fomented, apply.—_Another_: Of
Cretan cistus, of bdellium, of galbanum, of ammoniæ perfume, of bee-glue,
of turpentine, equal parts; to be pounded together in a mortar. It
applies to scrofula, parotis, furunculus, and phyma. But Archigenes
applies to meliceris aphronitrum, and double the quantity of hellebore,
with hard cerate. But septics cannot be applied while the skin remains
entire; we must therefore in the first place lay bare the meliceris,
atheroma, or strumæ, with caustic medicines, of which the most simple
is that consisting of quicklime (calx viva,) soap, and strained lye.
The following one is more complex, and admits of being kept: Of calx
viva, dr. iv; of red natron toasted, of burnt lees of wine, of each, dr.
ij; of vermilion, dr. j; triturate in lye; and having made it of the
consistence of liquid honey, boil three times, until it is of the proper
thickness, and lay it up in a leaden vessel, pouring in some lye, so
that it may not quickly become dry. It applies to acrochordon, myrmecia,
pterygium, clavus, callus, and excrescences of the gums. The lees of
wine should not be older than two months. Anoint the skin with this, and
when it begins to dry clean it away with a sponge, and anoint again; and
when the skin becomes black, wash away again, and use escharotics. When
the eschars fall off, apply the septic medicines. A septic application
which is not irritating: Of squama æris, dr. iv; of realgar, dr. ij;
of black hellebore, dr. ij; use with rose oil.—_Another_: Of squama
æris, of realgar, of nettle seeds toasted, equal parts; use with rose
oil.—_Another_: Of burnt sea-urchins, of the shell of the cuttle fish,
of arsenic, equal parts; use with rose oil, but rub all the parts around
with cerate and oil. This also is a good application: Of quicklime, p.
ij; of chalcitis, p. j; of arsenic, p. j.

       *       *       *       *       *

COMMENTARY. See most of the authorities referred to in the preceding
section.

Our author’s definitions seem to be taken from Galen. (De Tumoribus and
Meth. Med. xiv.) Galen states that the steatoma is to be cured solely by
a surgical operation; that the meliceris may be treated by discutients,
septics, or excision with the knife; and that the atheroma admits only of
excision, or the application of septics.

Aëtius may be referred to as an interesting authority upon this
subject. The steatoma, he says, is a preternatural tumour, free from
discoloration, and soft to the touch. He recommends excision for it. The
contents of the atheroma consist of a pultaceous substance surrounded by
a membranous tunic, within which are also sometimes found hairs; nay,
Philoxenus affirms that he had found animals like gnats and flies. The
meliceris also has a membranous coat, and its contents resemble honey. He
approves also of the surgical operation for the meliceris and atheroma,
but permits to attempt their reduction by means of discutients consisting
of such ingredients as ammoniac, ceruse, turpentine, galbanum, vinegar,
&c. He makes no mention of septics; indeed arsenic does not enter into
any of his compositions.

Oribasius and Actuarius lay down the same rules of treatment as our
author. Nonnus as usual epitomises him with some slight alterations. The
active ingredients in one of his septic applications are sandarach and
hellebore. Leo is brief and indistinct.

Celsus marks the differences of these tumours with his characteristic
terseness and precision: “Atheromati subest quasi tenuis pulticula:
meliceridi liquidior humor; ideoque pressus fluit: steatomati pingue
quiddam.” He recommends excision. (vii, 6.)

Avicenna’s plan of treatment is so like our author’s, that we need not
give it in detail. The steatoma is to be removed solely by an operation.
For the two others he permits the use of septic applications, such as
arsenic, quicklime, hellebore, the lees of wine, &c. Haly’s definitions
are similar to those of our author, and he recommends either excision
or the use of septics, such as vitriol. The treatment laid down by
Alsaharavius is quite the same. In the barbarous translation of his works
they are called by the names of _alsahamia_, _asalia_, and _accida_.
(Pract. xxix, 1, 22.)

Vegetius, the veterinary surgeon, describes these tumours as they appear
in cattle. He directs them to be treated by excision. (Mulom. ii, 30.)

It will be remarked from the text, that the ancients were well acquainted
with the caustic powers of the _calx cum kali_. In fact, our author in
this section has given a prescription for the paste now commonly used for
forming issues.

It appears from the works of Fabricius of Aquapendente, that the
practice of treating atheroma and meliceris by septic applications was
sufficiently common in his time. Andreas Laurentius approves of removing
_scrofulous tumours_ in this way when they are deep-seated and have a
broad base. He thus enumerates the septics used in his age: “Secundo
extrahi potest struma caustico, nunc affixo in ejus medio candente ferro,
nunc admotis erodentibus et putrefacientibus ut sandaraca, arsenico,
argento liquido usto, oleo quod ex atramento sutorio igne elicitur,
calce non extincta cum sapone, axungia porcina cum argenti sublimati
portiuncula, pulvere mercurii, erinaceorum cumbustorum, testæ sæpiæ,
auripigmenti.” He also recommends us to tie the base of the tumour with
a thread wet in a solution of arsenic (De strum. nat.) The treatment of
atheroma by caustics is well described in the ‘Bibliotheca Chirurgica’ of
Manget.


SECT. XXXV.—OF FAVI.

The favus is a swelling on the skin, having perforations through which a
honey-like fluid is discharged. Wherefore dried grapes with rue are to
be applied to it; or, the tender leaves of the fig tree with honey; or,
cresses with linseed in honey; or, the root of the garden cucumber with
honey; or, sulphur vivum with cerate or turpentine. You may vary the
treatment of favi by transferring hither what is said in the Third Book
regarding achores.

       *       *       *       *       *

COMMENTARY. Alexander states that the favus resembles the achores,
differing from them solely in magnitude: for the openings of the pores by
which the fluid escapes resemble the combs of bees, whence it takes it
appellation; but in achores we cannot see the pores by which the fluid
issues.

Aëtius gives a similar description of the complaint, which, he says,
mostly attacks muscular parts, as the limbs, soles of the feet, over the
sixth vertebra of the neck, and the sides. When it attacks the head,
he says, it sometimes spreads to the skull. In this case he directs us
to treat it with acrid applications, and even the actual cautery. For
incipient favus he recommends an application consisting of sulphur,
barley flour and meal.

Nonnus recommends the following application: of litharge, dr. ij; of
alum, dr. iij; of the leaves of rue, dr. ij; of wine and rose-oil, q. s.

Celsus’s description is so important, that we shall give a considerable
part of it in his own language. He mentions two species of the favus,
or κήριον. “Alterum est subalbidum, furunculo simile; sed majus, et cum
dolore majore: quod ubi maturescit, habet foramina, per quæ fertur humor
glutinosus et purulentus; nec tamen ad justam maturitatem pervenit. Si
divisum est, multo plus intus corrupti, quam in furunculo, apparet,
altiusque descendit. Raro fit nisi in capillis. Alterum est minus, super
corpus eminens, durum, latum, subviride, subpallidum, magis exulceratum;
siquidem ad singulorum pilorum radices foramina sunt, per quæ fertur
humor glutinosus, subpallidus, crassitudinem mellis, aut visci referens,
interdum olei: si inciditur, viridis intra caro apparet. Dolor autem, et
inflammatio ingens est, adeo ut acutam quoque febrem movere consuerint.”
For the second species he recommends as external applications a dried
fig, linseed boiled in mulse, and emollient plasters. To the other he
also directs us to make applications containing figs, turpentine, rosin,
&c. But when these have not the effect, he recommends us to cut the
fungous excrescences down to the sound flesh, and then to dress the sore
upon general principles. (v. 28.) The above account of an affection of
the scalp, which we have often met with in practice, is the most accurate
to be found in any author ancient or modern. We are even in doubt whether
the complaint be at all noticed in modern works on surgery. It is not
to be confounded with the Porrigo favosa, or Porrigo scutulata, of Dr.
Bateman.

Avicenna’s description of the achor and favus is far from distinct.
(iv, 7, 3, 1.) The favi appear to be the pustulæ capitis quæ dicuntur
_alsahafa_ of Alsaharavius. (Pract. i, 11.) His description, however,
is by no means distinct. He approves of general evacuants, and
local applications of a stimulant nature, such as sulphur, mercury,
birthwort, &c. Serapion has not described the favus very accurately,
but he has given a full account of the treatment. He properly forbids
strong applications at first. (i, 3.) Rhases recommends much the same
applications as Serapion. (Ad Mansor. v, 16.)


SECT. XXXVI.—ON THE SIMPLE ULCER.

Since a simple ulcer is merely a division, if one will bring together
the parts which are separated, and apply a circular bandage around, the
divided parts will adhere together without more ado. It is necessary,
however, when at one of its lips the ulcer is everted obliquely, to
begin the bandaging there, and turn it to the opposite side. When it is
deranged both ways, it will be proper to use a double-headed bandage, and
thus to bring the lips together; for when nothing has fallen between the
lips, such as a hair, or a sand, or oil, or filth, or the like, the ulcer
will adhere completely. When the ulcer is large, so that the separated
parts cannot be completely brought together by the aforesaid bandaging,
they are to be first united with sutures, and then bandages are to be
thus applied, and those remedies used which are called agglutinants,
which have the power of drying and consuming the collected moisture, and
prevent more from flowing to the part.

       *       *       *       *       *

COMMENTARY. On ulcers the following ancient authors may be consulted:
Hippocrates (De Ulceribus); Galen (Meth. Med. iii, & iv); Oribasius
(Synops. vii); Aëtius (xiv); Actuarius (Meth. Med. iv, 16); Nonnus
(Epit. 259); Pliny (H. N. xxxii, 44); Celsus (v); Octavius Horatianus
(i, 19, 20); Scribonius Largus (94); Avicenna (iv, 4, 1, 2, 3); Serapion
(vii, 28); Averrhoes (Collig. vii, 32); Haly Abbas (Pract. iv, 18);
Alsaharavius (Tract. xxix, 2, 2); Rhases (Ad Mansor. vii, 3; Divis. i,
138; Contin. xxviii.)

The author of the Hippocratic treatise quoted above particularly praises
wine as a lotion for ulcers; and we may mention that Dr. Hosack, an
intelligent American writer, states it as his opinion, that the surgeons
of the present day might learn from him an important lesson upon its
utility in such cases. He condemns the use of oils and fat.

Of all authors, ancient or modern, Galen has laid down the principles
upon which ulcers ought to be treated with the greatest precision.
He defines an ulcer to be, “a solution of continuity,” a definition
evidently very comprehensive, and including wounds as well as cases of
spontaneous ulceration. His directions for the treatment of a simple
ulcer or fresh wound are similar to those of our author; that is to say,
he directs us to bring the lips of it together, and secure them with a
bandage, or, if that is not sufficient, by sutures or clasps. Wine he
pronounces to be the best of all applications to ulcers, in as far as
they are ulcers.

Our author copies very closely from Oribasius.

In applying the bandage, Aëtius directs us to begin above the sore if
only one simple bandage is to be used, but if two are necessary, as in
fractures, he recommends us to begin at the ulcer and proceed upwards,
and in like manner to begin again at the ulcer and roll downwards. He
forbids us to loose the bandages oftener than every alternate day; and
directs us not to apply water to the ulcer, but to remove the sanies with
a soft, dry linen cloth.

Celsus describes very accurately the treatment of a recent wound or
simple ulcer. He approves, according to circumstances, of bandages,
clasps, or sutures, and his directions respecting the application of them
are highly important, but too long for our limits. After the sore is
dressed he directs us to apply over it a sponge soaked in vinegar, or, if
that cannot be borne, in wine or cold water. This practice is deserving
of imitation. He says afterwards: “Optimum etiam medicamentum quies est:
moveri et ambulare nisi sanis alienum.”

Octavius Horatianus directs us to avoid the bath, the fire, the sun, cold
air, loud cries, intoxication, venery, and passion, lest these should
occasion a rupture of the parts which had adhered.

Avicenna with his usual good sense gives judicious directions for the
treatment of simple ulcers, but his principles are nearly the same as
those laid down by Galen. He defines an ulcer to be “a solution of
continuity, attended with a discharge of sanies or pus.” This seems
to be an unexceptionable definition. He forbids all oily and watery
applications, and recommends us to observe that no body intervene
between the lips of the wound when the bandage is applied. Rhases gives
similar directions. He condemns the practice of those who put oil
into a wound, and who allow the patient to take wine and heating food.
Averrhoes lays down similar rules with considerable precision. Haly Abbas
and Alsaharavius follow the practice of Galen without the slightest
alteration.

Considerable difference of opinion has prevailed respecting the nature
of the clasps (Fibulæ ἄγκτηρες) recommended by Celsus and other ancient
authorities. Rhodius and Le Clerc maintain that no more was meant than
a _simple interrupted suture_, but to this opinion we cannot subscribe.
(See Le Clerc, Hist. de la Méd. iv, 2, 5, and Fabricius of Aquapendente
Œuvres Chirurg. ii, 108.) They would appear to have been metallic clasps
of a peculiar construction.


SECT. XXXVII.—ON AGGLUTINANTS.

Oak leaves applied, and those of the willow and cabbage; the fruit,
leaves, and bark of the mezereon, and the juice of the more austere
plantain, papyrus soaked in oxycrate or wine, and wrapped round in a
circular manner. The following are agglutinants of fresh wounds: the
leaves of the pine and spruce fir, and their fresh bark wrapped round
like a bandage, with water, oxycrate, or wine; and new cheese pounded.
But we must apply externally the leaves of dock, or of vine, or of beet,
or of lettuce. But cheese made of acid milk cures even the larger sores;
and the wild pears repress the discharge. The horse-tail (Hippuris) may
be applied with advantage, even if the tendons are divided asunder; and
the matured woad may be used to indurated bodies even when they occur in
the heads of muscles. The leaves and shoots of cypress, and its recent
and soft balls (pilulæ) may be applied to indurated parts, but we must
mix with it some of the fine dust taken from a wall near a mill. Myrrh
rubbed with water, or frankincense and earth worms, agglutinate even the
divisions of tendons; also, cinquefoil leaves with honey, and garlic
burnt and applied. Old ulcers again are remedied by barley burnt with
cerate, and by ceruse with a quadruple quantity of myrtle cerate. For
ulcers on the head sprinkle dried myrrh, and do not moisten it, for it
will speedily produce adhesion. Or, having triturated dried aloes or
birthwort, and having boiled it with honey in wine until it is of a
proper consistence, spread upon a pledget and apply it. Of the compound
agglutinants are those called the Barbarous, the Golden, that ascribed to
Nicolaus, that from willows and dittany, and others of a similar nature,
which can produce the adhesion even of very large sores.

       *       *       *       *       *

COMMENTARY. Celsus gives the following list: glutinant vulnus, myrrha,
thus, gummi, præcipueque acanthinum, psyllium, tragacantha, cardamomum,
bulbi, lini semen, nasturtium, ovi album, gluten, ichthyocolla, vitis
alba, contusæ cum testis suis cochleæ, mel coctum, spongia, vel ex aquâ
frigidâ, vel ex vino, vel ex aceto expressa, ex iisdem lana succida: si
levis plaga est etiam aranea.

Our author’s list is copied from Oribasius. Aëtius has a long chapter
on the composition of applications for agglutinating fresh wounds. The
ingredients of them are most various: sumach, litharge, wax, galbanum,
bee-glue, turpentine, alum, chalcitis, &c. Actuarius merely extracts a
few articles from our author’s list.

Avicenna’s list scarcely differs in any one particular from our author’s,
and nearly the same may be said of Haly’s. Isaac (ap. Rhasis Contin.
xxviii) particularly commends bdellium and myrrh, with honey and wine.

Galen has explained at considerable length the principles upon which
these applications should be used. Agglutinants, he remarks, are austere
and astringent medicines, being such as occasion a contraction and
condensation of the fleshy fibres; and they must not possess detergent
properties. They are principally applicable in the case of plane ulcers,
that is to say, ulcers without loss of substance. (See Meth. Med. iii.)


SECT. XXXVIII.—ON PAINFUL AND INFLAMMATORY SORES.

To painful and inflamed wounds desiccant and anti-inflammatory remedies
must be applied. Of liquid remedies the best is wine, but oxycrate
is also a good remedy. But if the ulcer is foul as well as inflamed,
much diluted hydromel may be used. Of dry medicines, those in general
will apply which are mentioned for phlegmons, except such as are oily
and acrid. This is a particularly excellent one: Having boiled the
sweet pomegranate in wine and pounded, apply it. This is an admirable
application and much used, for it applies to ulcers of the head, and
those of the privy parts, and to very painful sores on all parts of the
body, and to inflammations of the eyes. But if the erysipelas or the like
attack an ulcer, we must have recourse to the remedies described for them.

       *       *       *       *       *

COMMENTARY. Hippocrates gives a long list of applications for inflamed
sores. We have mentioned above that wine was one of his favorite
remedies. If erysipelas come on, he directs us to purge either upwards or
downwards.

Galen explains general principles. Our author copies closely from
Oribasius.

Avicenna and Rhases agree with Paulus in approving of cooling or
desiccative applications, such as a decoction of sweet pomegranate in
Pontic wine. This application is recommended by Haly Abbas, who also
mentions a cataplasm containing opium.


SECT. XXXIX.—ON UNCONCOCTED ULCERS, AND SUCH AS HAVE NOT SUPPURATED.

Recent ulcers, and such as being in an inflammatory state have not
suppurated, may be digested and made to suppurate by these things: of
simple things, tepid water poured on them, wheat flour, or chondrus,
or bread, or glue for books, applied with turpentine, wax, saffron,
frankincense, pitch, rose oil, axunge, or the fat of calves; but the
compound application called tetrapharmacon may be applied upon a pledget
mixed with rose oil. Old and callous ulcers are concocted by these simple
medicines: the dried grape, storax, galbanum, myrrh, Cretan cistus,
pitch, rosin, butter, Egyptian mastich and unwashed wool; and by these
compound ones: Galen’s plaster without wax, dissolved in oil of ricinus,
and applied upon a pledget with old oil, or oleum ricini; and in like
manner those called dichromos and basilicon, and the like.

       *       *       *       *       *

COMMENTARY. Celsus’s list is not very different from our author’s:
Concoquunt et movent pus, nardum, myrrha, costum, balsamum, galbanum,
propolis, styrax, thuris et fuligo et cortex, bitumen, pix, sulphur,
resina, sevum, adeps, oleum. These articles furnish the ingredients of
most of our modern applications. For further information respecting each
article, the reader is referred to Dioscorides, Galen, and Serapion.


SECT. XL.—ON HOLLOW ULCERS.

The hollow ulcer requires the filling up of the deficient flesh, the
_materiel_ of which is a moderate quantity of good blood. Wherefore we
procure a moderate supply of it by a sufficiency of food, and produce
a proper temperament of the sore by food of wholesome juices, and a
suitable temperament of the part in which the sore is seated. With regard
to the discharge, that which is thin renders the sore more humid, and
that which is thicker makes the sordes adhere to it; on that account it
requires applications that are moderately desiccant and detergent; such
as frankincense, the flour of barley, that of beans and tares, iris,
birthwort, calamine, panax, and pompholyx. When one incarnative remedy
does not answer another must be tried. But if the sordes of the ulcer
appear greater, and the ulcer more humid, it is to be understood that the
medicine has not dried properly, and its powers are to be increased by a
mixture of honey. If it is clean, but with less moisture than natural,
the medicine has dried more than was proper, and we must apply a cerate
mixed with more oil. It sometimes happens when the application is too
strong, that the flesh is melted down, so that the ulcer appears foul and
moist, like those which have been imperfectly dried; but that from the
melting of the flesh becomes more hollow, its lips are callous, and it
is red and inflamed; and sometimes the patient has very acute pain. But
the other, which arises from the applications being less desiccant than
proper, is attended with none of these characters. Wherefore the caries
of wood, more especially of such as is possessed of a moderate degree
of astringent and detergent qualities, as that of the elm, purges and
incarnates clean ulcers; or anemone may be applied for the same purpose.
Having shaven down the bark of the pine and pounded it with cerate, and
rubbed it upon pledgets, apply it to hollow ulcers, more especially to
such as are recent, for it will fill them. The compound medicines for
ulcers which are clean, are, that from snails, that ascribed to Manetho
from the lees of wine, that from aloes, the dry powder called meletera,
that containing equal parts of starch, of manna, of halica, and of
tares; and in like manner, the composition from frankincense and that
called aphroditarium. But when the ulcers are fouler the powders called
cephalic are to be applied, and of those applications that are made upon
pledgets, that called trophos, the isis and the athena, and that from
distaff-thistle (atractylis,) and moreover that called Italicum, and any
others of tried efficacy.

       *       *       *       *       *

COMMENTARY. The resemblance here pointed out between an ulcer too
strongly stimulated and one too little is highly deserving of attention.
Our author appears to have borrowed his description from Oribasius, who
however abridges it from Galen. Galen and Aëtius give a somewhat fuller
account than our author, but their principles of treatment are the same.
They remark that frankincense in humid intemperaments engenders flesh,
but in dry ones only pus. Pompholyx burnt and washed; calamine and
the shells of oysters are said to be incarnant and dissiccant without
pungency. Galen inculcates that the greatest difficulty in treating these
ulcers, is to find out the nature of the intemperament of the part, and
correct it.

Celsus gives the following list of incarnants: Carnem alit et ulcus
implet resina pinea, ochra attice, vel asterace, cera, butyrum. He
recommends the use of hot water; an application consisting of butter,
roses, and a small portion of honey; or the tetrapharmacum with roses. He
approves of giving wholesome and nutritious food, such as fowls, venison,
pork, and even wine. The list of the Pseudo-Dioscorides contains nearly
the same articles as that of Celsus. (Euporist. i, 186.)

Octavius Horatianus recommends a composition of equal parts of honey,
turpentine, rosin, and wax, melted in a vessel; or a mixture of powdered
rosin, wax, and fat.

Scribonius Largus recommends basilicon, and a composition consisting of
calf’s marrow, the fat of geese, butter, stag’s marrow, wax, turpentine,
honey, and roses.

Avicenna remarks, that in treating hollow ulcers we must not use very
desiccative applications, as they dry up the fluids which are necessary
for forming flesh; nor for the same reason, very astringent applications,
nor abstergents of any greater strength than to remove the sordes. Rhases
recommends a mixture of equal parts of olibanum, aloes, sarcocolla,
and dragon’s blood. Camphor is an ingredient in one of his incarnative
applications. Alsaharavius makes mention of an application from olibanum,
like that of Rhases.

All the ancient authors say that round ulcers are more difficult to
heal than those of any other shape; and Cassius Medicus and Alexander
Aphrodisiensis assign various reasons for this, the most probable of
which seems to be, that in this case the sound parts are further removed
than in any other.

Apollonius Dyscolus states that ulcers are prevented from healing by
pregnancy, by disease of the spleen, and by varicose veins. (Histor.
Mirab. 42.)


SECT. XLI.—MEDICINES FOR CLEANSING FOUL ULCERS.

Foul ulcers, whether hollow or level with the surface, may be properly
cleansed by birthwort in honey, turpentine with an equal portion of rose
oil and honey, or instead of rose oil butter may be substituted, with
Illyrian iris and honey; and by pickled olives applied. To nervous parts,
turpentine melted with butter may be applied. When the sores are very
foul and spreading, horehound with honey is a good application, which
removes the eschars. The following are compound applications: Of boiled
lees of oil, of scummed honey, of the species of alum called phormion,
equal parts.—_Another_: Of the dried serapias, called also triorchis, of
Illyrian iris, of dried horehound, of birthwort, of each, dr. viij; of
the flour of tares, dr. x; use in a powder and with honey. And for foul
ulcers the Egyptian cerate is useful, also those from salts when melted,
the Indian, that called athena, the green plasters diluted, the powder of
dried pumice stone, those from tares, the trochisk called melanchlorus,
and in like manner that called criogenes.

       *       *       *       *       *

COMMENTARY. The following are the most important articles in Celsus’s
long list of substances for cleansing ulcers: Purgant, ærugo,
auripigmentum, quod ἄρσένικον a Græcis nominatur; (huic autem et
sandarachæ in omnia eadem vis, sed validior est) squama æris, thus,
resina, et pinea, et terebinthina liquida, misy, chalcitis, galla,
sulphur, pix, oleum, ruta, ammoniacum, &c. Hippocrates makes mention
of many of these, namely, arsenic, verdigris, flowers of copper,
frankincense, myrrh, hellebore, &c.

Scribonius Largus recommends honey, Illyrian iris, and a compound
application containing arsenic, scales of copper, elaterium, and burnt
paper.

One may find in Galen and Aëtius many compound applications, but as they
are all formed from much the same ingredients as those of our author, it
will be unnecessary to take further notice of them. Aëtius commends a
combination of turpentine and honey.

Avicenna and Haly Abbas recommend the same applications as our author.
They make no mention of arsenic. Alsaharavius gives very particular
directions for treating these ulcers; when the edges are hard, he directs
us to rub them until they become red, or to cut them off and apply to
the sore the green ointment; and when the ulcer is covered with much
sordes, he recommends us to dress it with the Egyptian ointment. Rhases
mentions antimony as an excellent application for cleansing foul ulcers.
He properly recommends us to consider whether the foulness of the ulcer
be the effect of too much or too little stimulation. He relates a case of
the former description, in which the sore got worse under the application
of the green ointment. (Cont. xxviii.)


SECT. XLII.—FOR WORMS IN ULCERS.

For worms which form in ulcers, the first thing to be done is to stop the
humidity and the putrefaction which occasion them. Worms may be killed by
all the things in general which are described for those in the ear. But
for those which form in ulcers Archigenes says, mix equal parts of ceruse
and poley with liquid pitch, and anoint with it.

       *       *       *       *       *

COMMENTARY. Aëtius recommends dried plantain, the ashes of the wood of
figs, and the juice of calamint. Galen and Avicenna also mention calamint.

Pliny mentions the gall of frogs.


SECT. XLIII.—ON FUNGOUS ULCERS.

The fungous flesh of ulcers is to be removed by medicines which are
powerfully desiccant, such as diphryges sprinkled upon it, the squama
æris, all the testacea burnt, both the echini (the hedgehog and
sea-urchin,) burnt entire. But the following things are moderately
cleansing, and repress the fungous flesh: the flower of the Asian stone,
and still more powerful than it, the sori and chrysocolla, chalcitis
and misy (when burnt they are less caustic,) and the flos æris in like
manner; but verdigris is the most powerful of all. Salts, when burnt,
consume the foul flesh, and in like manner charpie that has been soaked
in strong brine and dried, consumes fungous flesh that is moderately
large. But verdigris with the squama æris is powerfully repressing. Of
the compound applications the powder called rhodium, and the psarum, and
that named yellow, repress fungous growth without being pungent. But the
trochisks called phaustiani, when levigated and sprinkled on the sore,
and the dry medicine (or powder) called heliocaes, make fungous flesh
slough off to the bottom. But the application consisting of equal parts
of calx viva, squama æris and manna, answers with fungous flesh; with
honey it cleanses such as resemble a mushroom, and with cerate it proves
incarnating.

_A powder for keeping down fungous flesh_: Of litharge, of chalcitis,
of verdigris, of plumbago, equal parts.—_Another_, which represses
strongly without being pungent, and applies also to spreading ulcers,
and more especially the epulis of the gums, and whitens the teeth: Of
quicklime, lb. j; of arsenic, oz. vj; having triturated the dried arsenic
with water, add the lime washed like calamine, and, having rubbed them
together dry and use. And of the trochisks, that called pantolmios, and
those described for polypus, are excellent for repressing fungus in
ulcers. But the green plasters, more especially the one from Cappadocian
salts, and in like manner the isis, are most effectual in preventing
fungous flesh in ulcers.

       *       *       *       *       *

COMMENTARY. The powerful applications mentioned by our author will be
found amply sufficient to fulfil every intention in conducting the
treatment of these ulcers. Many of them are mentioned by Hippocrates.

Galen lays it down as a rule that these fungous excrescences are to be
repressed by powerfully desiccative substances, such as misy, chalcitis,
or more especially verdigris; when burnt and washed they become mild
detergents. (Meth. Med. iii.)

Aëtius gives many useful prescriptions for such preparations, but they
are entirely formed of the ingredients which enter into those of our
author.

Celsus gives a long list of caustics highly applicable in such cases:
Adurunt, auripigmentum, atramentum sutorium, chalcitis, misy, ærugo,
calx, charta combusta, sal, squama æris, veratrum et album et nigrum,
cantharides, sandaracha, alumen scissile, &c. Pliny speaks of a
composition of unwashed wool, with barley flour, and verdigris.

Octavius Horatianus recommends the Phrygian stone pulverized, and a
powder consisting of the recrementum plumbi, verdigris, aloe, and
quicklime.

Rhases and Avicenna copy from our author. Haly Abbas speaks of removing
the superfluous flesh with an instrument.


SECT. XLIV.—ON SPREADING ULCERS, PUTRID ULCERS, AND PHAGEDÆNA.

Spreading and putrid ulcers are to be bathed with vinegar and oxycrate,
an astringent wine, cold water, sea-water, or the decoction of lentil,
of pomegranate rind, of the flowers of the wild pomegranate, of lentisk,
of myrtles, of Egyptian thorn, or some other astringent and desiccant
medicine. Cataplasms are to be applied to them of the flower of tares and
liquid alum, the inner part of bread made of similago, an old goby fish,
or some other old pickle, unwashed flesh, and liquid turpentine; these
things are to be all pounded together in equal proportions. Or the parts
may be anointed with equal proportions of birthwort, and the juice of
the leaves of the Palma Christi, and half the quantity of verdigris, made
with water to the thickness of honey; but if the eschar is not removed
an equal proportion of elaterium is to be mixed with the verdigris.
For putrid ulcers sori levigated and sprinkled on them is an effectual
remedy, and above is to be put dried charpie; or the round birthwort and
galls in equal quantities may be rubbed in with oil; or the root of the
wild cucumber, or of cabbage, or of beet, or the leaves of dock are to
be bound in a piece of linen, and put into ashes; when they are softened
triturate with salt and apply; they will cleanse powerfully. Or apply
green olive leaves boiled in wine with honey; or apply chalcitis, or
parsley seed levigated, or apply linseed triturated with copperas, or use
an application of thyme, dried grapes and boiled figs, or of fig leaves
triturated with honey; or of nitre, cumin, and fine flour with honey;
or of the root of the wild cucumber, or of squill boiled with honey; or
of sori, dr. xij; of chalcitis, dr. x; of misy, dr. iv; triturate with
half an hemina of the strongest vinegar until it is dried, and taking
it off use by dipping a specillum in it, and rubbing it over the ulcer,
and placing above it a double pledget out of wine and oil. But if it is
inflamed apply henbane with polenta, or cabbage with honey.

_For putrid and spreading ulcers on all parts of the body._—Of quicklime,
of chalcitis, of each dr. ij; of arsenic, dr. j. This may be used for
pterygia of the fingers, for phagedæna and carbuncle, with honey if on
the genital organs, but dry if on any other part of the body. Above apply
an oblong pledget with rosin.

_An universally applicable powder for all spreading sores, and those
of the mouth, for hemorrhages, and for repressing fungous flesh._ Of
chalcitis, of misy, of both in a crude state, dr. xx; of squama ferri,
dr. vj; of immature galls, dr. viij.

_For spreading and putrid sores._ Of salts, dr. ij; of any species of
alum which has been burnt, dr. j; of squama æris, of burnt pumice stone,
equal quantities. Scraped verdigris, with burnt misy mixed with liquid
pitch; and the flakes of iron with oil also answer well.

_For spreading ulcers of the pudendum._ These things will apply to
them, and also the composition called meliterium, the powder of the
wild myrtle, and that from paper; also the composition from oxymel
called coracion, the trochisk of Andron and the like, will answer with
all spreading ulcers. The same things also apply with phagedæna; for
phagedæna is an ulcer that spreads by eating.

_For foul and fetid ulcers._ The Lemnium sigillum (Lemnian earth) mixed
with vinegar, oxymel, oxycrate, or wine, until it is of the consistence
of clay, may be rubbed on them with advantage; or the leaves of cypress,
its shoots, and tender balls (pilulæ), or the ashes of dried gourd burnt,
or of the burnt bark of the plane tree, or of burnt dill in like manner,
or of foul wool burnt, or of plaintain; also woad by itself or with
polenta, or the dried root of hog’s fennel.

       *       *       *       *       *

COMMENTARY. It will be remarked that the milder applications mentioned in
this section are all powerful desiccants and astringents. Most of them
are mentioned by Dioscorides as possessing these properties.

Galen recommends the compound applications mentioned by our author,
containing verdigris, squama æris, &c.

For these spreading and putrid sores Aëtius, among other prescriptions,
gives one which would no doubt be applicable in the worst cases: “Of
crude misy, of crude chalcitis, ā dr. viij; of ochre, dr. iij; of
sandarach, dr. iv; of quicklime, dr. ij; of the scales of copper, of
alum, ā dr. ij; of diphryges dr. iij; m.” These caustic and escharotic
medicines enter into the composition of many of his applications. Some
of them contain astringents and desiccants, such as sumach, galls, alum,
fossil salts, frankincense, calamine, birthwort, pomegranate rind, &c. In
short the ingredients in his applications correspond with Celsus’s list
of corrosive substances: Rodunt, alumen liquidum, sed magis rotundum,
ærugo, chalcitis, misy, squama æris, sed magis rubri, æs combustum,
sandaracha, galla, thus, auripigmentum, calx, nitrum et spuma ejus,
alcyonium, resina, squama ferri, atrumentum sutorium, veratrum, &c.

The other authorities give only combinations of these substances; for a
full account of which preparations we refer the reader to Galen. (Med.
sec. gen. iv.)

Octavius Horatianus recommends lentils boiled and mixed with honey; the
leaves of cabbage, coriander, or ivy, all mixed with honey.

The Arabians, although they supply nothing new, add their authority
in confirmation of the remedial virtues which the Greeks assigned to
the substances mentioned above. Avicenna and Rhases recommend arsenic,
copperas, misy, sori, chalcitis, flos æris, quicklime, alum, galls,
ammoniac, the trochisk of Andron, &c. When a part becomes black and
putrid, Haly Abbas directs us to open a vein leading to it, if the age
and state of the patient permit, and afterwards to apply odoriferous
things, such as camphor, &c.


SECT. XLV.—ON ULCERS REQUIRING CICATRIZATION.

By drying and constringing the flesh of ulcers requiring cicatrization
to such a degree as not only to dissipate the preternatural superfluity,
but also to touch upon that which is in its natural state, we may render
the surface of the sore like skin, and make the ulcer cicatrize. This is
promoted by immature galls, the moderately desiccant bark of pomegranate,
and whatever else is desiccant without being possessed of pungent
astringency. And such things as these promote cicatrization: myrrh,
litharge, and oysters if burnt, for they must be sprinkled on the sore
dry. And these things often produce cicatrization: pine bark with myrtle
cerate, ivy flowers with cerate, the root of the lily with rose-oil,
dried pine-rosin, burnt pumice stone, the flakes of copper; they are to
be used in equal proportions dry. The following also repress: mix a small
quantity of manna and of diphryges with levigated pumice, and use; or
of litharge p. j; of diphryges p. ss, apply on a pledget with cerate.
Birdlime with frankincense cicatrizes old ulcers, also verdigris with an
equal portion of diphryges and with myrtle cerate, or the small centaury
applied fresh. To the more humid apply the root of cypress. To those
about the anus and pudendum, more particularly if inflamed, use levigated
aloes, either in a dry state or with water, or squama æris; or soften
chrysocolla in the sun with wax, and apply.

_A dry application for producing cicatrization._ Of oysters, dr. xij;
of manna, dr. vj; of calamine, dr. iv. It applies also to spreading
sores.—_Another_: Of birthwort, dr. vj; of pine bark, dr. vj; of manna,
dr. vj; of pumice, dr. iv; of Colophonian rosin, dr. iv; of iris, dr.
iv.—_Another_: Of hart’s horn burnt, dr. iv; of pine-bark, oz. vj:
of ceruse, oz. iv; of scraped verdigris, oz. ix; of calamine, dr.
xviij.—_Another_: Of the flowers of pomegranate, of copperas, of each,
dr. xvj; of squama æris, of fissile alum, of each dr. viij; of galls, dr.
j.—_Another_: Of ceruse, of litharge, of each, oz. viij; of the dross of
lead, of galls, of dried myrrh, of each, dr. iv.

_A cicatrizing application._ Take of fissile alum, oz. j; and having
levigated it, macerate in a sextarius of water: when dissolved in the
water soak pledgets in it, and having dried them apply.

_A plaster for cicatrizing the more simple ulcers._ Of wax, dr. xl; of
litharge, dr. xxxv; of diphryges, dr. viij; of myrtle-oil, half a hemina.
The plaster called phœnicinum, that from calamine, the myrsinatum, and
the like, are also applicable in such cases. For ulcers of difficult
cicatrization: Of wax, of myrtle-oil, of each, dr. vj; of calamine, oz.
vj; of lead, of frankincense, of each, dr. ij; of fissile alum, of burnt
copper, of each, oz. j; of scraped verdigris, dr. ij; dissolve them
singly. For chronic ulcers, and such as are of difficult cicatrization:
Of calamine, dr. viij; of chrysocolla, dr. viij; of fissile alum,
dr. viij; of verdigris, of the flakes of copper, of each, dr. j; of
pine-rosin, dr. xl; of wax, dr. c; of myrtle-oil, q. s.—_Another_: Of
wax, of pine-rosin, of each, oz. vj; of calamine, oz. vj; of crude
chalcitis, oz. iij; of myrtle-oil, q. s. The calamine and the chalcitis
are to be triturated with wine during the season of the dog-star; use it
upon a broad compress, and apply above it a pledget and sponge out of
wine.—_Another_: Of burnt copper, oz. ij; of fissile alum, oz. ij; of
sal ammoniac, dr. ij; of wax, oz. vj; of Colophonian rosin, oz. vj; of
myrtle-oil, oz. ij; the dry things are to be triturated in the vinegar in
the sun for twenty days, and when it becomes of the consistence of honey,
having melted the wax, mix it and soften. The medicine from pumice-stone,
the isis, and the like, are also applicable in such cases.

       *       *       *       *       *

COMMENTARY. Celsus gives the following list of the more active articles
of this class: Crustas ulceribus tanquam igne adustis inducunt, præcipue,
chalcitis, utique si cocta est, flos æris, ærugo, auripigmentum, misy, et
id quoque magis coctum.

For a variety of applications suitable to this class of ulcers, we refer
the reader to Galen’s 4th book of ‘De Med. sec. gen.’ The ingredients
of them are powerfully desiccative, astringent, and escharotic. Many of
our author’s prescriptions will be recognized in it. For an account of
the isis, and the other compound medicines mentioned towards the end of
this section, we refer the reader to Galen (l. c.) and to the Seventh
Book of this work. Galen, in another place, and after him Aëtius, give
the following important directions for the use of these applications. The
ulcers to which this mode of treatment is applicable, being very foul
and filled with a vitiated discharge, are first to be wiped clean with
a soft linen cloth, and then the cavity of them is to be filled with
the medicine, and a splenium (oblong compress) applied externally. Then
having put a piece of linen above the splenium and bound it on, we are to
place over it a sponge squeezed out of cold water or wine, endeavouring
to keep the sponge cold during the whole time of the treatment, which
may easily be done by pouring cold water upon it without loosing the
bandages. They are not be removed until the third day. Galen states
that the articles which answer best in such applications are galls,
pomegranate-rind, alum, chalcitis, misy, and the like.

A similar mode of treatment, without any material alteration, is
described by the Arabians. Haly Abbas remarks, that cicatrizing medicines
are powerfully desiccative with some astringency, such as galls, alum,
and the like.


SECT. XLVI.—ON THE MALIGNANT ULCERS CALLED CHIRONIAN AND TELEPHIAN.

Old ulcers which are difficult to get cicatrized are called chironian, as
if requiring Chiron himself to cure them; and telephian, from Telephus
having long laboured under such a sore. We must attend then whether
the whole body being in a state of cacochymy, sends such defluxions to
the ulcer, and the prevailing humour is to be evacuated by appropriate
remedies. Or if it is a varix which sends these humours to the legs, the
ulcer being in it, it is to be cured as will be described in the Surgical
part of this work; or the humours are to be evacuated by venesection,
taking away blood frequently, and then using topical applications which
have the property of extirpating the disease without being pungent. These
therefore are simple applications; those from pumice and diphryges, and
flakes of copper, verdigris, and lime moderately washed; sprinkle fissile
alum levigated, or of unwashed wool, dr. iv; of dried grapes, dr. iv; of
natron, dr. ij; having previously anointed with honey, sprinkle of flakes
of copper, dr. x; of alum, dr. ij; and having softened in the sun with
dr. x of wax, apply.

These are compound medicines. _A plaster for chironia._ Of ceruse, oz.
viij; of fissile alum, oz. ij; of the flakes of copper, dr. ij; of sal
ammoniac, of frankincense, of scraped verdigris, of pomegranate rind,
of each, oz. ij; of quicklime, oz. j; of wax, lb. j; of myrtle-oil, lb.
j. ss; triturate the dry things with wine. At first it removes callus;
and it is laid by and kept, and at last when used, being softened with
myrtle-oil, it cicatrizes.—_Another_: Of litharge, lb. j; of oil, lb.
ij; of black chamæleon, of the roots of birthwort, of immature galls, of
each, oz. j; of galbanum, of ammoniac perfume, of frankincense, of each,
oz. ij; prepare, stirring with the roots of green reeds.

_From Archigenes, for chironia, and malignant ulcers in the legs and
breast, for struma, and parotis._ Of the fat of an ox lb. iij; of
turpentine, oz. v; of manna, oz. vij: of the earth called sarda which
painters use, oz. v: having put the soluble and dry articles together
and melted, use.—_Another_, of Archigenes: Of wax, oz. iv; of oil of
unripe olives, of manna of frankincense, of diphryges, of the flakes
of copper, of each, dr. iv; having triturated the powder with vinegar,
and made of the thickness of honey, mix with the cerate, and use upon
a pledget.—_Another_, for the malignant ulcers of women, and of other
persons having a soft skin: Of Tuscan wax, dr. viij; of bulls’ fat,
of turpentine, of burnt lead, and of pepper, of each, dr. j; use on a
pledget with rose-oil or myrtle-oil.

       *       *       *       *       *

COMMENTARY. Celsus describes the chironian ulcer as being large, and
having hard, callous, and swelled edges, with a copious discharge of thin
sanies. It is attended with no inflammation, the pain is moderate, it
does not spread, and therefore it is not dangerous, although not readily
cured. Sometimes, he says, it becomes covered with a thin cicatrix, and
then again the ulcer breaks out. It occurs mostly in the feet and legs.
From this description it is evident that by the chironian ulcer Celsus
meant merely an ill-conditioned ulcer, and that he distinguished between
it and the _cacoethes_, or malignant ulcer, which last he held to be
nearly allied to the carcinoma. However, most of the Greek authors apply
the term malignant to the chironian ulcer. For the cure of it Celsus
recommends an application consisting of squama æris, lead burnt and
washed, calamine, wax, and a small quantity of roses.

Galen furnishes us with an account of the manner in which Thessalus the
Methodist proposed to cure all chironian and malignant ulcers. Thessalus
lays it down as a rule for the treatment of all sores which are difficult
to cure, or which break out again when healed, to remove the exciting
cause, whether local or constitutional, by means of proper alteratives.
He adds: “In cases of chronic ulcers which cannot be got healed, we
must remove the parts which prevent adhesion, and convert the sore into
the state of a recent ulcer; and then having allayed the inflammation
proceed accordingly. Those sores which heal up and break out again during
their exacerbations, and when ulcerated, are to be cured like recent
inflammations by soothing applications until the irritation subside,
after which cicatrizing applications are to be used, and then the
surrounding parts are to be covered with a malagma of mustard, or some
other rubefacient and alterative, to remove the indolence. If this is not
sufficient, we must attend to the general health, attempting to effect a
change of the system by repeated exercise, gestation, a diet increased
or diminished according to circumstances, and at the commencement by
administering an emetic of radishes, or even the white hellebore.”
(Galen, Meth. Med. iv.) Although Galen, who all along displays a strong
hostility to the _Thessalian asses_, (so he calls the Methodists,) has
animadverted in severe terms upon the rules here laid down, they would
appear to be highly proper and ingenious. Galen in another place (Med.
sec. gen. iv) gives from Asclepiades, Andromachus, and others, a great
collection of applications for chironian, malignant, and indolent ulcers.
One by Asclepiades consists of the scales of copper, scraped verdigris,
wax, and larch rosin. Others by Andromachus contain sori, misy,
chalcitis, verdigris, alum, turpentine-rosin, and the like, mixed with
wax. Hippocrates directs us to treat a callous ulcer by applying to it
septic medicines to make the hard parts slough off, after which the edges
are to be brought together. (De locis in homine.)

The directions of Aëtius, more especially respecting the constitutional
treatment, are highly important. In cases where there is a redundance of
blood he recommends venesection, in others both purging and bleeding; and
in certain cases he directs us to pay attention to the state of the liver
and spleen. He relates a case of an ulcer on the hand, which he cured by
opening a vein leading to it. He also directs us to scarify or cut off
the callous edges of the ulcer. He gives various prescriptions for sores
of this description, containing verdigris, sori, chalcitis, burnt copper,
alum, &c.

Octavius Horatianus recommends a plaster consisting of equal parts of
chalcitis, wax, and alum. For phagedænæ Pliny mentions an old shad-fish
triturated with sandarach. (H. N. xxxii, 44.)

The Arabians treat of these ulcers very fully. Avicenna in particular
gives very proper directions for the constitutional treatment. When
the state of the ulcer is occasioned by an intemperament, it is to be
corrected, and if the blood is deficient in quantity or quality, this is
to be remedied by a proper diet; and when on the contrary it is connected
with plethora, venesection is to be had recourse to, and if the veins
leading to it are varicose, it may be proper to open them. When the sore
is kept from healing by a spiculum of bone, we are to cut down and remove
it. His applications consist of the same ingredients as those used by
the Greeks, namely, the flower of copper, copperas, alum, ceruse, lime,
arsenic, &c., mixed with wax and oil. The directions given by Rhases are
less circumstantial, but to the same purpose. He particularly directs us
to remove the callous edges by friction, scarifications, and septics.
He speaks of turpentine as an excellent addition to other ointment.
(Contin. xxviii.) He mentions that in case of malignant ulcer on the leg
connected with varix, Galen opened the enlarged vein.

The _cacoethes_ of Celsus was evidently the disease called _noli me
tangere_ by Theodoricus; a very absurd appellation, which however has
been retained to the present day. Celsus has pointed out its resemblance
to carcinoma, and recommended the only mode of treatment which ever
does any good in these cases, namely, the application of septics, such
as arsenic, quicklime, &c., or the actual cautery. As our limits will
not permit us to enlarge further on this subject at present, we must be
content with referring to No. 108 of the ‘Edinburgh Medical and Surgical
Journal,’ where we have given a full exposition of the ancient principles
of treatment. (See also the Commentary on s. xxvi of this Book.)


SECT. XLVII.—FOR BLACK CICATRICES.

Let the root of the white and black bryony be boiled in oil until they
are reduced to the state of juice, and the oil applied will take away
black scars; and so in like manner calamint boiled in wine, and litharge
washed with white rose-oil. But the scars from lichen, and all other
kinds are made like the other skin by anointing them with the fat of
asses; or the seed of rocket triturated with the gall of a goat, of an
ox, and of a sheep may be rubbed in with litharge; or a lamb’s foot
burnt may be triturated with austere wine for the same purpose; or,
ammoniac perfume may be rubbed in with swines’ gall. These are compound
applications: Of litharge, of mint, of frankincense, equal parts with
honey.—_Another_: of natron, of ammoniac perfume, of sulphur vivum, of
myrrh, equal parts; having triturated with vinegar, white wine, or water,
rub in but a very little, so as not to produce an ulcer.—_Another_: Of
Cimolian earth, of pigeons’ dung, of soap, of frankincense, equal parts
with vinegar. A detergent ointment for black scars: Of Cimolian earth,
dr. xiij; of aphronitrum, dr. v; of white hellebore, dr. v; of the greasy
dregs of nut-ben, dr. iv; scrub with it while in the bath.

       *       *       *       *       *

COMMENTARY. Avicenna condenses all the information contained in the
authors who preceded him. He sets out with stating that the class of
medicines which are applicable in such cases are the abstergents; of
which he enumerates verdigris, stavesacre, the scales of copper, and even
arsenic. Among the less active ingredients he mentions, like our author,
the fat of asses. We need not give extracts from the other authorities,
as no one has treated of this case so fully as Avicenna.


SECT. XLVIII.—ON SINUOUS ULCERS.

When the skin adjacent to an ulcer is not united with the parts below,
we call such a complaint a sinus. When, therefore, the sinus extends
upwards, the ichor readily flows out from the sore, and adhesion easily
takes place; but when it extends downwards the ichor by remaining within
corrodes the continuous parts, and unless you first make an incision
for its discharge, you will be able to effect nothing; for the sores
can neither be incarnated nor the parts made to unite. But if the sinus
is in any of the limbs, as the arms or legs, one may produce adhesion
without a counter-division by putting the limb in a declining position.
Thus when the sinus is in the arm, and the mouth of the sore is near the
elbow, by placing the hand in an elevated position, you will render the
discharge from the ulcer below easy. And when the sinus is in the thigh,
and has its outlet near the knee, you must make the position declining
by putting a soft pillow below the back part of the knee, so that the
groin may be in a lower position than the knee; and if the sinus does not
require incarnation, forthwith by means of a straight and hollow pipe
having a bladder attached to it, syringe it with honey so diluted with
water that one could drink it, in order to clear away the ichor from the
sinus. For promoting adhesion when about to take place, do it with wine,
or wine and honey, and then proceed to the agglutinating medicine. But
if the sinus being hollow requires incarnation, first inject a little
of the composition from dried paper with much rose-oil, then plug up
the mouth of it with charpie, and afterwards the plaster of iris, or of
Machærion, or of some such, may be melted with liquid rose-cerate, and
injected in like manner. If the sinus is moderately incarnated you may
apply some of the agglutinating medicines, as if you were curing a case
of recent bloody wound. Such are those called the barbarous, dichromos,
and gilvus; and more especially that prepared from the oil of palma
Christi and the metals without wax which is called the dun plaster of
Galen, is applicable. After the application of the medicine, a recent
sponge out of wine and honey, or wine alone, is to be put on particularly
in a soft manner, and the bandaging is to commence at the bottom of the
sinus and end at its orifice. The folds of the bandage should bind the
bottom of the sinus firmly, yet so as not to occasion pain, but ought to
be gradually relaxed towards its orifice; and the plaster which is put
on should be so cut as to leave an opening at the orifice for the escape
of the matter, but another small plaster of the same materials should be
applied to it in a loose state, so as to favour the discharge. This is to
be left on till the bandages are loosed, which is to be done on the third
day, when they are to be taken off and changed, but the application along
the sinus is to be left. You may judge whether the bottom of the sinus
has adhered, from observing if the matter be small and well concocted,
or if there be no discharge at all; and moreover if there be no sensible
pain along the sinus nor swelling, but the whole part is contracted,
dry, and free from pain. But if you see a little well concocted pus at
the orifice, you may still more confidently entertain good hopes. If on
the second or third day a thin ichor be discharged from the sinus, you
need not despair that adhesion has taken place, for often the strength of
the medicine squeezes out from the parts below a thin fluid, which being
discharged the parts become dry and adhere. But if on the third or fourth
day from the commencement the matter appear unconcocted as it runs from
the opening, you may be sure that the sinus has not adhered, and you must
persevere with the same application. When owing to the moisture of the
part it falls off, as is not unlikely, it will not be improper to make
some change in the medicine itself.

_On sinuous ulcers with a thin covering of skin._ When the abscess is too
long opened, owing either to the unskilfulness of the surgeon, or the
timidity of the patient, the skin which lies over it becomes thin and
ragged, and it cannot be removed, then after the syringing which has
been described, we must have recourse to an agglutinating application of
a humid consistence, but of desiccative properties, such as that from
chalcitis called phœnicinum, diluted with old oil, so as neither to be
very hard nor of such a consistence as not to stain the finger; and
afterwards it is to be mixed with moderately old wine, and applied in a
circular form with corresponding bandaging. To skin in this ragged state
honey, as was said, is not one of the least proper applications when
boiled to the consistence of a plaster and applied. It will be better,
however, if after spreading it on the rag you sprinkle over it from a
sieve some myrrh finely pulverized, or aloes, or frankincense, or all
of these together. I have also found the lesser centaury a wonderful
application for the same purpose; next to it is comfrey, after which is
the root of the Illyrian iris, and after these is the flour of tares.
Sometimes during the process of boiling we sprinkle these upon the honey
when the vessel is about to be taken off from the fire. It is better,
however, to do so after it is taken off, and then it is to be stirred
about, and when it becomes tepid applied to the sinus, and bandaged as
aforesaid.

       *       *       *       *       *

COMMENTARY. Similar directions are given by Galen and Aëtius, but upon
the whole those of our author are superior; and as those of the other
two supply no additional information, it will be unnecessary to multiply
extracts from them. (See Galen, Therap. ad Glauc. ii.)

Actuarius, in like manner, briefly directs that unless the sinus open
downwards, it shall be cut open and dressed with an agglutinative
application. You may think well of the case, he adds, when the part is
dry and free from pain, or when only a little well-concocted pus is
discharged from it.

In the translations of the Arabians, the sinus is described by the names
of _absconsio_ and _caverna_. Avicenna states that the sinus differs
from the fistula in having a larger cavity, and its edges not being
indurated. He lays down very correct rules of treatment, but they are
all copied from Galen. Thus he directs, when the orifice of the sore is
above the cavity of the sinus, that it should be cut open; or, if this
cannot be conveniently accomplished, he recommends us to introduce a tent
smeared with some incarnant or detergent application. Upon the authority
of Dioscorides he recommends the lesser centaury in such cases. His
directions for the application of the bandages are similar to those of
our author.

Celsus, and other of the ancient authorities, do not treat of the sinus
separately from the fistula.


SECT. XLIX.—ON FISTULA.

Fistula is a callous sinus formed for the most part from abscesses,
and deriving its appellation from the pipes of reeds (fistulæ). If,
therefore, it terminate with a bone, it cannot be cured without a
surgical operation, unless in process of time a scale of the bone
come off spontaneously. But if it does not terminate with a bone, it
is to be cured by the applications for removing callosities, and the
agglutinative medicines. The applications for removing callosities are
such as these: the root of spondylium scraped around and applied removes
the callus of fistulæ. And in like manner black hellebore applied
removes the callus in two or three days; also lees of oil boiled and
injected; sori in a crude state, or burnt and injected with some diluted
wine, or sori and crocomagma with hydromel. Or make collyria by mixing
elaterium with turpentine, and apply. Or syringe with the juice of the
root of laserwort. This melts down the callus: of verdigris, dr. xij; of
ammoniac, dr. ij; mix with vinegar, and form into an oblong collyrium.

_A collyrium which I use for removing the callosities of fistulæ._ Mix
with vinegar equal parts of ammoniac perfume, of copperas, of verdigris,
of misy, of chalcitis, and of gum.—_Another_, from the surgical works
of Heliodorus: Of calamine, of misy, of copperas, of burnt copper, of
gum, of each, dr. iv; of crude chalcitis, dr. iij; mix with the urine
of a young person not come to manhood, and form collyria. Put this
collyrium into the fistula, and apply externally the inner part of bread
soaked in water, changing it until the inflammation subside, and the
eschar fall off.—_Another_, which I received in Alexandria: Of the roots
of alkanet, of toasted misy, of chalcitis, of verdigris, of fissile
alum, of copperas, of aloes, of each, oz. j; triturate along with fine
cantharides in vinegar, and make collyria.—_Another_: Of copperas, dr.
ij; of chalcitis, of verdigris, of each, dr. j; mix with ammoniac and
use, and when the callus is thrown off, cleanse with verdigris and eight
times the quantity of the purest honied water; but after the discharge of
the callus, incarnants must be used. An incarnative collyrium: of aloes,
of myrrh, of ammoniac, of the cinders of egg shells, equal parts; having
triturated with water form collyria, and apply.—_Another_: Of myrrh, of
aloes, of frankincense, of pomegranate rind, equal parts, mix with water;
but some use bull’s gall. The oil of unripe olives is incarnative when
injected. I knew a person who injected cedar-rosin into fistulæ, and
succeeded surprisingly. After it is incarnated we must have recourse to
the agglutinative medicine, according to the plan described for other
sinuses. “When the fistula is narrow and long,” says Galen, “and does
not appear to me to contain callus internally, but only sordes, I first
inject lye into it, and then allowing it to remain in the fistula until I
expect that the sordes has fallen completely off, I afterwards apply the
medicine.” It was the one from the oil of palma Christi, mentioned above.

       *       *       *       *       *

COMMENTARY. We shall have occasion to refer to the Hippocratic treatise
‘De Fistulis,’ in the Sixth Book.

Celsus treats of fistulæ with more than his wonted minuteness. This is
his definition: “Id nomen est ulceri alto, angusto, calloso.” He has
described all the complications of it with great accuracy. He directs
us to commence by making an inspection with a probe or sound, so as to
ascertain the state of the parts and of the discharge. If a soft body is
felt at the bottom, we conclude that the fistula terminates in the flesh,
but if a hard one is felt, we know that it ends with a bone. If the probe
slide readily over the bone, it is free from caries, but if it does not
so, and yet no inequalities are felt on it, caries has taken place, but
it is still smooth: if it feel unequal and rough, the bone is eaten with
caries. For a simple and recent fistula, not deep-seated or in a joint,
the plaster for recent wounds will be sufficient, provided salt, or alum,
or the scales of copper, or verdigris, or any of the other metals, be
added to it. The application is to be made upon a piece of linen, and
a sponge soaked in vinegar is to be put over it, and is to be removed
on the fifth day. The patient must live upon nutritious food. If the
fistula is at a distance from the præcordia, emetics with radishes are
said by him to be proper. When the fistula is old it becomes callous, and
requires stronger applications, containing such ingredients as calamine,
atramentum sutorium, verdigris, galls, lime, orpiment, or realgur. He
mentions as a very ready application a solution of ammoniac in vinegar,
with some verdigris added to it. However, he remarks, any other caustic
will accomplish the same purpose. If the fistula is long and transverse,
an incision is to be made at its commencement, after which the collyrium
may be applied. When the fistula is double, or consists of still more
passages, he recommends us to blow in with a writing pen the medicines
in the form of powder, or to apply them dissolved in wine, mulse, or
vinegar. But whatever the internal dressing be, he recommends us to apply
on the outside of it something of a refrigerant and repressing nature,
as the parts around are generally affected with inflammation. When the
dressings are removed the fistula is to be syringed with wine if the
discharge of the pus is copious, with vinegar if its edges are callous,
but with mulse, or a decoction of tares, if the passage be clean. By the
means we have been describing it will generally happen, he says, that the
inner coat of the fistula will slough off, and leave the ulcer in a clean
state. Agglutinants are then to be applied, especially a sponge smeared
with boiled honey. When the sides of the fistula are clean there need be
no apprehension lest they do not adhere, since, he remarks, we often see
in ulcerations of the fingers that without great care one finger is apt
to adhere to another.

In the ‘Euporista’ of the Pseudo-Dioscorides, it is recommended first to
dilate the fistula with a piece of sponge, and then to use a stimulant
application containing verdigris, ammoniac, &c.

Aëtius gives an excellent account of fistula, but it is mostly borrowed
from Galen. We can afford room only for a few extracts. When a fistula
extends obliquely, nothing can be done without making a free incision,
for which purpose he directs us to introduce a sound and cut along it.
His directions for examining into the nature of a fistula are such as
ample experience alone could have dictated. He seems to be decidedly of
opinion that, except in cases of a recent fistula, or when it is not
deep-seated, an incision ought always to be made at first; after which
applications for removing the callus may be used. When, however, the
patient refuses to submit to an operation, and the case is recent, the
cure may be attempted by means of escharotics and incarnants, such as
verdigris, misy, alum, &c., mixed with frankincense, aloes, and myrrh.

Oribasius briefly recommends white hellebore, a mixture of equal parts of
verdigris and ammoniac, and a few other such articles, as applications
for fistulæ.

Scribonius Largus mentions several compound applications containing misy,
chalcitis, verdigris, alum, &c.

Marcellus gives one consisting of ceruse, ammoniac, and oil.

Actuarius gives a brief but distinct account of the nature and treatment
of fistula, but it is taken almost entire from our author.

Avicenna inculcates that a fistula is only to be cured by a free
incision, or by removing the callous sides of it by burning with fire
or caustic medicines, such as arsenic, ammoniac, sulphur, the flour of
copper, or mercury. This in fact is the sum of the medical practice in
such cases. There is nothing particularly interesting in Haly Abbas.
Alsaharavius truly states that a diseased bone is the common cause of
fistulous ulcers not healing, and inculcates that in this case there can
be no hope of recovery until the carious portion be removed. Rhases, upon
the authority of the celebrated Antyllus, directs us to use corrosive
applications when a fistula cannot be operated upon with the scalpel. He
intimates that this is particularly the case when the disease is seated
in the groins.

The earlier modern surgeons, such as Gulielmus de Saliceto, Arnoldus,
Rogerius, Rolandus, and Guy of Cauliac, in imitation of the Arabians,
direct fistula to be treated by the application of septics, the actual
cautery, or incision. Rogerius recommends a tent spread with quicklime
and soap, or with arsenic. Guy of Cauliac, like Avicenna, speaks
favorably of sublimed quicksilver or corrosive sublimate.


SECT. L.—FOR SORES WHICH BREAK OUT AGAIN.

Some sores which have become cicatrized, often after no long time become
inflamed and break out again; for a bone being diseased, sometimes the
flesh which covers it heals up readily and appears sound, but in a short
time a strong defluxion taking place from the corrupted bone below,
inflammation supervenes, and pus is formed which corrodes the cicatrix.
What then is the cure of such ulcers? Dry the diseased bone to such a
degree that it may exfoliate. But the diseased part of the bone may
easily be brought up if you apply a cataplasm, consisting of fig leaves
triturated with fine dried barley flour and wine. Or you may apply equal
parts of the reed of henbane and of copperas triturated together. The
root of hog’s-fennel speedily removes the laminæ of bones.

       *       *       *       *       *

COMMENTARY. This chapter is copied from Aëtius, who gives some additional
prescriptions, such as one consisting of the scales of copper,
frankincense, alum, sal ammoniac, pomegranate rind, and ceruse, with or
without cerate; and another consisting of red arsenic finely triturated
with bear’s fat.

Avicenna recommends strong attractive applications, such as a plaster of
the leaves of the black poppy with fig leaves; and another containing the
atramentum sutorium (sulphate of copper.)


SECT. LI.—ON ULCERS IN THE JOINTS.

The joints being drier than the fleshy parts, they therefore require
when ulcerated more desiccative applications. Wherefore the trochisk of
Polyides, when rubbed with wine until of the consistence of the sordes
of baths, is an excellent application; and in like manner all equally
desiccative medicines. And we have seen them benefited by bathing
with sea-water and brine frequently. Wherefore we must use the most
desiccative applications to the joints.

       *       *       *       *       *

COMMENTARY. This is copied from Oribasius. (Synops. vii, 19.)


SECT. LII.—THOSE THINGS WHICH EXTRACT SHAFTS, JAVELINS, THORNS, AND THE
LIKE.

Javelins, reeds, and shafts, and thorns, are extracted by the two
pimpernels, the round birthwort, ammoniac with honey, the fruit of
henbane triturated and sprinkled upon the part. Mix the pounded root
of calamus with honey, put it into a piece of linen, and use in great
quantity; it will speedily extract them.

       *       *       *       *       *

COMMENTARY. This subject will be more fully treated of in the Sixth Book.

Our author copies from Oribasius. (Synops. vii, 17.)

Most of the articles here enumerated are mentioned by Dioscorides
as possessing strongly attractive properties. Avicenna, Rhases, and
Haly Abbas, speak of similar articles, without any new remedies of
consequence. See in particular Haly. (Pract. iv, 24.)

The applications mentioned by Pliny are ridiculous. (H. N. xxx, 42, and
xxxii, 43.)


SECT. LIII.—ON HEMORRHAGE FROM VEINS AND ARTERIES.

In cases of hemorrhage from parts, the contrary position to that for
sinuses will be the proper one, that is to say, the upright, but that
must not be in too great a degree, for there is danger of pain being
excited, and of the blood bursting forth from the vessel again; for
nothing produces hemorrhage and increases inflammation more than pain.
Wherefore apply your finger immediately to the part from which the blood
flows, putting it gently upon the orifice of the opening in the vessel,
and pressing it so as not to excite pain, for by this means you will
restrain the bleeding, and block up the opening with a thrombus, and
should the bleeding vessel be deep-seated you will thereby ascertain
most correctly its situation and magnitude, and whether it be an artery
or a vein. After this, if the vessel be small we must use some of the
styptics. The best of these are the obstruents, composed of roasted
rosin, of fine flour of wheat, and of gypsum, and such like, mixed up
with the white of an egg and applied upon the down of a hare. When the
vessel is large seize it with a hook, stretch and twist it moderately.
When the bleeding is stopped, endeavour if it is a vein to restrain the
blood without a ligature, by the same medicines. But if it is an artery,
one of two things must be done, either apply a ligature around it, or
cut the vessel asunder, by which means you will restrain the blood.
Sometimes, too, we are obliged to apply a ligature to large veins, and
also occasionally to cut them asunder transversely. We are sometimes
driven to this necessity with regard to veins which arise from a
deep-seated place, more especially when they run through a narrow passage
or important parts, for thus the portions will be retracted on either
side, and the wound will be blocked up and covered by the parts above it.
But the safer practice is to do both these things, applying a ligature to
the root of the vessel and then dividing it. Having done these things,
the wound is to be incarnated as quickly as possible, before the ligature
slip from the vessel. For if it is not speedily incarnated, but the
emptied portion is dilated, the disease called aneurism is formed. You
may know whether it is a vein or an artery that pours forth the blood,
from this, that the blood of an artery is brighter and thinner, and is
evacuated by pulsations, whereas that of the vein is blacker and without
pulsation.

The most excellent of all the incarnative medicines which we know, is
that used with safety for hemorrhages from the meninges of the brain, and
which may be used in wounds of the neck, even for those of the jugular
veins; for it will restrain the bleeding from them without a ligature. It
contains of the fattest frankincense, p. j; and of aloes, when applied
to soft bodies, p. ss; but when too hard, an equal quantity, and instead
of the frankincense manna is to be substituted. These are to be mixed
with the white of an egg until they become of the consistence of honey,
when it is to be applied upon the soft down of a hare to the vessel and
the whole wound; and a bandage is to be put on externally, the first
four or five turns of which we are to make upon the bleeding vessel, and
from thence extend to the root of it. Then having loosed it on the third
day, if the medicine should still be properly applied to the wound, we
are to put on another one all around, soaking it, as it were, and then
bandaging. But if the first pledget come away of itself, the finger is
to be pressed gently upon the root of the vessel, so as to prevent all
discharge, and it is to be removed softly and another pledget applied.
Thus it is to be treated until the vessel heal up, the upright posture
being still preserved, but so as not to excite pain. Those things which
form sloughs render the part more exposed than it was naturally, owing
to the falling off of the sloughs; for in many cases a hemorrhage which
can hardly be restrained supervenes upon the falling off of the sloughs.
And yet we must have recourse to them when a great necessity compels
us. A great necessity for using escharotics, or cauteries with fire,
occurs when the bleeding proceeds from the vessels being corroded by
mortification; and indeed, when in such affections we cut off the whole
mortified part, it is safer to burn, as it were, its root, or to use
escharotic medicines. This happens more especially upon the pudendum and
fundament. The object of escharotics is to produce heat with astringency,
as in chalcitis, misy, and copperas. Those from quicklime are stronger
indeed, but owing to the want of astringency in the lime, the eschars
from them fall sooner away; but it is better that they should remain
longer, for thus will flesh have time to form previously at their root,
and become as it were a cover to the vessels. In such cases of hemorrhage
matured woad (isatis sativa) when sprinkled upon the part is excellent
for restraining the bleeding, or burnt galls, but they must first be
heated in the fire, and extinguished in vinegar or wine. The following
Simples stop hemorrhages: Aloes, frankincense, manna, Samian earth, the
rust of iron, the ashes of burnt wool finely powdered, the dung of an ass
or of a horse, a small quantity of bitumen, pomegranate-rind, diphryges,
galls, dried myrtle, all kinds of alum whether crude or burnt, roasted
rosin, the bark or green leaves of the vine, and the down of the peels
of the plane tree, more especially when the vessels throw off their
crusts. In particular, hemorrhage from the nostril is to be restrained
by the application of the fruit of the sharp rush, the juice of nettle
leaves, chalcitis, burnt anthyllis, the down of a hare, the middle part
of a ferule when burnt with vinegar, an ass’s dung dry or moist, the
juice of leeks with frankincense applied upon lamp-wick. The following
are compositions for restraining all kinds of hemorrhage: Having soaked
a fresh sponge in liquid pitch, and smeared it with bitumen, burn it in
a new pot. Mix together of the ashes of it, p. ij; of lead, p. j; of
antimony, p. j.—_Another_: Sprinkle on the part equal quantities of the
manna of frankincense, and sulphur vivum.—_Another_: Of chalcitis, dr.
viij; of frankincense, or of its manna, dr. xvj; of roasted rosin, dr.
viij; of burnt gypsum, dr. viij.—_Another_, an escharotic styptic: Of
chalcitis, of burnt copper, of copperas, of roasted misy, equal parts.
And the medicine called the Rhodian, and that called the yellow, are
excellent styptics.

       *       *       *       *       *

COMMENTARY. See Celsus (v, 26); Galen (Meth. Med. v, _et alibi_);
Oribasius (Med. Collect. x, 22; Morb. Curat. iii, 36; Synops. vii, 20);
Aëtius (xiv, 51); Actuarius (Meth. Med. vi, 4); Palladius (Comment. in
Hippocr. Epidem. ed Dietz, ii, 189); Albucasis (Chirurg. i, 58); Avicenna
(iv, 4, 2,16); Averrhoes (in Avicennæ Cantic. ii, 2, and Collig. vii,
23); Serapion (v, 16); Haly Abbas (Pract. iv, 21); Rhases (Divis. i, 139;
Contin. xxviii.)

Contrary to what is often stated in modern works on surgery, the ancients
appear to have been very well acquainted with the proper treatment of
hemorrhage. Celsus directs us when a dangerous hemorrhage is apprehended
from a wound, to fill it up with dry pledgets, then to apply a sponge
squeezed out of cold water, and to make pressure with the hand. If the
bleeding does not stop, he directs us to change the pledgets often,
and if dry ones do not answer to soak them in vinegar. For fear of
inflammation he recommends us not to use caustics and escharotics except
in urgent cases. When all other means fail, he directs us to seize upon
the vessels (venæ) which pour forth the blood, and having tied them
in two places about the wound, to cut them asunder, so that they may
contract and still have their mouths shut up. If circumstances prevent
this from being done, they are to be burnt with a red-hot iron. He also
speaks of stopping bleeding by revulsion, as for example, by applying a
cupping-instrument to the hindhead for bleeding in the forehead.

Galen has treated of this subject at great length in the Fifth Book of
the ‘Meth. Med.’ When blood is discharged from a wounded artery, he
directs us to apply a finger to the orifice of the vessel firmly, yet so
as not to occasion pain, and thus a thrombus will be formed that will
stop the flow of blood. When the vessel is deep-seated he advises us to
examine accurately into its situation and size, and to ascertain whether
it be an artery or vein; after which it is to be seized with a hook
and twisted moderately. If the flow of blood is not stopped thereby,
he recommends us, if the vessel is a vein, to endeavour to restrain
it without a ligature by means of styptics, or things of an obstruent
nature, such as roasted rosin, the fine down of wheaten flour, gypsum,
and the like. But if the vessel is an artery, he says, one of two things
must be done,—either a ligature must be applied to it, or it must be cut
across. He adds, we are even obliged sometimes to apply a ligature to
large veins and cut them across. From this extract of Galen’s practice,
it will be readily perceived how much our author is indebted to him. He
makes mention of the ligature in many other parts of his works. He also
recommends the actual cautery.

To stop bleeding, Oribasius directs, in the first place, cooling and
astringent applications to be used, and if these do not succeed,
caustics, such as misy, chalcitis, copperas, or the actual cautery. Upon
the whole, his account of hemorrhage is nearly the same as our author’s,
only he says nothing of the ligature.

Aëtius treats of this subject in the same terms as Galen, recommending
the ligature under the circumstances mentioned by him. Some of his
styptics are powerful escharotics and astringents, such as copperas,
chalcitis, alum, galls, quicklime, rosin, and frankincense. He informs us
that Ammonius, the famous Alexandrian lithomist, used a composition of
arsenic, sandarach, chalcitis, and quicklime.

Actuarius recommends a composition containing burnt copper, chalcitis,
galls, frankincense, &c.

Palladius, in his Commentary on the ‘Epidemics’ of Hippocrates, treating
of hemorrhage says, we often stop the bleeding by applying a ligature to
the divided vessel.

Albucasis mentions four methods of stopping the discharge of blood from
an artery: 1, by the cautery; 2, by dividing the artery across; 3, by
using the ligature; 4, by styptics applied upon a bolster or compress,
and tightly bandaged.

Averrhoes recommends to stop bleeding by styptics, the cautery, or the
ligature. He says distinctly, that when the bleeding cannot be stopped,
the artery or vein is to be secured with a thread.

Avicenna treats of all the modes of stopping hemorrhage with singular
accuracy, but at so great length that we can only afford room for a few
remarks. He recommends stupefying things, cold water, exposure to cold,
escharotics, and the actual cautery. He also directs in extreme cases the
vessel to be cut across, or a ligature to be applied, namely, a flaxen
thread. His description of the process of taking up and tying an artery
has quite a modern complexion. He also recommends the application of a
compress with tight bandaging when the ligature cannot be applied.

Rhases makes mention of the cautery, of the application of snow, of the
ligature, of styptics, and of cutting the vessel across. He mentions that
Galen in certain cases approved of two ligatures, as it sometimes happens
that the inferior portion will pour forth blood. He further speaks of his
having occasionally used two or three ligatures for the sake of greater
security. He also mentions torsion of the artery.

Haly Abbas gives an interesting account of hemorrhage, and makes mention
of bandages and the ligature. He and Serapion agree in recommending
strongly as a styptic a mixture of one part of frankincense, with a half
part of aloes, applied upon the down of a hare. This is the application
called the plaster of Galen, and is much recommended by Zacutus Lusitanus
(Pract. Admin. i, 85), by Scultet (Arsinal de Chirurg. Tab. 33), by
Brunus (Chirurg. Maj. i, 12), and Lanfrancus (Chir. parva. 5.)

The early modern writers on surgery make mention of all the ancient
methods of stopping hemorrhage. Guy of Cauliac recommends the ligature
upon the authority of Galen and Avicenna (iii, 1, 3.) It is also
recommended by Brunus (i, 12), Theodoricus (i, 13), Rolandus (ii, 1),
and Lanfrancus (iii, 1, 9.) It appears, therefore, that the use of the
ligature for stopping hemorrhages was well understood by the ancients,
and had never been lost sight of even in the darkest ages.


SECT. LIV.—ON WOUNDS OF THE NERVES.

When the nerves are wounded or pricked, they experience great
inflammation and pain owing to their great sensibility; and therefore
fever and convulsions supervene upon them, and in some cases delirium,
owing to the continuity of the nerves with the brain. And sometimes
phlegmons and abscesses form in the other parts adjacent to the wound,
arising from the wounded nerve, owing to their continuity with it.
Wherefore we must preserve the wound of the skin from adhering, that
the ichor may escape by it. And in punctures, if they appear blind, the
part must be divided by two incisions intersecting one another. With
regard to the treatment, if the body is plethoric, and the inflammation
strong, it will be proper to begin with venesection; and when the body
appears to be in a state of cacochymy, purging must also be had recourse
to. We must apply to the wound medicines for allaying pain, and for
increasing the discharge, more especially if the cross incisions have not
been practised. It is necessary to know that warm water, which is most
applicable to other inflammations, is inimical in these cases, and it is
better to bathe the part with a thin oil which has no astringency and
is warm to the feeling; for nothing either very cold or very hot can be
applied without detriment. Of medicines turpentine-rosin is beneficial by
itself in the case of children, women, and persons of tender flesh, but
softened with euphorbium for those of a firmer fibre; and if it become
too hard it is to be mixed with some of the thinner oils. To nerves
in a state of inflammation and mortifications, we may use cataplasms
consisting of the flour of barley or of beans, or by boiling that of
tares in trained lye with oxymel. But without boiling we may use the
following cerate for punctures: of wax, oz. iij; of euphorbium, oz. j;
or of pigeon’s dung; for harder parts, of oil, oz. ij; and sometimes
of turpentine, oz. j. When you wish to give the medicine the form of
a plaster, you may add to the preparation from euphorbium, of wax, of
boiled rosin, of oil, and of fat pitch, of each, oz. vj; but you will
make it better by substituting the fattest bee-glue instead of the rosin.
The following is a good remedy for punctured nerves, applying also to
persons bitten by mad animals: Of vinegar one sextarius, of fat pitch,
lb. j; of opoponax, oz. iij; having dissolved the opoponax in the vinegar
triturate it more, and having melted the pitch, boil. This medicine is
applicable to punctures of the nerves not allowing the mouth of the
puncture to close up, as in the case of persons bitten by rabid animals
it does not permit the wound to cicatrize. But it answers only with hard
bodies, and when you wish to apply it to the punctures of children, or
of persons of soft skin, you must melt it in some discutient article
such as the oil of marjoram, of opobalsam, or old oil.—_Another_ suitable
application is basilicon with the addition of natron, or quicklime,
or euphorbium, or sulphur vivum, or wild pigeon’s dung, or opoponax,
or sagapene, or Cyrenaic juice, or castor, adding to a pound of the
ointment an ounce of one of these medicines. It answers well for wounds
of nerves, and more especially punctures. And in the country when one
is not supplied with any other medicines, one may apply fresh and fat
bee-glue to the wound, or leaven more especially if old, by itself or
mixed with bee-glue, or with the juice of tithymal. But cataplasms may
be applied made of oxymel, or of strained lye, with the flour of beans,
or of tares, or of chick-peas, or of bitter lupines, or of barley, or
of the flour of polenta, not only when in a state of inflammation, but
they may be used from the commencement. But relaxing cataplasms are to be
entirely rejected for wounds of nerves. If the nerve is not cut, but laid
bare by a wound, the surrounding skin being divided so that the nerve
appears naked, and is wounded longitudingly and not transversely, we must
use none of the afore-mentioned from euphorbium, nor any thus acrid, for
the nerve being bare will not bear their power which is strong, but one
may use lime that has been washed often in the warm season mixed with
much honey. The preparation from pompholyx, and that from honey melted
with much rose-oil, are also excellent ones. But these things must not
touch the wound, for the nerve is sensitive, of a cold temperament, and
continuous with the most important part. And neither is it proper to
bathe such an ulcer with oil, for it will make it become foul, and we
must only wipe away the ichor with soft wool wrapped about a probe. When
all things succeed agreeably to our wish, there will be no danger in
fomenting with must. For stronger persons the trochisk of Polyides with
sodden must may be used upon a warm pledget. After the exposed nerve has
been covered over, we must apply externally pledgets, with some of those
things which are fitting for narrow wounds, such as that from euphorbium,
or that from pigeon’s dung, taking in also much of the sound parts. When
the wound is transverse there is greater danger of convulsions, but
everything relating to the cure is in this case the same, except that
while the wound is recent some have used sutures and certain of the
agglutinative applications; but the sutures must not be applied very
superficially lest the part below remain ununited, but more deeply,
taking care however that the nerve be not punctured by the needle. It is
to be known once for all, that in wounds of the nerves the medicine which
cures punctures being of a bitter nature, it is not possible to cure with
it the division of the nerve, as the parts cannot endure pungency and
inflammation. And neither does the medicine which cures incisions answer
with punctures. For its strength does not reach the bottom of it, the
incision of the skin being narrow. A spare diet is to be allowed, and
a soft couch; and warm oil is to be applied to the armpits, head, and
neck; but when the wound is in the leg, the medicine is to be applied to
the groins, pubes, and the parts there. Baths, until the inflammation is
on the decline, are to be abstained from, water not agreeing with these
wounds, as we have said. But since some from habit cannot bear to want
the bath, if the wounded part be the hand it must not, if possible, be
wet in hot water, and still less in cold; but when the wound is in the
foot, since it is impossible to preserve it from being wet, when about
to go into the bath apply to the wounded part some of the plasters, and
externally a compress consisting of many folds and moistened with oil;
and again external to that a linen bandage; and after having done these
things when the person affected is about to take his seat in the bath
pour oil once more upon the bandage. When he comes out of the bath take
away all those applications, and have recourse to the treatment described
above. When there is only contusion of the nerve, if along with it there
be contusion of the skin and ulceration, the cataplasm of the flour of
beans and of oxymel will be a fit one, but you may add sometimes the
flour of tares, and some iris; and when the contusion is attended with
pain, you may mix a little liquid pitch with it. If there be no contusion
of the skin, it will be more discutient to bathe frequently with an
oil of a heating nature, I mean that of dill, of rue, of iris, or of
marjoram. When the whole nerve is cut asunder no danger will result from
it, but the part will be mutilated; and the treatment is to be conducted
as in the case of other ulcers. The treatment of the wounds of nerves
by simples is sufficient for accomplishing the whole cure, but some are
in the practice of using compound applications in such cases, as the
plaster from metals, those called barbarous, and the cissinum, that
from groundsel, the melanchlorum, the indicum, harmonica, and athena,
the composition of which, and the manner of using them you will find
described in the Seventh Book. And since some very wealthy people are
fond of using expensive applications to wounds of the nerves, Galen has
described the following for punctures of the nerves: Of cinnamon, oz.
j; of dittany, oz. j; of marum, oz. j; of amaracus, dr. ij; of wax,
oz. viij; of opobalsam, oz. x; of turpentine, oz. x.—_Another_: of
cyrenaic juice, oz. j; of wax, oz. iij; of opobalsam, oz. xij. This is
an application for exposed nerves: Of wax used for ointments, oz. iij;
of the ointment called spicatum, or foliatum, or that of nard, oz. xij;
of washed pompholyx, oz. j; of spikenard, oz. j; of amomum, oz. j; of
the leaf (malabathrum), oz. j. And these, Galen says, are superlatively
excellent.

       *       *       *       *       *

COMMENTARY. Galen has devoted a whole book of his work ‘De Med. sec.
genera’ to the consideration of wounds of tendons, membranes, ligaments,
and nerves properly called, and he also treats of them more generally
in the sixth book of his work ‘Meth. Med.’ He professes to have had
ample experience in the treatment of these cases while attending wounded
gladiators. As our author has given a very comprehensive abstract of
Galen’s principles of cure, it will be unnecessary for us to enter
into any minute detail of them. He states very decidedly that cold
applications, especially cold water, are highly dangerous, and inculcates
that calefacient oils are the most proper applications. He particularly
praises oils medicated with spurge, or sagapene, or turpentine-rosin.
They are to be applied upon soft wool. In certain cases, he says, I have
mixed the powerfully desiccant substances, such as quicklime, misy,
chalcitis, pompholyx, arsenic, and sandarach, with the oils or cerates.
When tendons are cut across he directs us to unite the ends together
by sutures. Wounds of membranes and ligaments are said to be less
dangerous than those of tendons. In general he further recommends either
bloodletting or purging.

Oribasius, Aëtius, and, in short, all the subsequent authorities, like
our author, copy everything from Galen. As a specimen we shall give an
abstract of the method of treatment recommended by Octavius Horatianus,
who, it is probable, belonged to the Methodical sect. He commences with
stating that wounds of nervous parts are in general very dangerous,
and recommends applications of a digestive nature to avert the violent
symptoms and pains. In such cases he directs us to bleed and purge,
forbids all fomentations of warm water, but approves of those made with
tepid oil, after which dressings composed of turpentine-rosin, either by
itself or with some sponge, are to be applied. But for women and children
of a delicate frame he recommends turpentine alone; for others, however,
he recommends turpentine with spurge and oil, to which occasionally may
be added bee-glue, sagapene, assafœtida, and opoponax. He also from
personal experience speaks favorably of an application prepared from lime
washed in water, spurge, sulphur, turpentine, wax, and pitch. He mentions
other preparations from rosin, spurge, with oil and sea water.

The Arabians copy from Galen very closely. Thus Avicenna condemns cold
applications, and recommends calefacient ones. He approves of sutures
when the tendons are cut asunder. Haly Abbas cautions against cold
water, and particularly commends wool dipped in hot oil of violets. When
spasm (tetanus) supervenes owing to the wound of a nerve, he directs us
to divide it asunder lest the affection of it spread to the brain and
prove fatal. Rhases also forbids all relaxing applications. He commends
hot stimulant oils, and basilicon mixed with spurge, natron, lime,
assafœtida, castor, &c.

Gulielmus de Saliceto, Guido de Cauliaco, Severinus, and Lanfrancus in
laying down the treatment of wounded nerves and tendons, follow closely
the principles delivered by their Arabian masters. They approved of
sutures when the tendon is cut across.


SECT. LV.—ON ANCYLOSIS.

Contractions of joints arising from impacted humours, or some nervous
tension, we are accustomed to call ancylæ and ancylosis, which cases
require emollient and relaxing applications. Wherefore, in general, those
things recommended for scirrhous parts, but still more particularly the
applications to paralysed members will be proper, and more especially
pouring upon the part water and oil, in which linseed, fenugreek,
marshmallows, bay, the root of the wild cucumber, and the Sicyonian oil
itself, have been boiled. After bathing we may apply first the more
simple acopa, such as that from poplar, that from fir, the one called
bromium, that ascribed to Basilius, and the pyxis; and after these the
Aristophanian, and that ascribed to Azanites. But the strongest are those
called lysoponium and varium. Of plasters, that ascribed to Amathaon, and
the anicetum. This is a most excellent one: Of bdellium, of calves’ fat,
of ammoniac perfume, of Illyrian iris, of each, dr. xvj; of opoponax, of
galbanum, of the seeds of rosemary, of storax, of frankincense, of each,
dr. viij; of pepper, clx grains; of wax, lb. ss.; of turpentine-rosin,
lb. ss.; of the lees of the oil of iris, q. s.; of wine, q. s.; the
medicine is pounded. It forms a good acopum when diluted with oil of
iris, of privet, or of bay. Intermediate between the acopa and plasters
is the preparation from bacon called polymigmaton. The acopa are to be
used with soft and continued friction, along with gentle attempts to bend
and stretch the affected joint.

       *       *       *       *       *

COMMENTARY. The principles of treatment here laid down are the same as
those inculcated by all the other authorities. For a complete account of
the formation of malagmata, we refer the reader to Galen (Med. sec. gen.
vii), and to Aëtius (xii, 42.)

Actuarius recommends an acopum composed of old oil, the oils of bay,
iris, and storax, with turpentine, spurge, castor, ammoniac, pepper,
opoponax, galbanum, and stag’s marrow. He remarks that emollient and
relaxing medicines are indicated. (iv, 16.)

Celsus recommends, “ad recenti vulnere contractos articulos, quas ἀγκυλας
Græci nominant,” a malagma consisting of frankincense, rosin, galbanum,
ammoniac, and bdellium, with wax. (v, 18.) Avicenna makes mention of
a similar one. Scribonius Largus gives a prescription for ancylosis
consisting of bdellium, opoponax, ammoniac, galbanum, calves’ fat, &c.
(civ.)


SECT. LVI.—ON RELAXATION OF THE JOINTS.

The joints often become relaxed from protracted febrile complaints, and
from colic, and paralytic affections, especially when a hot and humid
intemperament seizes them; and hence the motion of the joint is impeded.
In these cases the juice of acacia mixed with water may be poured upon
the part; or a decoction of bramble, of myrtle, of lentisk, or of the
bark of elm roots will answer well; or the rind of pomegranate may be
formed into a cataplasm, or myrtle leaves with myrtle ointment may be
applied. For the ligaments require to be strengthened by astringent and
desiccative powers; and such applications are therefore to be made to the
joints, as that from willows, that called oxyrum, and the phœnicinum,
with the addition of an astringent wine or vinegar. Some imagining that
the weakness of the joints proceeds from cold, and having had recourse to
more heating remedies, have only increased the mischief.

       *       *       *       *       *

COMMENTARY. Our author has correctly stated that relaxation of the
joints is to be cured by astringent desiccant applications. Aëtius makes
mention of the simple articles enumerated here (xiv, 72), and Oribasius
recommends a few of the same. (Synops. vii, 23.) Our author is much
fuller than Oribasius on this head. (Ibid.)


SECT. LVII.—ON WORMS.

There are three different sorts of worms, the round, the broad, and
thirdly, those called ascarides. They are all the offspring of crude
and thick pituitous matters with a suitable putrefaction, such matters
collect in children, and others who take too much food. But they do
not grow from hot, acrid, or melancholic humours; for these being too
strong for nutrition, are inapt for the generation of worms; and, on the
contrary, bilious superfluities are particularly destructive of them.
Or if at any time yellow bile be discharged along with worms, either
downwards or by vomiting, you may be sure that they have been formed
in the intestines, whereas the bilious humour had been collected at
the mouth of the stomach, or in some other part. We shall now describe
the form, generation, situation, diagnosis, and cure of each variety,
beginning with the round.

_Of the round worms._ The form of the round worms must be known to
everybody, because they are more common than any of the others. They are
generated principally in the small intestines, and are very prevalent
in the stomach; wherefore they are often discharged by the mouth, and
sometimes by the nose. They are most common in children, more especially
in fever. For they are formed about the commencement of fevers from a
corruption of the matters; at their acme from the malignant nature of
the disease; and during the decline from a change of the whole system
to a better state. Wherefore Hippocrates says, “it is a good symptom
when round worms are evacuated at the crisis of the disease, and these
speedily die.” Those who have round worms experience pain of the
intestines and stomach, small dry tickling cough, and in some cases
hiccough, sleep with palpitations and irregular startings; and some
start from their sleep with a scream, and again fall over asleep. The
pulse is unequal, and the fever has irregular exacerbations, making its
attacks with coldness of the joints, and coming on three and sometimes
four times in the day or night without any stated form. Children have
mastication and projection of the tongue without cause, and grinding
of the teeth; they shut their eyes and wish to remain silent, and are
offended when disturbed. Their eyes appear bloody, their cheeks red, and
again change to pale. But these things occur at intervals in a short
time. Sometimes the worms crawling up to the stomach occasion nausea,
gnawing pain, and anorexia to the patients. When forced to take food they
can scarcely swallow for nausea, or they vomit what they have taken,
or their bowels are loose with corruption of the food, or are inflated
like a bladder; but the rest of the body is wasted in an unaccountable
manner, there being neither famine nor any extraordinary evacuation. But
one must not expect to find all these symptoms in all cases, but certain
ones, according to prevailing circumstances, and occasionally the most
of them. These symptoms occur from the animals turning themselves about
in the intestines and biting them, and the febrile heat raising noxious
vapours to the brain from putrid humours collected in the belly, in
which case we must sometimes pay attention alike both to the fever and
the worms, and sometimes we must bestow little attention to the fever,
and direct our efforts to remove the worms from the body. Many having
neglected them have been eaten through by them, and have died convulsed.
And others say that they have seen them come out from the groins of the
patient. You may remove them from the body by killing them, and you may
kill them principally by using bitter remedies. When both the treatment
of the fever and of the worms is common, the simple remedies will be
proper. Wherefore the patients must first drink a decoction of camomile,
and of the fruit of the sebesten plum, or these medicines themselves may
be given boiled. We may also give the juice of endive, or coriander seed,
triturated with hot water or with oxycrate; or a decoction of the herb
mouse-ear, or the shavings of hart’s horn, or sinopic vermilion finely
levigated. And they may swallow by degrees two spoonfuls of the oil of
bitter unripe olives, for by its bitterness it kills them, and by its
lubricity it drags them along and evacuates them with the fæces. When
inflammation and distension of the intestines are present, we must have
recourse to a cataplasm of linseed and of the flower of lupines, and
of wormwood, and of the roots of bryony in hydromel, or pour upon the
hypochondria the oil of camomile, wine, and the infusions of the fruit of
wormwood and aloes. When the fevers are not very troublesome we may mix
with the sebesten plums some mint, and give them: and when there is no
fever we may administer the more drastic medicines, such as the decoction
of seriphum, or of calamint, or of fern, or the seed of cardamon, or
a decoction of the root of acid pomegranate reduced to one third, or
of toasted cumin, and of tawny-coloured natron, of each, scr. iij; or
wormseed, or southernwood, or both made into pills with honey, or scr.
iij of bitter lupines, or the levigated seed of cabbage or of rocket, or
wormwood which is often sufficient alone. We may give of washed aloes to
the amount of scr. iij; which is one of our most celebrated remedies; but
to stronger persons we may give them unwashed. And since children will
not take the aloes from a cup, they are to be secured upon their back,
and their mouth being forced open by a spoon, we are to inject in spite
of them the aloes by means of a syringe having a strong pipe, throwing
it in as far as possible. This is an admirable method with children who
can hardly be prevailed upon to take medicines, and in this way we may
often inject soup in cases of anorexia. And cyphi and masuaphium may be
properly administered, and burnt hart’s horn with pepper in honey or
oxymel; and we may also endeavour to give the other medicines in oxymel.
But the vinegar of squills will be still better, especially when given
to adults. Or mustard with oil and vinegar may be given to the amount of
a spoonful. Those whose bowels are troubled with a flux owing to worms
may take a potion of the juice of plantain, or the plaintain itself may
be given in a dry state, for it is of use both for the flux and the
worms. We may apply to them cataplasms of crude barley flour, of fern,
of wormwood, of the flower of lupines, of wormseed, and of southernwood,
and likewise pomegranate rind, acacia, galls, and the flowers of the wild
pomegranate are to be mixed with them. And since many people often loathe
bitter draughts, we may give of those we have mentioned, such as are not
decidedly bitter, and in addition, ground pine and horehound, elecampane,
bay berries, cassia, thyme, pennyroyal, carpesium, cyperus, polypody,
iris, bastard-saffron, madder, Egyptian thorn, with an equal quantity
of pepper, to the amount of scr. vj, to a decoction of mint, the juice
of the root of mulberry, or the decoction of stone parsley, or of other
aromatic seeds. Externally we may use aloes with the oil of apples and
wine. This also whets the appetite, which is a thing to be much attended
to. With the aloes we may often mix wormwood; or the navel may be filled
with bull’s gall along with some of the bitters formerly mentioned; or
the oil of rose-bay may be constantly rubbed in, or cedar-pitch may be
applied alone and along with cerate to the whole belly; or dried pitch
may be levigated and sprinkled on it; or it may be anointed with mint and
gith in rose-oil; or we may mix with them the decoction of seriphum; or
we may triturate peach leaves and apply. We may use stag’s marrow in the
form of an ointment to the navel, pubes, and loins; and, if necessary, we
may apply the cerate of aloes, of wormwood, of the flour of lupines, of
seriphum, of gith, of each, scr. vj; of wax, oz. jss; of oil of camomile
q. s.; triturate the powders with bull’s gall. We may give them frequent
injections of honied water, that the worms may be attracted downwards
by the sweetness of the honey. But if they putrefy in the deep-seated
parts, and are not discharged, but on the contrary raise effluvia,
we must evacuate them by giving aloes, or the medicine called picra,
prepared from it. In certain cases a moderate evacuation, by means of a
suppository, is not unuseful to them.

_Of the broad worm (tænia)._ The broad worm is (if I may say so) a
conversion of the membrane which lines the inside of the intestine
into a living body, which is often either discharged whole, when its
size appears incredible to be seen; or it is evacuated in parts; but
when loosed from its attachment it does not form again. It occurs most
frequently without fever, but sometimes in fever after a protracted
disease, when it brings on constant gnawing pains of the stomach,
and an insatiable desire of food; for the animal which is formed in
the intestines seize the food lying there, so that another supply is
straightway required, and, if not furnished with it, the worm will bite
the bowels. It is accompanied with emaciation of the body and loss of
strength, with anomalous symptoms: but the most unerring symptom is when
certain substances, like the seed of gourd, are discharged with the
fæces. The cure resembles that of the former kind; taking the bitter
draughts, eating garlic, drinking or injecting a decoction of fern, or
of centaury, or of calamint, of dittany, or of pennyroyal. And we may
also inject brine. The patient may also drink this potion, which is
not unserviceable to those who are troubled with other worms, if they
happen to have fever: Of red natron, of pepper, of cardamom, equal parts:
the dose is gr. iij, with wine or hot water.—_Another_, a linctus: Of
pepper, of pure bay berries, of Ethiopian cumin, of mastich, equal
parts; of honey, q. s.; the dose is a spoonful taken in the morning and
at bedtime. But if you wish to make it stronger, add an equal part of
red natron.—_Another_: Of elecampane, of ammoniac perfume, of pepper,
(in another formula, of fern,) of each, dr. v, with hot oxymel; and
after an interval give adults one or two drachms of euphorbium in a
draught.—_Another_: Of fern, an acetabulum; of natron, dr. ij; give it
in a hemina of water, but it will be better if a little scammony be
added to it.—_Another_: Of the bark of the roots of sour pomegranate
stripped of its rind above, dr. iv; of pepper, dr. iv; of cardamom, dr.
vj; of horehound, dr. ij; give it in honey to the patient after he has
previously eaten of garlic, until the affection is completely removed.
Give also of theriac, when not prevented by strong fever.


SECT. LVIII.—ON ASCARIDES.

Ascarides, as we formerly mentioned, are a kind of intestinal worms
resembling earth-worms, being formed about the extremity of the rectum
and the beginning of the sphincter ani, and occasioning a great itching
of the parts. This species is formed by bad diet, cold, and indigestion
of the food. Wherefore they are to be discharged, in children, by
suppositories of honey with a moderate quantity of salts or natron; but
in adults by acrid brine, or a decoction of centaury with natron and
honey, or of colocynth, or of wormwood, or of chamæleon, or of alkanet,
or of bastard saffron, or of hyssop, or of pennyroyal, or of calamint,
or of lupines. After the injections we may anoint the rectum with these
simples: Acacia, or hypocistis with natron, or Syriac sumach with liquid
alum; and in those which are bound, with Lemnian earth in wine, and with
these compound medicines, the trochisk of Andron and the like. And we
may give them an injection of cedar-rosin with a syringe having many
perforations, such as those used for the uterus; or salted flesh is to
be adapted to the part and secured with a bandage, as long as it can be
allowed to remain, and changed often. In general all those infested with
worms derive benefit from fumigations with the hairs of ichneumon. The
food should contain wholesome juices, and such as are easily distributed
over the system, neither increasing the cause which engenders the worms,
nor allowing the strength to sink; and on that account we may give some
diluted wine. And we must give food frequently on that account, and
in order that the worms may not bite the intestines for want of their
food. The best time for taking food is when the worms are full. If
there be a defluxion of the belly you may be sure that the worms are on
the increase, the food not being properly distributed, and we are to
give soups with a mixture of astringents, such as pears, apples, and
pomegranates, more especially such as are acid; and we may apply to the
belly, externally, astringent remedies as mentioned above.

       *       *       *       *       *

COMMENTARY. On this curious subject consult Hippocrates (Aphor. iii,
26; De Morbis, iv, 27); Aristotle (H. A. v, 9); Celsus (iv, 17);
Cælius Aurelianus (Pass. Tard. iv, 8); Scribonius Largus (36); Serenus
Samonicus; Marcellus (31); Octavius Horatianus (ii, 30); Dioscorides
(pluries); Galen (Meth. Med. xiv; Isagoge;) Aëtius (ix, 39); Oribasius
(Morb. Curat. iv, 90); Actuarius (Meth. Med. i, 21); Nonnus (172);
Myrepsus (8); Avicenna (iii, 16, 5); Serapion (iii, 30); Averrhoes
(Collig. vii, 37); Avenzoar (ii, 7, 22); Haly Abbas (Theor. viii, 28;
Pract. vii, 29); Alsaharavius (Pract. xvii, 2, 9); Rhases (Divis. 169;
Contin. xxvi); Alexandri Tralliani Epistola ap. Alb. Fabricii Bibl. Græc.
xii, 602, and ed. Ideler, 1842.

Hippocrates states that the round and broad lumbrici are often passed
with the first discharges from the bowels of children. This is a fact
very difficult to account for. When, and how did the _seed_ of the worm
get access to the belly of the child? He rejects the opinion that the
rings of the broad lumbricus (tænia) which are passed from the bowels are
its offspring. He says it does not occasion death, but continues to live
as long as the man lives.

Aristotle divides intestinal worms into the lumbrici teretes, the
l. lati, and ascarides. He remarks that the broad produce something
resembling the seeds of the gourd. He believed in spontaneous generation.

The pomegranate seems to have been a popular remedy for intestinal worms.
Cato the Censor gives directions for medicating wine by the addition of
pomegranate and fennel, of which, he says, “Id vinum tinias perpurgat et
lumbricos, si sic concinnes.” (De re rust. 127.)

Celsus treats of the lumbrici lati and teretes. For the cure of the
former he recommends a draught containing lupine and the bark of
mulberry, with the addition of hyssop, pepper, or scammony. He also
recommends emetics with garlic, or pomegranate rind with some nitre.
For the teretes he recommends the same, and also the seed of nettle,
or of cabbage, or mint, or wormwood, or hyssop with mead, or the seed
of cresses with vinegar. He advises, likewise, to eat garlic, and use
clysters of oil.

Scribonius Largus directs first garlic and old soft cheese to be eaten,
and then Macedonian fern to be taken with honey. After four hours a
mixture of aloes and scammony with honied water is to be given, and a
clyster of warm water administered. He also recommends wormseed and the
shavings of hart’s horn. Marcellus mentions the same remedies.

Serenus Samonicus recommends hartshorn, calamint, garlic, southernwood,
coriander, pennyroyal, horehound, &c.

The beginning of the chapter of Cælius Aurelianus on lumbici
unfortunately is lost. He mentions the usual symptoms which accompany
them, namely, occasional deliquium, agitation, grinding of the teeth,
change of colour, convulsions, &c. Worms are discharged by the mouth or
anus, sometimes single, and at other times in great numbers rolled up
in a ball; sometimes dead, and at other times alive; and they are of
various colours. For ascarides he recommends when there is inflammation
of the rectum an injection of oil, to which may sometimes be joined a
decoction of wormwood and centaury. But if bloody scrapings of the bowels
are discharged, he directs us to give a decoction of pomegranate-rind,
and, if the complaint continue, equal parts of burnt paper and of
arsenic, to the amount of six drs., with the infusion of plantain. Surely
there must be some mistake as to the amount of the dose, for so great a
quantity could not be injected with safety. When there is putrefaction
he recommends an injection of salt water, with other suitable remedies.
When complicated with any other disorder he properly directs us to pay
attention to it; after which the animals may readily be discharged by
drinking oil, or a decoction of sebesten plums (myxæ), or of liquorice:
these things, he says, will obviate constriction and swelling, while by
lubricating the bowels they will promote the discharge of the worms.
When complicated with relaxation he recommends astringents externally
and internally, such as vinegar with honey, lupine, the shavings of
hart’s horn, &c. Sometimes, he says, in order to expel them we must have
recourse to acrid substances, such as onions, garlic, mustard, cresses,
cardamus, assafœtida dissolved in vinegar, wormwood, &c. In stating the
detail of the treatment he mentions various other anthelmintics, such
as the hiera of aloes, gentian, mulberries, squills, spurge, alkanet,
colocynth, and scammony. All these things may be given by the mouth or in
injections, with a considerable admixture of oil. For the lumbricus latus
he directs, first, an emetic of oil, and next day a clyster with nitre or
salt. Saltish things are also to be given in drink, with liquorice, or
scammony, or polypody, &c. When the animals are discharged, to prevent a
renewal of the complaint, he recommends friction, vomiting, acrid food,
calefacient plasters, sinapisms, paroptesis, and the like.

Pliny recommends the ashes of hart’s horn for tænia. (H. N. xxviii, 59.)

Dioscorides ascribes anthelminthic properties to various acrid and bitter
substances, such as garlic, cresses, fern, gith, mulberry, pomegranate
rind, lupine, cabbage, nettle, hyssop, mint, calamint, wormwood,
wormseed, rue, coriander, thyme, &c. Similar remedies are recommended in
the ‘Euporista,’ which is falsely ascribed to him.

Galen mentions that bitters in general are destructive of intestinal
worms. The teres, he adds, is killed by the absinthium; but the latus and
ascaris require stronger medicines, such as the filix. The author of the
‘Isagoge,’ a work generally ascribed to Galen, divides intestinal worms
into the broad, the round, and the ascarides. The round are about the
length of a span or somewhat more, especially such as are formed about
the stomach. The ascarides are short, and form in the rectum. The broad,
called also fasciæ or tæniæ, from their resemblance to tape, are said to
be sometimes the length of the intestines. The round are most common in
children, the ascarides before manhood; and these are difficult to remove
except by bitters, elecampane, and acrid food.

Oribasius treats briefly of lumbrici, recommending for the l. rotundus,
southernwood, wormwood, calamint, gith, &c., taken internally or applied
outwardly; for ascarides, the juice of calamint, and cedar rosin, in like
manner; and for the tænia the bark of the root of mulberry, and the roots
of fern in honied water, and also the root of the white chamæleon and
costus.

Aëtius gives a full and accurate detail of the symptoms and treatment
of lumbrici, but as his remedies are much the same as our author’s, it
will be unnecessary to deliver any account of them. He remarks, that
anthelminthics either kill worms by their acrimony, or remove them by
their bitterness, or irritate them so as to expel them, or by lubricating
the parts facilitate the expulsion of them.

Actuarius gives a sensible account of the formation of worms, which he
ascribes to putrefaction or indigestion. White worms, he says, are the
product of indigestion, but the red, and those of any other colour, arise
from putrefaction.

Nonnus merely abridges our author’s account of this subject.

The ingredients in the compositions recommended by Myrepsus, are such as
aloes, scammony, southernwood, and bitter almonds.

Octavius Horatianus gives a good account of worms, but it contains
scarcely anything that is not to be found in our author’s. He says, that
from long experience he had great confidence in a purgative draught
consisting of scammony, the ashes of burnt peas, euphorbium, and nitre,
given in sweet wine. But garlic, and other acrid things, are to be first
eaten.

The Epistle of Alexander Trallian on worms, first published by Hieronymus
Mercurialis, and afterwards by Albertus Fabricius, and again lately by
Ideler, contains an interesting exposition of the ancient views on this
subject. He divides intestinal worms into three genera: the ascaris,
the strongylus or round, and the latus or broad. He remarks that the
small worms (ascarides) are generally found in the large intestines,
the round in the small intestines, and hence they are often vomited up;
while the broad worms (tænia) are sometimes as long as the intestines,
some having been discharged sixteen feet in length. He states that they
are engendered by corruption of the food, and putrefaction of crude
humours. He lays down at great length the plan of treatment, which he
varies according as they are with or without fever. His remedies consist
of cathartic, acrid, oily, acid, and bitter substances. Of purgatives
he mentions aloes, scammony, and hellebore; of acrid articles, garlic,
cresses, and the like; of oily medicines, the oil of roses, castor oil
(oleum ricini), and common oil boiled with rue; of acids, salt and nitre
(soda); and of bitters, southernwood, wormwood, hyssop, fennel, and
the like. For the expulsion of the strongylus he speaks favorably of a
decoction of gagate stone (jet). For ascarides and lumbrici he recommends
a lavement prepared from juniper. He concludes his treatise by stating
that “ten thousand” other things had been recommended as anthelminthics
by the ancients.

Avicenna in his account of worms condenses all the information contained
in the Greek authors, but we do not find that he supplies anything new.
He in particular copies freely from Aëtius and our author. The same may
be said of Serapion, who recommends wormwood, bitter lupines, calamint,
peach leaves, cabbage, onions, thyme, colocynth, &c. Averrhoes says that
the lumbrici in general are removed by bitters, such as wormwood or
wormseed, but that the cucurbitini (tæniæ) require strong medicines. Of
the pineæ nuces he says, “Occidunt vermes qui sunt in ventre.” (Collig.
v, 42.) Probably this hint may have led to the use of turpentines for the
cure of tænia. Avenzoar attributes the formation of worms to ill-digested
food in the stomach, and recommends much the same remedies as the Greeks.
Haly Abbas describes the three species of worms, and details the symptoms
of them. He remarks that these animals are to be killed by medicines of
a hot and dry nature, such as bitters. He recommends wormwood, fern,
and the like, pounded with honey, vinegar, &c. The remedies mentioned
by Alsaharavius are oils, bitters, and drastic purgatives. He treats of
lumbrici very fully. Rhases recommends in general terms bitters; for the
round, wormwood, for the broad, (tæniæ, called by him semina cucurbita)
seriphium, bitter lupines, narcissus, &c. And for the ascarides he
directs us to apply a suppository of wool dipped in the gall of a bull.
He remarks that they occur most frequently in autumn, being engendered
by fruit. He states correctly that they often bring on epilepsy, and
looseness of the bowels. He much commends the oil of unripe olives.

Vegetius recommends nearly the same medicines for removing the vermes of
cattle as those already mentioned, namely, wormwood, cresses, coriander,
fenugreek, and the like, boiled in oil, and administered by the mouth and
in clysters. (Mulom. i, 44; see also Columella vi, 25.)

According to Michaelis and Sprengel the ancient Brahmins were acquainted
with the anthelminthic properties of the dolichos pruriens.

We have stated above that the most celebrated of the ancient _savans_
believed in the _spontaneous generation_ of animals. This doctrine,
although generally rejected at the present time, has been advocated
by many modern naturalists of great eminence, such as Baron Buffon
and Professor Rudolphi. Virey gives a very impartial statement of the
arguments for and against this physiological doctrine. (See Hist. des
Mœurs et de l’Instinct des Animaux, ii, 121.) Mr. Madden, the traveller,
relates that the bark of the pomegranate is still considered in the
east as a specific, not only for ascarides, but also for the tape-worm.
He says, “I have rarely seen it fail in the cure of tænia. They make a
decoction of two oz. of the fresh bark in a pint of water, this they
drink daily till the worm is expelled, which it generally is the third
day.” (Travels in Egypt, ii, 371.)


SECT. LIX.—ON DRACUNCULUS, OR THE GUINEA-WORM.

In India and the upper parts of Egypt a class of worms called dracunculi,
resembling the intestinal, are formed in the muscular parts of the body,
such as the anus, thighs, legs, and in the sides of children, under the
skin; and they move in a perceptible manner. Then in process of time at
the extremity of the dracunculus matter is formed in the part, and the
skin being opened the head of the dracunculus comes forth. But if the
worm be dragged it occasions pains, and particularly when it breaks.
Wherefore some say that it is proper to fix a piece of lead to the worm
in order that its discharge may not take place at once, but gradually
with the weight of the lead. Some disapproving of this practice, inasmuch
as the worm is apt to break with the weight of the lead and occasion
violent pains, direct the part to be put into hot water, in order
that the dracunculus being warmed may come forward, when it is to be
seized with the fingers and dragged forth by degrees. But Soranus is of
opinion that the dracunculus is not an animal originally, but a nervous
concretion, which has only the appearance of moving. Whether this or
the former be the true account of the matter, it appears to Soranus,
Leonides, and others, that they are to be treated with the affusion
of warm water, and digestive cataplasms made of honied water and the
flour of wheat or barley; and they approve of sometimes using a plaster
possessed of similar properties. Wherefore that from bay-berries, and
the one from honey are proper. For by the use of these the dracunculus
or concretion dies and falls out. But when suppuration takes place, if
it does not fall out, the skin is to be divided, and the part being laid
open, that which is contained in it is to be taken out, when a tent is
to be put into the skin, and then the treatment for suppurations is to be
applied.

       *       *       *       *       *

COMMENTARY. The following authors treat of the vena medinensis, or
dracunculus, now generally called the Guinea worm: Galen (De Loc. Affect.
vi, 3; Isagoge;) Aëtius (xiv, 85); Pollux (Onomast. iv); Plutarch (Symp.
viii, 9); Theophrastus (H. P. ix); Actuarius (Meth. Med. vi, 8; iv, 16);
Avicenna (iv, 3, 2, 21); Avenzoar (ii, 3, 20); Haly Abbas (Theor. viii,
18); Alsaharavius (Pr. xxviii, 12); Rhases (ad Mansor. vii, 24; Cont.
xxvi.)

Galen admits that he had never seen the dracunculus, and that therefore
he could not be positive respecting its origin and nature. He had known
many persons, however, who had seen it, and was inclined to believe that
it is of a nervous nature, and resembles lumbrici only in colour and
thickness. The author of the Isagoge states that dracunculi resemble
varices, and that when they project or move about they occasion great
pain, and are to be removed by making an incision of the skin as for
varices.

Plutarch briefly mentions the dracunculus as being a disease which had
newly attacked the inhabitants of the country adjoining the Red Sea.

Aëtius professes to derive his account of the dracunculus from Leonides.
He says, like our author, that it is formed most commonly in the legs and
muscular parts of the arms in India and Ethiopia, and that the generation
of it is not dissimilar to that of intestinal worms. He adds, that in
process of time suppuration takes place at the end of the worm, when an
opening is made in the flesh, and the head of the dracunculus protrudes.
If dragged out considerable disturbance is produced, especially if the
worm should be broken, for what remains occasions the most excruciating
pains. He directs us, therefore, to put a ligature round the arm, and to
tighten it every day so that the dracunculus may come forth by degrees
without breaking. The part is to be washed with honied water, with oil
in which wormwood or southernwood has been boiled, or with some such
anthelminthic decoction; but all acrid things are to be avoided for fear
of inflammation. He recommends us to forward suppuration by means of
maturative cataplasms, and the other means mentioned by our author.

Pollux calls the dracunculus a piece of _corrupted nerve_ which sometimes
comes from the sores of Ethiopians, but seldom troubles other people.

Actuarius, like our author, mentions that the dracunculi occur most
commonly in the region above Egypt, being generally formed in the
muscular parts, and that in process of time the part becomes livid and
suppurates. They are killed, he adds, by bitter and acrid things.

Avicenna comprehends in his account whatever information could be gleaned
from preceding writers. He says the dracunculus is called _vena medine_,
from Medine, the name of the country where it is most prevalent. It
occasions a blister in the part which bursts, when a red and somewhat
blackish substance protrudes and gradually increases in length. He
directs us to correct the habit which gives rise to it by baths, humid
food, and the like. His treatment is similar to that of Aëtius and our
author, namely, binding a ligature round the arm, fastening a piece of
lead to the worm, using fomentations of warm water, and the like.

Haly Abbas mentions the vena as being a worm which forms principally in
the legs of the inhabitants of warm countries, such as India, Egypt,
Ethiopia, and Lybia.

Avenzoar says that the complaint most commonly attacks negroes, being
formed by gross humours, for dispelling which he recommends internally
various sharp and acrid medicines, such as squills, nettles, colocynth,
&c. He further directs a piece of lead to be bound firmly over the worm
so that it may be made to crawl out gradually, which, however, he says,
will not be accomplished in less time than a year.

Alsaharavius states the danger of breaking the worm (vena). He recommends
the same treatment as Avicenna. The conclusion of his chapter on the
dracunculus decides him to be the same person as Albucasis.

Albucasis recommends us to fasten to the end of the animal a piece of
lead from one to two drs. in weight, and thereby to extract it gradually.
He says that in some cases the animal is as long as fifteen palms, nay,
that he had seen one twenty palms long.

Rhases says that the dracunculus takes place in hot and squalid bodies,
and is formed by the use of potherbs and fruits. He recommends gradually
increased doses of aloes, and when the animal protrudes it is to be
wrapped round a leaden reed one dr. in weight, so that it may be dragged
out gradually. He cautions us not to leave any part of it in the body. He
also approves of incision as described by our author. In his ‘Continens’
he collects the opinions of Galen, Paulus, and others. He says that it
forms most commonly in the bodies of persons who bathe frequently, and
drink much wine. He says that he had seen it extracted by making free
incisions.

See an interesting account of the guinea-worm in No. 66 of the ‘Edinburgh
Medical and Surgical Journal,’ by Mr. Scott, surgeon, Madras.

Bertapalia, Guy of Cauliac, and all the early modern writers on medicine,
repeat the ancient accounts of the vena civilis vel medine. They direct
us to extract it by attaching a small piece of lead to its extremity.
Ambrose Paré adopted Galen’s notion, that it is corrupted animal matter;
but Andry held that it is a real animal. It appears, however, from some
statements which we have seen in the periodicals of the day, that some of
our English surgeons in the East Indies still advocate the doctrine of
Galen; but we are inclined to think that the other opinion is the more
correct one.




BOOK V.


SECT. I.—ON THE PRESERVATIVES FROM VENOMOUS ANIMALS IN GENERAL.

In giving an account of animals which emit poisons we shall begin with
some general remarks upon them, treating of the preservatives from them
in the first place. If therefore a person be compelled to sleep in
places infested by venomous animals, especially in such as salamanders,
phalangia, or reptiles abound, it will be proper to shut up their holes
under ground with garlic pounded in water, or some of the herbs about
to be mentioned; and to fumigate with hartshorn, the hoofs or hairs
of goats, gagate stone, bitumen, bdellium, galbanum, the shavings of
the cypress or cedar, gith, hog’s fennel, the leaves of the chaste
tree, calamint, sagapene, castor, the root of rosemary, fleabane, or
some of the strong-scented things. Gnats in particular are driven away
by fumigations with copperas, the seed of wild gith, and of cumin in
equal proportions, and by cows’ dung. In addition to these, frequent
fires should be lighted, for reptiles commonly flee from the light. A
couch should be prepared by strewing asphodel, calamint, chaste tree,
pennyroyal, poley, fleabane, and southernwood; or if it is not possible
to make a couch entirely of these, they should at least be laid around
the bed. Attention should be paid to such things as are to be boiled, to
the water, and wine vessels that they be properly covered up. Fires for
the purpose of cooking should not be lighted under particular trees, more
especially pitch trees or pines, for salamanders and deadly caterpillars
abound on them, which being warmed by the heat of the fire fall upon the
victuals, or any other vessels which happen to be uncovered. Those who
wish to be particularly guarded, anoint their bodies with a liquid cerate
composed of wax, rose-oil, and a little galbanum, and with a little of
the shavings of hart’s horn, or Ethiopian cumin. The leaves of mallows
triturated with oil when rubbed on the skin protect in an especial manner
from bees and wasps.

       *       *       *       *       *

COMMENTARY. The following is a list of the ancient authorities on
Toxicology:

Nicander (Theriaca et Alexipharmaca); Dioscorides (Liber de Venenis);
Celsus (v); Scribonius Largus (47, et seq.); Galen (Ther. ad Pison.;
Meth. Med., De Antid.); Aëtius (xiii); Pliny (Hist. Nat. pluries);
Oribasius (de Morb. Curat. iii); Solinus (Polyhist. 40); Serenus
Samonicus; Nonnus; Simeon Seth (de Alimentis pluries); Actuarius (Meth.
Med. v); Vegetius (de Mulo-medicina, iii, 77); Avicenna (iv, 6); Rhases
(ad Mansor. viii, and Cont. xxxv); Haly Abbas (Pract. iv, Theor. viii);
Alsaharavius (Pract. xxx); Serapion (pluries); Anonymi (Fragmentum apud
Bernardi Reliq.) The work of Ælius Promotus on Venomous Animals and
Poisonous substances, which exists in MS. in the Bibliotheca Vaticana,
has never been published as far as we know. It is quoted by Hieronymus
Mercurialis (Var. lect), and is noticed by Albertus Fabricius (Bibl.
Græc. xiii, 780.) Fabricius supposes it to be the production of Æschrion
Empiricus. It is proper to state that whenever we quote the work, it is
from the extracts given in Schneider’s Annotations on Nicander.

It is to be borne in mind that the work on Poisons, usually published as
the production of Dioscorides, is not held to be genuine by his latest
editor, Sprengel; still, however, it is acknowledged by all to be a
work of considerable antiquity and of great authority on the subject of
ancient Toxicology. The work ‘Euporistôn,’ which is also published with
the works of Dioscorides, is generally admitted not to be genuine. It
contains, however, some valuable matter on Toxicology and other medical
subjects.

These directions of our author for driving away reptiles are mostly taken
from Nicander, who recommends fumigations with hartshorn, gagate-stones,
sulphur, bitumen, galbanum, juniper, and other such articles. (Ther. 35.)
See also Dioscorides (M. M.); Orpheus (de Lapidibus); Geopon. (xiii, 8);
and Nonnus (Epit. 261); also Aristot. (H. N. iv, 8); and Pliny (H. N. x,
90).

Virgil makes mention of this practice:

    “Disce et odoratam stabulis accendere cedrum,
    Galbaneoque agitare graves nidore chelydros.”

                              _Georg._ iii, 314.

See a long list of substances used in fumigations for driving away
serpents in Lucan. (Pharsal. ix, 916.) It is different from that of
Nicander and our author. For example: it contains tamarix, costus,
thapsos, &c. Arsenic occurs among the articles mentioned by Rhases.
(Cont. xxxv.) It is also mentioned in the Geoponics (l. c.)

Nicander affirms, and it has been generally believed, that human saliva
proves destructive to serpents. Galen says that it will kill the
scorpion. Aristotle states, that it is destructive to most venomous
reptiles. (H. A. viii, 28.) Redi maintains that this is an ancient error;
but Andreas Laurentius declares that he knew from experience that the
human saliva is destructive to serpents.

Nicander recommends a composition containing cedar-berries, fleabane,
sage, and other such articles for preserving the body from venomous
reptiles. Paxamus directs us to smear the face with a composition made of
the roasted flour of fenugreek, with the juice of the wild mallows and
oil. (Geopon. xv, 6.) He says it preserves the face from the stings of
bees in particular.

The κώνωψ, here translated _gnat_, as it is in the English version of
the scriptures, (Matt. xxiii, 24,) is proved by Bochart (Hierozoon. iii,
442); and by Harris (Nat. Hist. of the Bible), from Aristotle, Plutarch,
and others, to mean properly a kind of insect that is bred in the lees of
wine.


SECT. II.—THE GENERAL TREATMENT OF ALL PERSONS BITTEN OR STUNG BY ANY
VENOMOUS ANIMAL.

If a person happen to be bitten or stung by any venomous animal he ought
immediately to get the part sucked. The person who sucks it should not be
fasting, and he ought first to rinse his mouth with wine and retain oil
in it; and then, if the part admits, it should be cupped with much heat,
scarifying also the surrounding parts; for the poison is forced back out
of the body along with the spirits and blood which are drawn out. The
part in which the wound is situated ought also to be burnt and eschars
formed on it, and amputation of the extremities may then be seasonably
practised if the animal that inflicted the bite be of a deadly nature,
such as the asp, the cerastes, the viper, and the like: as Galen relates
that a certain vine-dresser being bitten by a viper, and knowing the
animal, immediately cut off the finger that was bitten with his pruning
hook, and was entirely freed from the danger. But if the poison be
already distributed over the body, venesection ought to be had recourse
to immediately, especially if the person bitten be plethoric; and pepper
and garlic given to eat with the food, and strong wine to drink, whereby
the system will be filled with fresh vapours and a suitable heat.
Afterwards cataplasms are to be applied that can warm and stimulate the
bite, such as a mixture of the ashes of cabbage or of fig with vinegar,
or with the strained lye, or with the sauce of pickle. Likewise onions
may be mixed with polenta or bread, and strong leeks with salts, or warm
liquid pitch with salts, or cedar-rosin, or goat’s dung. It will also
be proper to pour upon the parts hot vinegar in which calamint has been
boiled, or with vinegar and sea water, or with brine. We are to apply to
the part fowls, more especially hens, cut up and still warm, or other
such animals, for they absorb the poison and soothe the pains. And we
must have recourse to plasters, such as that formed from salts, that from
rosemary and adarce, and on the whole such things as are of an acrid
nature. And in general all persons bitten or stung by any venomous animal
ought, unless the deep-seated parts are wholly unhurt, to take in the
first place potions containing endive, heath, or astragalus with vinegar,
or bitumen and Christ’s thorn in like manner, or a decoction of Christ’s
thorn; or two drachms of dried weasel with wine, which is a cried-up
remedy; or the blood of the sea-tortoise, or a drachm of castor with
diluted wine, or a drachm of frankincense, or of Sicyonian root, or the
juice of leeks, or ground pine, or alsander, or cinnamon, or birthwort,
or the seed of the chaste tree, or cypress balls, or seseli, or pepper,
or the seed of trefoil, or bay berries, or river crabs roasted or boiled.
Use the following compound theriac.

_A theriac for venomous animals, and deleterious substances, and for
persons bitten by vipers and scorpions._ Of bryony, of opoponax, of
Illyrian iris, of the root of rosemary, of ginger, of each, dr. iv; of
birthwort, dr. v; of frankincense, of wild rue, of each, dr. iij; of the
flour of tares, dr. ij; form trochisks with wine, and give three oboli
with wine. Purging will also be proper for them, with sudorifics, and
taking the theriac of vipers.

       *       *       *       *       *

COMMENTARY. These general directions are mostly taken from Dioscorides,
who is greatly indebted to Nicander. Neither of them, however, makes
mention of venesection among his remedies.

The remedial means recommended by Dioscorides are scarification, cupping,
sucking, excision; and in extreme cases, amputation; clysters, and acrid
applications to the part in order to clear out the venom; pure wine,
must, or acrid substances to extinguish it and counteract its effects;
and finally as adjuvants of these means, purging of the bowels, sweating,
and some other particular remedies as stated under their proper heads.

The general remedies mentioned by Nicander are, sucking the wound,
applying cupping instruments to it, and afterwards strong stimulants,
hot irons, and leeches. He directs that the person who sucks it should
not be fasting; from which it may be inferred that he had a correct
idea that the vessels absorb most readily when in an empty state.
This physiological doctrine was lately announced as a new discovery;
but frequent allusions to it are to be met with in the works of
Galen, our author, Avicenna, Avenzoar, Averrhoes, and Haly Abbas.
The dangers resulting from an empty state of the vessels, whether
produced by fasting or venesection, is well expressed by Gorræus in
his Preliminary Dissertation on the Alexipharmics of Nicander: “Nec
vero id tantum incommodi habet fames, sed in multo majus periculum
adducit hominem, quando et venæ plurimum exinanitæ et cibum vehementer
appetentes, venenum avidius ad se pertrahunt et in intima viscera,
cordisque arcem immittunt.” “Quod si quis etiam abundare videatur, et
nihil eorum repugnet quæ sunt in venæsectione observanda, sanguinem
audacter mittamus, non quidem per initia (sic enim in venas deleteria
traherentur, a quibus omni studio atque industriâ excludi debent) sed
post vomitus alvique dejectiones,” &c.

Serapion, contrary to most of the authorities, recommends that the person
who sucks a poisoned wound, should be in a fasting state; but as he is
a servile copyist from his predecessors, it might be suspected that the
text is in fault, if the same directions were not given by Rabbi Moyses,
with this explanation: that a fasting person will perform this office
with more risk to himself, but with greater advantage to the patient,
than one who had taken food immediately beforehand. (De Venenis, i, 1.)
All this shows how well the ancient savans were acquainted with the
physiological fact, that the absorbent powers of the vessels is in the
inverse ratio of their state of repletion.

Celsus recommends nearly the same general remedies as Nicander. Thus he
directs us in the first place to apply a ligature round the limb, but
not too tightly, for fear of occasioning torpor; and then to extract the
poison by sucking, or by a cupping instrument along with scarifications.
His local applications are of a hot stimulant nature. As internal
remedies he recommends emetics, which may be supposed to expel the
poison from the system by the concussion which they produce, and various
articles of a calefacient nature, such as wine and pepper; because, says
he, “maxima pars venenorum frigore interimit.”

Isidorus states in still more general terms that the poisons act by
oppressing the vital heat. He says, “Omne autem venenum frigidum est, et
ideo anima quæ ignea est, fugit venenum frigidum.” He states, likewise,
that poisons do not act upon the system unless mixed with the blood:
“Venenum autem dictum eo quod per venas vadit. Infusa enim pestis ejus
per venas vegetatione aucta discurrit et animam extinguit. Unde non
potest venenum nocere nisi hominis tetigerit sanguinem.” Lucanus: “Noxia
serpentum est admixto sanguine pestis.”

This, however, is an imperfect account of the action of poisons, whether
such as act by being introduced into the stomach, or those that prove
deleterious when applied to a wound. Perhaps the classification given by
Avicenna may be mentioned as the most complete of any proposed by the
ancient authorities. He states that poisons act either by some certain
quality, or by their whole substance. Of the former class some are
corrosive and putrefactive, like the lepus marinus; some inflammatory
and calefacient, like euphorbium; some frigorific and stupefying, like
opium; some prove obstruent of the respiratory passages, like litharge;
some act with their whole substance, as the wolf’s bane, and these
are the most deleterious of all. Of these some act upon one member in
particular, as cantharides upon the bladder, or the lepus marinus upon
the lungs, and some upon the whole body as opium. (iv, 6, 1.) Schulze, in
his ‘Toxicologia Veterum,’ has stated the ancient arrangement somewhat
differently, and we are at a loss to think what authors he has followed.
He says, the ancients arranged poisons according to their properties
into the frigorific (ψυκτικὰ), corrosive (διαβιβρώσκυντα), and septic
(σηπεδονώδη). The frigorific, he properly remarks, are those substances
now called narcotics; to which class, as Galen mentions, the conium,
poppy, henbane, and mandrake belong. On the action of narcotics, see
section xliii. Galen remarks that the human frame becomes habituated to
bear the action of these medicines without injury. He mentions the case
of an old Attic woman, who by little and little had accustomed herself to
take hemlock in any quantity. (De Simpl. iii.)

Avicenna states that the great indications of cure in all cases of
poisoning are to comfort and rouse the vital heat, and to resolve
(neutralize?) or expel the poison. When the poison is distributed over
the system, his remedies are venesection, purging, and the like. He
states decidedly that the proper time for venesection is either when
the poison is distributed over the body, more especially when it is in
a plethoric state, or when the poison is a substance not likely to be
absorbed. His other remedies are such as expel the poison from the body,
namely, emetics and sudorifics, or such as prevent it from entering the
system, namely, ligatures to the extremities, prohibiting sleep, applying
cupping instruments, or leeches, sucking the wound, amputation of the
limb, using actual and potential cauteries, and keeping the wound long
open. Upon the whole the general remedies recommended by him and the
other Arabians are little different from those of the Greeks, especially
of Dioscorides, who is the great authority upon theriacs.

Haly Abbas allows bleeding when the poison is distributed over the body,
and like the others also, makes mention of cupping with heat and of
amputation. He also joins in the general praise of the theriac.

Alsaharavius recommends strong ligatures, cupping, and, in urgent cases,
amputation. He also approves of applying the bodies of hens still warm.
Serapion approves of bleeding under the same circumstances as the others,
and of the same general treatment that they recommend. Rhases recommends
sucking and cupping the wound, and the application of stimulant
dressings, such as a plaster consisting of mustard, lime, and pitch.
He, and most of the ancient authorities on toxicology, recommend salt
as an application to the wound. Most of them also join Dioscorides in
recommending the application of caustic leys. They also in general direct
us to prevent sleep. The ligature to prevent absorption is recommended
by Rhases, as it is in fact by most of the ancient authorities. As a
matter of course all of them speak highly of the theriac, and acquiesce
in Galen’s celebrated eulogy upon its virtues. (Ad Pison. ii, 457, ed.
Basil.)

The Arabian authorities notice cursorily the treatment of poisoned
weapons of war, more especially of the Armenian arrows. Galbanum and
assafœtida administered internally, and applied to the wounds in various
forms, are the two articles which are most generally approved of by them.
They also recommend sucking the wound, as in other cases of poisoning by
a wound. (See further, B. vi, 88.)


SECT. III.—ON PERSONS BITTEN BY MAD DOGS, AND ON HYDROPHOBIA.

We have placed the account of persons bitten by mad dogs before all
the others because these animals are numerous and domestic, and are
frequently seized with madness; because the complaint is difficult to
guard against, and the danger inevitable, unless one have recourse to
many and suitable remedies. Dogs for the most part become mad during
violent heat, but also, as Lycus says, sometimes in extreme cold. When
mad they shun drink and food, for they are thirsty but do not drink,
and for the most part they pant, hang their ears, and emit much frothy
saliva. Generally they utter no sounds, and are as it were delirious, so
that they do not recognize persons with whom they are familiar. Wherefore
they attack equally without barking all animals, whether wild beasts or
men, and bite them. Their bite at first occasions nothing disagreeable
except the pain of the wound; but afterwards it brings on the affection
called hydrophobia, which makes its attack with convulsions, redness of
the whole body, but especially of the countenance, sweating, and anxiety;
and those affected shun water when they see it, and some every fluid that
is presented to them. Some bark like dogs and bite those who approach
them, and so doing they occasion the same affection. The cause of the
other symptoms is obvious, being occasioned by the poison affecting
all the parts, but as to the dread of water some have said that it is
occasioned by inordinate dryness, as if the whole fluids of the body
had undergone a change. But Ruffus has pronounced it to be a species of
melancholy which affects them, the poison putting on the nature of that
humour in like manner as we know other melancholic persons dreading some
one thing and some another; which reason accords also with those who say
that they think they see the image of the dog that bit them in the water.
Of persons falling into this affection we know none who has been saved,
except that we have learned the histories of one or two cases, and these
were of persons who had been bitten, not by a mad dog, but by some person
who had been bitten and imparted the disease to them. But before the
affection has made its attack many, even of those who have been bitten
by a dog, have been saved. Wherefore we must begin the treatment from
thence. And since often from the attack of hydrophobia having not yet
come on (for most commonly it comes on about the fortieth day, and in
some cases after six months, nay, instances are related of its coming on
after seven years,) some supposing that the dog who inflicted the bite
was not mad, and making haste to heal up the wound have thereby given
rise to the complaint. By the following experiment you may ascertain
whether the bite was inflicted by a mad dog or not: Pound walnuts
carefully and apply them to the wound, and next day take and present
them for food to a cock or hen. At first indeed he will not touch them,
but if he is compelled by hunger to eat of them, observe, for if the dog
that inflicted the bite was not mad, then the fowl will live, but if mad
he will die next day; and then you must hasten to open the wound, and
after a few days repeat the same experiment; and when the fowl does not
die you may bring the wound to cicatrization, inasmuch as the patient is
then freed from danger. Oribasius recommends this experiment: If from
the symptoms which we have mentioned we know for certain that the dog is
mad, we must have recourse to medicines for laying open the sore, the
principal of which is that from pitch, very acrid vinegar, and opoponax,
which is described accurately in the section on the wounds of nervous
parts. But if the person who has been bitten has a tender skin, it is
to be diluted with oil of iris, of balsam, or the like; or having first
fomented the sores, apply a cataplasm of garlic. This also forms eschars.
A dry escharotic for persons bitten by mad dogs: Of fossile salts, dr.
viij; of chalcitis, dr. xvj; of squills, dr. xvj; of green rue, dr. iv;
of scraped verdigris, dr. iv; of the seed of horehound, dr. j; use it
at first dry that it may form an eschar, and then with rose-oil that
the eschars may fall off. Keep the parts from cicatrizing for forty-two
days at least. A cataplasm for persons bitten by mad dogs, which keeps
the mouth of the wound open: Apply a cataplasm of onions with salts and
rue, or of laserwort with salts, or of old pickle, or of the cinders
of burnt wood with oil, or of garlic, or apply the leaves of the elder
tree, or mint, or baum, each with salts, or walnuts with onions, salts
and honey, or the ashes of figs mixed with cerate. Wash the sore with a
decoction of camomile in water, and the root of the wild dock. But some
burn the sore with heated irons. They ought in the first place to get
draughts of simple things, such as buckthorn, wormwood, the juice of
laserwort, germander, the water germander, and poley. These are compound
applications: Of river crabs, of the shoots of the white vine burnt in a
vessel of copper or bronze two spoonfuls, of gentian root triturated one
spoonful, give to drink for forty days, with two cyathi of old undiluted
wine. Some add two spoonfuls of the blood of the partridge. The crabs
are to be taken when the moon is on the increase before sun-rising. But
to those who do not drink it every day give a double doze, and sometimes
a triple. And the theriac from vipers may be given with advantage. The
patient is to be purged with the preparation from the wild cucumber,
which is to be given every day with the decoction of sage, or with the
Heraclean ironwort, which is also called alysson. Some also give the
liver of the dog that inflicted the bite to eat. Such a diet is to be
given as blunts and extinguishes the power of the poison, and at the
same time prevents it from being carried deeper into the system. Both
these ends may be accomplished by drinking old sweet wine that is both
undiluted and strong, or milk, and in like manner by eating garlic,
onions, and leeks. But if from some hinderance at the commencement the
remedies which we have described have been neglected, scarification,
cupping, or burning the wound, must not be had recourse to, because the
poison has already been carried to the deep-seated parts; but we must
use the remedies called metasyncritica, that is to say, when the attack
of hydrophobia has not come on. Purging with hiera and divided milk is
also to be had recourse to, with sudorifics; and calefacient plasters,
and sinapisms are to be applied to every part of the body. But the most
effectual of all remedies is a course of hellebore frequently repeated.

       *       *       *       *       *

COMMENTARY. Aristotle is the first author who mentions hydrophobia, but
his account of it is remarkably incorrect, if the text be not corrupted.
He says, all animals that are bitten by a rabid dog are affected with the
disease _except man_; and that the disease proves fatal to all animals
_but man_. (H. A. viii, 22.) But see the Annotations of Schneider. (l.
c.) Ovid ranks inveterate gout and hydrophobia among the incurable
diseases:

    “Tollere nodosam nescit medicina podagram,
      Nec formidatis auxiliatur aquis.”

                         _Ex Ponto_, i, 3, 24.

Celsus, also, was well aware of the fatal nature of the disease, for
which he says the only remedy is to plunge the patient unexpectedly into
the cold bath, after which, to prevent convulsions, he is to be put into
warm oil. He also approves of giving undiluted wine. As a preventive of
the disease he directs the wound to be cauterized. (v, 27.)

Pliny in like manner reckons the disease dangerous, and mentions
hellebore as a remedy for it. (H. N. viii, 63; xxix, 32.)

But without doubt the best account of hydrophobia contained in any
ancient author is that given by Cælius Aurelianus. We shall now give a
short abstract of it. He says the disease may be produced not only by the
bite, but likewise by the breath of a rabid dog. This fact is mentioned
by other authorities, such as Aretæus (Morb. Acut. vii), and Vegetius
(Mulo. Med. iii, 84); and it is confirmed by modern writers, as Gokel,
Lister, Rhazouz, and others. He also relates the case of a sempstress
who fell into the disease from having sewed a robe which had been torn
by a mad dog. Similar cases are related by Hildanus and Heister. He
likewise states, what is confirmed by the Arabian authorities, and also
by modern experience, that the disease may be brought on by the bite of
wolves, bears, leopards, horses, and asses. He mentions the case of a
person in whom it was occasioned by a wound inflicted with the spurs of
a cock while fighting. Sometimes, too, he adds, it arises in the human
subject without any manifest cause, which also is confirmed by modern
experience. We once saw _the horror of water_ in a case of Phrenitis. He
mentions a singular case of hydrophobia in a child which was affected
with a horror of its mother’s breast. His description of the symptoms, if
compared with modern descriptions (for example that given by Dr. Goden in
Hufeland’s ‘Journal,’ Jan. 1816), will be found in every respect complete
and accurate. Thus Cælius says that the pulse is _densus_, _parvus_,
_inordinatus_, and Goden found it intermittent and irregular. Cælius
says there is a frequent desire of making water, which Goden found to
be a constant attendant of the disease. Cælius thought that the stomach
is more deranged than any other part, and Goden is of opinion that the
splanchnic nerves are particularly affected. In short, Cælius maintained
that it is an _incendium nervorum_; and it appears from him that some
of the ancient authorities believed it an inflammatory affection, and
treated it by bleeding. He treats it upon much the same principles as
Tetanus, that is to say, his great object seems to have been to remove
constriction, and with this view he recommends friction with tepid oil,
venesection, and all remedies of a relaxant nature. He also directs us
to administer clysters of tepid water and oil; and proposes to quench
the thirst by forcing a cooling injection up to the stomach; for which
purpose pressure with the hands is to be applied externally. He makes
mention of the internal administration of hellebore, but disapproves of
it. The use of white hellebore, however, is favorably mentioned by Aëtius
(vi, 24), by Actuarius (Meth. Med. vi, 11), by Theomnestus (Geopon.
xix, 3), by Dioscorides (ii, 3), by Alexander Trallian (i, 15), and by
Avicenna (iv, 6, 9.)

Galen, in his work on ‘Antidotes,’ gives prescriptions for several
compositions of this sort for the prevention and cure of hydrophobia;
and mentions the disease incidentally in several parts of his works, but
has nowhere given any description of it. Dioscorides’ account of the
symptoms, and his plan of treatment are nearly the same as our author’s.
He strongly recommends the cautery.

The external application of the cautery is also commended by Celsus,
Galen, Pliny, Scribonius Largus, Aëtius, Actuarius, Nonnus, Avicenna,
Rhases, and Alsaharavius.

See a good account of hydrophobia in Haly Abbas (Theor. viii, 20); and in
Alsaharavius (Pract. xxx, 2, 30.) None of the ancient authorities insists
with so much earnestness as Haly Abbas on the necessity of applying
strong stimulants to the wound, namely, the most acrid vinegar, copperas,
and the like, so as to keep up a discharge from it for a considerable
time. Rhases is a strong advocate for bleeding when the poison is
distributed over the system. (Cont. xxxv.)

Perhaps Alexander Aphrodisiensis is correct in stating that the disease
in the dog is a species of fever. (Problem.)

There is a sensible account of hydrophobia in a ‘Fragment’ of an
anonymous Greek author, published in Bernard’s ‘Reliquiæ.’ The complaint
is said to arise either from the bite of a dog, or from humours
engendered in the body. It is correctly stated that persons affected with
it dread all liquids, so that at the bare mention of them they start
up with a scream, trembling, cold sweats, and chattering of the teeth.
Among other things cold applications over the stomach and chest are
recommended.


SECT. IV.—FOR THE BITES OF DOGS THAT ARE NOT MAD.

On the bites of dogs that are not rabid, as even in this case they
possess some poisonous quality, immediately sprinkle some vinegar, and
strike the bite with your hand spread out, and then having rubbed nitre
with vinegar, pour it from above upon the part. Afterwards, having soaked
a new piece of sponge in vinegar or in the vinegar and nitre, apply it
for three days, and moisten it; for it will effect a complete cure. Or
apply the flour of tares mixed with oil, or new sponge, or unwashed
wool soaked in vinegar and oil may be applied; or triturate the leaves
of bramble with vinegar, and apply; or onions triturated with honey, or
equal parts of the hair of marjoram, of salt, and of onions with honey;
or black horehound, which they also call ballotes, with salts. When the
bites have already suppurated, apply the flour of tares mixed with honey,
for it is particularly applicable. When they are inflamed anoint with
litharge triturated with water.

       *       *       *       *       *

COMMENTARY. See Rhases (ad Mansor. viii, 9; Cont. xxxv); Haly Abbas
(Pract. iv, 28); Alsaharavius (Pract. xxx, 2, 31). Haly adopts the
treatment laid down by our author. Alsaharavius recommends a composition
of fat, wax, pitch, and galbanum.


SECT. V.—ON WASPS AND BEES.

Those who have been stung by bees experience pain, redness, and swelling
in the wound, the surrounding parts become tumefied, and the sting
remains in the wound; and those stung by wasps experience all the other
symptoms, and that in an aggravated degree, only the sting does not
remain. Both cases are remedied by rubbing the parts with clay, or
cow’s dung, or with the juice of figs, or with the triturated leaves of
sycamore, or of mallows; or by applying a cataplasm of barley flour mixed
with vinegar. Foment also with brine or sea-water.

       *       *       *       *       *

COMMENTARY. See a similar plan of treatment recommended by Aëtius,
Dioscorides, Nonnus, and Rhases. Simeon Seth recommends the decoction
of mallows, which appears to have been a domestic remedy generally used
in such cases. See also Geopon. (xii, 12); and Pliny (H. N. xx). Virgil
alludes to this practice in a passage which has been often misunderstood.
(Georg. iv, 230.) Haly Abbas recommends cold water or snow, also Armenian
earth with vinegar, and other applications of the same nature. (Pract.
iv, 34.) Alsaharavius mentions the same remedies as Haly, but expresses
himself sceptical as to their efficacy. (Pract. xxx, 2, 29.) Rhases,
among other applications, mentions a composition of camphor and vinegar;
and another containing opium, henbane, and camphor, to be used along with
a cloth moistened in snow-water. The Arabian writers on husbandry also
recommend the composition from mallows and oil, as a preservative of the
face and hands from the stings of bees and wasps. (Casiri, Bibl. Arab.
Hisp. 335.)


SECT. VI.—ON THE PHALANGIA, OR VENOMOUS SPIDERS.

When a person has been bitten by a phalangion the part itself appears
red, and as if pricked by a sharp-pointed instrument, but it does not
swell, nor is it very warm, but it is moderately red, cold, and itchy.
Those who have been stung experience a great sense of cold, trembling,
heaviness of the body, a cold sweat, constant pain, paleness, and a
perpetual desire to make water; in some cases there are dysuria, erection
of the genital member, humid eyes, and spasmodic distension about the
groins and thighs, a violent gnawing pain of the stomach, loss of taste
in the tongue, vomiting of water, or of substances resembling webs, and
sometimes these substances are discharged by the urine or bowels. By
going into hot water they are freed from pain, but the pain returns again
with violence. They are relieved by the application of the ashes of figs
mixed with salts triturated in wine, or of the pounded root of the wild
pomegranate, or of birthwort with barley flour mixed with vinegar. Bathe
the ulcers with hot sea-water, or with the decoction of baum, the leaves
of which may also be applied. Recourse must also be had frequently to
baths, and potions composed of these things, the seed of southernwood,
dill, birthwort, wild chick-peas, Ethiopian cumin, pounded cedar-berries,
the bark of the plane tree, the seed of the herb trefoil, the fruit of
tamarisk; give two drachms of each of these with one hemina of wine, or a
decoction of the green parts of cypress, or of its balls mixed with wine.
Some say that the river crab when reduced to juice, with milk, and the
seed of parsley, and given, removes the mischief.

       *       *       *       *       *

COMMENTARY. Nicander describes several species of phalangia, whose bites
occasion a variety of symptoms, such as a cold horror, tremblings of
the limbs, and in some instances tension of the genital members. On the
phalangia, see Aristotle (Hist. Anim. ix, 39); Xenophon (Memorab. i,
3); Pliny (H. N. xix, 9, and xxix, 27); Ælian (H. A. xvii, 11); Solinus
(Polyhist. xvii); Phile. (66). The distinction between the phalangia and
common spiders is thus stated by Humelbergius: “Araneorum primâ divisione
duo genera sunt, unum eorum qui innoxii sunt quos Græci arachnas, Latini
araneos dicunt, quorum etiam a Dioscoride duo genera recensentur, unum
quod holcon et lycon vocat, alterum vero dicit esse quod candidas, tenues
et densas telas operetur. Alterum genus est eorum qui noxii sunt, quos et
Græci et Latini phalangia vocant.” (Apud Apuleium.)

Similar modes of treatment to that of our author are recommended by
Dioscorides (vi, 42); Celsus (v, 27); Nonnus (270); Aëtius (xiii,
16); Actuarius (Meth. Med. vi, 10); Haly Abbas (Theor. viii, 22); and
Alsaharavius (Pract. xxx, 2, 26).

Sprengel allows that there is considerable difficulty in determining
the nature of the ancient phalangia. He attempts, however, to refer the
different species described by Nicander to their proper names in the
Linnæan classification. (Comment. in Dioscoridem.)

Many modern authorities, for example, Gesner, Baglivi, and Andreas
Laurentius, have held that the Tarantula, so famous in the annals of the
Dancing Mania, was a species of the phalangium. See further Hecker’s
Epidem. 113. This seems to be confirmed by Rhases calling a species of
the phalangium by the name of tarantula (Contin. xx and xxii); and,
indeed, Ardyen seems to settle the question that the tarantula is a
species of the phalangia. (De Venen. viii, 5.)


SECT. VII.—ON THE BITE OF THE SPIDER.

There is also a kind of spider, the sting of which occasions intense
pains about the middle of the hypochondrium, difficulty of making water,
erythema, and sometimes convulsions. Those who are stung by such animals,
are relieved by the Theban wild cumin, the seed of the chaste-tree, and
by draughts from the leaves of the white poplar, or by applying garlic
alone, and taking full draughts of undiluted wine.

       *       *       *       *       *

COMMENTARY. For the sting of the spider, Celsus recommends garlic mixed
with rue and pounded in oil. (vi, 27.) See also Pliny (H. N. xxix, 27);
Haly Abbas (Pract. iv, 35); Alsaharavius (Pract. xxx, 2, 24).


SECT. VIII.—ON THE STING OF THE SCORPION.

When one has been stung by a scorpion, the part immediately begins
to inflame, becoming hard, red, tense, and painful, being seized at
one time with heat, and at another with cold; and when pain is an
attendant symptom, it has remissions and exacerbations. These symptoms
are followed by sweating, a sense of shivering, trembling, coldness
of the extremities, tumour of the groins, and erection of the genital
member: sometimes there is a discharge of flatus by the anus with a
loud noise, and horripilation, and a painful discoloration on the
skin, the pain resembling the prick of a needle. These are immediately
relieved by having the juice of the fig poured into the wounds, and the
scorpion which stung the person may be pounded and applied to the bite;
afterwards salts triturated with linseed and the seed of marshmallows
may be applied. Native sulphur, mixed with rosin or turpentine, is also
of service; and in like manner, galbanum, spread out into the shape of
an oblong pledget and applied, or calamint pounded and applied; and
crude barley-flour prepared in wine and the decoction of rue; and in
like manner the pounded seed of the herb trefoil may be applied with
advantage. They may also take propomata containing two drachms of
birthwort, more particularly of its bark with wine; or gentian pounded,
or pennyroyal properly boiled, and ten bay-berries bruised, and calamint
long boiled with oxycrate, and cyperus with wine; and in like manner,
rue, the juice of the fig, and laserwort, if at hand; but otherwise
we must use the Parthian juice. The fruit of trefoil and the seed of
basil-royal may be taken in a draught with advantage. Silver immediately
applied to the wound has a wonderful effect. The benefit of all these may
be increased by the frequent use of the bath, copious perspirations, and
drinking strong or diluted wine. The following compound propomata may
be taken: Of sulphur vivum to the size of an Egyptian bean, with eight
grains of pepper in half a hemina of wine, or the juice of laserwort
triturated with crabs in wine, or equal parts of gith, Ethiopian cumin,
and the seeds of the chaste-tree in wine.

_For severe stings of scorpions and phalangia._ Of the lees of wine, dr.
xvi; of pellitory, dr. iv; of the seed of wild rue, dr. iij; of castor,
of the seeds of rocket, of each, dr. ij; let them be mixed with the blood
of the sea-tortoise. The dose is four oboli with wine, or three cyathi of
unmixed vinegar.—_Another_: Of pellitory, of birthwort, of each, oz. iv;
of pepper, dr. ij; of the juice of the laserwort, dr. j. The dose is the
size of an Egyptian bean.

       *       *       *       *       *

COMMENTARY. Nicander describes several species of the scorpion. The
white, he says, is innoxious. The red occasions a fiery heat with
restlessness and great thirst. The black brings on inquietude, delirium,
and laughter. The green occasions chilliness with horror. The symptoms
superinduced by the other species are also detailed. (See Theriac. 775.)
Ælius Promotus gives a very circumstantial description of the effects
produced by the sting of the different species of scorpions, but it would
appear to be mostly taken from Galen and other Greek authorities. On the
nature of the scorpion, see further, Pliny (H. N. xi, 25); and Ælian (vi,
20.)

On the medical treatment, see in particular Dioscorides (vi, 44); Aëtius
(xiii, 19); Nonnus (269); Actuarius (Meth. Med. vi, 10); Celsus (v, 27);
Rhases (ad Mansor. viii, 3); Haly Abbas (Theor. viii, 22, and Pract. iv,
33); Alsaharavius (Pract. xxx, 2, 20); Avicenna (iv, vi, 5.)

Galen gives a variety of prescriptions for the composition of antidotes
for the cure of persons stung by scorpions. The following one may be
taken as a specimen of them: Of birthwort, dr. iv; of pepper, dr. ij; of
opium, dr. j; of pellitory, dr. iv; form into trochisks of the size of
an Egyptian bean, and give to swallow along with two cyathi of undiluted
wine. (De Antidot. ii.) Rhases gives another receipt of Galen’s for the
sting of the scorpion, viz. equal parts of opium and of the seed of
henbane given with honey. (Contin. xx, 24.)

On the use of venesection for the cure of the sting of the scorpion,
Celsus says, “Cognovi tamen medicos qui ab scorpione ictis nihil aliud
quam ex brachis sanguinem miserunt.” Rhases has pointed out the proper
time and circumstances which require venesection: “When you have
administered the theriac, and the pain has subsided, if fever supervene,
bleed the patient on the following day in the morning, and give him
barley-water and diluent food.” The symptoms as detailed by Haly Abbas
are pain, swelling, hardness, and inflammation, which occasionally
superinduce asphyxy and epilepsy. He directs a ligature to be put
immediately around the member, and a bruised scorpion to be applied to
the wound. He also mentions cataplasms with olive oil, and recommends
the internal use of wine either alone or with garlic. The treatment as
given by Alsaharavius is very similar. Dioscorides, Aëtius, Haly Abbas,
Alsaharavius, Actuarius, and Nonnus, omit to mention venesection.

The veterinary surgeons recommend bleeding, scarifications, and burning
with red-hot irons. See Vegetius (Mulom. iii, 77, and Geopon. xvi, 20.)

Sprengel remarks that Nicander’s division of scorpions is adopted by
modern naturalists. (Hist. de la Méd.) Conrad Gesner gives a very
elaborate dissertation on them. The _scorpio Europæus, L._, is not
venomous. The African, however, is a very dangerous reptile. The
inhabitants of Morocco, at the present day, treat its bite with the
ligature, the cautery, and by applying the body of a dead scorpion to
the wound. See Jackson’s Morocco (108). The Arabian authorities describe
a highly venomous species of scorpion, which they call _scorpius
rastellans_, _carrareti_, and _algreta_. See in particular Rhases, Haly
Abbas, and Alsaharavius.


SECT. IX.—ON THE LAND AND SEA SCOLOPENDRA.

When one is bitten by a scolopendra the general symptoms are lividity
of the parts around the bite, and swelling; sometimes it is of a
feculent appearance, and sometimes, though rarely, red; and a painful
and ill-conditioned ulcer takes place, beginning with the part that is
bitten; and in addition to these, there is a sensation of pruritus over
the whole body. Those bitten by the sea scolopendra in particular have
a watery and transparent swelling, whereas that occasioned by the land
scolopendra is red. It is proper therefore to apply to the wound pounded
salts, or levigated rue, or ashes mixed with vinegar, or squills. Bathe
the part with vinegar and brine; but Archigenes directs it to be done
with much hot oil, and thus to apply the things formerly mentioned; and
to administer potions containing birthwort with wine, or wild thyme, or
calamint, or wild rue, or trefoil, or the juice of the root of asphodel
to the amount of half a hemina with wine.

       *       *       *       *       *

COMMENTARY. Nicander says, that the scolopendra has two heads, and walks
in both directions upon its many feet. Avicenna admits that he was wholly
unacquainted with it. See in particular Ælian (H. A. iv, 22; and vii,
35.) Our author and Actuarius copy almost every word from Dioscorides.
See also Aëtius (xiii, 15); Nonnus (272); Alsaharavius (Pract. xxx, 2,
23); Avicenna (iv, vi, 3.) Avicenna calls them, _saculufudurni_; and
Alsaharavius, _alhatrabay_. Alsaharavius approves of wine with birthwort,
rue, mint, &c., internally; and of salt, with honey, vinegar, &c.,
externally. The Pseudo-Dioscorides recommends salt with vernix, pitch,
and honey. (Euporist. ii, 121.) We need have no hesitation in deciding
with Sprengel and the other authorities on this subject, that the land
scolopendra is the _scolopendra morsitans_, and the sea, the _aphrodite
oculeata, L._


SECT. X.—ON THE STELLIO OR SPOTTED LIZARD.

Those bitten by the spotted lizard experience intense pain and lividity
of the part, but are relieved by the immediate application of cataplasms
consisting of onions and garlic to the wound; and some by eating these
things and drinking undiluted wine have been cured.

       *       *       *       *       *

COMMENTARY. That the galeotes and ascalabotes are but different names
for the same animal is evident from Aristophanes (Nubes, 170, et seq.);
and from the Scholiast’s note on Nicander (Ther. 484.) Pliny says of the
stellio: “Hunc Græci coloten vocant et ascalaboten.” (H. N. xxix, 28.) On
the stellio, see further Bochart (Hieroz. ii, 510); Harris (Nat. Hist.
of the Bible, in the word spider); and Dr. Martyn on Virgil (Georg. iv,
244.) All agree that it was a kind of lizard. In short it is the _lacerta
stellio, L._ A learned modern authority says it is venomous in Greece,
but innocuous in Sicily. He describes it as resembling the lizard in
shape, and the chamæleon in nature. (Agricola de Anim. Subterran.)

Dioscorides does not treat of the stellio. Aëtius recommends very nearly
the same treatment as our author. (xiii, 12.) Avicenna and Rhases direct
us to get the wound sucked, to put the patient into a warm bath and
administer the theriac. The harbæ of Avicenna is probably only a species
of the stellio.

Alsahaya and alvesghe of Alsaharavius seem to have been two species of
stellio. (Pract. xxx, 2, 27.) He approves of the same treatment as that
recommended by Avicenna and Rhases.


SECT. XI.—ON THE MUS ARANEUS OR SHREW-MOUSE.

When persons are bitten by the shrew-mouse, throbbing pains supervene,
erythema of every part pierced by a tooth, blisters along the skin
filled with an ichorous fluid, and all the surrounding parts are livid;
and if the skin be stripped off from the blister, the ulcer appears
white, owing to the skin being torn into nervous membranes. In addition
to these symptoms, the mortified parts drop off, the disease extending
like a spreading ulcer; and besides tormina supervene, with dysuria and
the discharge of a cold fluid. They are relieved by the application of
galbanum in the form of an oblong pledget, by itself, or triturated with
vinegar, or of barley-flour mixed up with oxymel. And the shrew-mouse
itself which inflicted the bite may be torn in pieces and applied, and
pellitory may be applied, or the boiled rind of the sweet pomegranate,
or wild mallows, or pounded garlic, or mustard triturated with vinegar;
and the parts may be bathed with warm brine, and then a cataplasm of
burnt barley with vinegar may be applied. They may take propomata of
southernwood boiled in wine, or sisymbrium, or wild thyme, or rocket,
or galbanum, or sage, or the tender balls of cypress with oxymel, or
pellitory with wine, or the root of chameleon, or the rennet of a kid
or of a lamb, or gentian root, or vervain. These things may also be
administered in the form of a cataplasm. But some give in a potion the
shrew-mouse itself that inflicted the bite, having triturated it with
wine. This one also is effectual: Of myrrh, dr. vj; of the bark of
birthwort, dr. iv. To the bites of the shrew-mouse and of the scolopendra
apply salts with liquid pitch, or cedar-rosin with honey, or garlic with
the leaves of the fig-tree and cumin, or the leaves of calamint, or
barley with vinegar.

       *       *       *       *       *

COMMENTARY. Nicander says that the bite of the blind Mus araneus is
mortal. Our author’s plan of treatment is taken from Dioscorides.
Oribasius recommends garlic and cumin, mixed with oil. (De Morb. Curat.
iii, 70.) Aëtius says that the Mus araneus is an animal resembling the
weasel. His plan of treatment is similar to our author’s. (xiii, 14.)

Isodorus says of it: “Mus araneus, cujus morsu aranea moritur, est in
Sardiniâ animal perexiguum, araneæ formâ, quæ solifuga dicitur, eo quod
diem fugiat.” (Orig. xii, 3.)

Vegetius, the veterinary surgeon, recommends garlic pounded with nitre,
or with salt and cumin. (Mulom. iii, 82.) See also Columella (vi, 17);
and Ælian (H. A. ii, 37.)

Most of the Arabians treat of this case in the same terms as the Greeks.

Without doubt it is the _sorix araneus, L._ The accounts which the
ancients give of its venomous qualities are said by Buffon and Sprengel
to be exaggerated. Probably Agricola states the matter correctly when he
says, that the mus araneus is venomous in warm climates, but innocent in
cold. In size, he says, it is nearly equal to a small weasel. (De Anim.
Subter.)


SECT. XII.—ON VIPERS AND ECHIDNÆ.

When persons have been bitten by the viper or echidna, or some such
venomous animal, pain supervenes, at first of the part which has been
bitten, but afterwards of the whole body. In the bite there appear two
perforations at a little distance from one another, from which there is
a discharge of blood and ichorous fluid, and afterwards of an oily one,
but in all cases of a poisonous fluid, which they affirm to be the poison
of the reptiles. Swelling comes on around the wound, which is reddish
and livid; there is paleness of the whole body, vertigo, and resolution
of the stomach, deliquium animi, and in some cases bilious vomitings
and dysuria. Around the bite blisters arise, as from burning with fire,
the disease spreads by extending to the surrounding parts, and the gums
discharge blood. Trembling, heavy sleep, and a cold perspiration succeed
these symptoms. Those bitten by the echidna appear to escape with less
danger than those by the viper; and of these they run the least risk who
have previously taken food. In treating them the most effectual remedy is
eating garlic and drinking wine, so that if one can endure this course
he will not stand in need of any other remedy. And let them eat also
leeks, onions, and acrid pickle. Some likewise give frogs prepared with
sauce to eat. The following things are effectual, each of which may be
taken with wine: the dried blood of the sea tortoise with wild cumin, the
rennet of a hare or a hind to the amount of three oboli, a drachm of the
dried testicle of a stag, a whole alkanet with the slender leaves, which
also some apply as an amulet. In like manner the juice of leeks, to the
amount of half a hemina, in honied water, the juice of baum leaves, wild
rue, the brains of domestic fowls, the root of panacea boiled in wine,
one drachm of agaric, juniper berries, the root of asphodel, pounded
pistachia, the seed of the chaste tree, two drachms of dried weasel, the
root and juice of vipers’ bugloss, river and sea crabs alone or with
stavesacre, salts and poley, the root of birthwort with equal parts of
myrrh, gentian, and bay-berries mixed with honey. The following is an
admirable remedy of Oribasius for persons bitten by vipers: Of anise,
an acetabulum; of pepper, dr. iv; of the bark of birthwort, of opium,
of castor, and of myrrh, of each, dr. j; triturate with must, and form
to the size of a Grecian bean, and give according to the patient’s
strength in three cyathi of diluted wine.—_Another_, from the works
of Lycus, a medicine for the bites of vipers: Of myrrh, of castor, of
pepper, of purslain, of each, dr. j; of the seed of dill, an acetabulum;
triturate in must, and give.—_Another_, from the works of Archigenes:
Pound carefully twenty crabs with a sufficient quantity of wheaten flour
in a mortar, and having mixed some calamint and salt with it, form
trochisks of it, and dry. Use in a cataplasm with milk, and give one in
a draught with honied water. But, says he, if you have not river-crabs,
use sea-crabs. Goat’s dung applied externally to the wound with wine is
a powerful remedy; or bay-leaves boiled with oil, or bay-berries, or
calamint, heath, rue, parsley, southernwood, galbanum on a pledget, green
marjoram pounded; also young fowls torn in pieces, and applied warm and
frequently changed, the flour of tares mixed with wine, the pounded bark
of radish, boiled squills, raw barley-flour in oxymel, the leaves of the
wild cucumber with fine polenta, the lees of wine in like manner with
fine polenta, rue with salts and honey, bran boiled in vinegar, ashes
with vinegar, cedar-pitch with salts, liquid pitch with salts. Bathe also
with the decoction of trefoil, or of pennyroyal, or with vinegar and
brine. When the blisters become bloody let out their contents without
taking off the skin, then bathe with much water, and apply a cataplasm
of boiled lentils with honey till the cure is completed. The antidote
of vipers is particularly efficacious, both when taken in a draught and
applied externally.

       *       *       *       *       *

COMMENTARY. Most of the ancient authorities appear to have considered the
echidna the female viper; but, as will be seen below, there is reason to
suppose that it was a different species altogether. It is the colubra of
Celsus. (v, 27, 3.)

Our author’s description of the symptoms is closely copied from Nicander,
who also recommends similar treatment. Dioscorides in like manner directs
us to give wine, and various articles of an acrid and calefacient
nature, such as garlic, onions, pepper, squills, &c. Archigenes (ap.
Aëtium, xiii, 21) affirms that eating garlic and drinking undiluted wine,
constitute the most effectual part of the treatment. Of course these
things were given upon general principles with the view of supporting
the strength and vital heat. Hence it may be understood why the ancients
reposed so much confidence in the theriac of Andromachus, most of the
ingredients of which were stimulant, acrid, and calefacient substances.
The body of the viper, which entered into this famous composition, is
said by a modern authority on the Materia Medica, Moses Charras, to
contain a certain volatile oil. (See Book VII, sec. ii, of this work.)

Avicenna delivers his plan of treatment at great length, enumerating many
Arabic substances, the nature of which cannot now be easily determined.
His general principles, however, seem to have been much the same as
those of our author. He recommends in the first place the ligature,
and cupping with scarifications. Wine and the theriac are to be given
unless inflammatory symptoms come on, in which case the patient is to be
bled. (iv, 6.) In another place he praises the juice of the citron as a
remedy against the sting of the viper. Haly Abbas recommends immediate
amputation of the part when this is practicable, and otherwise directs
us to apply a ligature around it, to make scarifications, and use
stimulant applications, such as onions, leeks, &c. Like most of the other
authorities, he recommends the theriac, and wine, with other stimulants,
such as pepper, birthwort, bay-berries, &c. In certain cases he also
approves of bleeding. (Pract. iv, 32.) Alsaharavius recommends cupping,
the ligature, and in short nearly the same plan of treatment as Haly.
(Pract. xxx, 2, 18.)

Garlic was used in common cases as a substitute for the theriac, both
internally and in cataplasms. (See, in particular, Geopon. xii, 30.)

On the viper, see Ælian (H. A. x, 9); Phile (70); Galen (Ther. ad Pison.)
The ancient stories of the fatal copulation of the male viper with the
female, and of the loves of the muræna and viper, are probably fabulous.
(See De Pauw, apud Phile.) The latter story is told by Aristotle (H. A.
v, 10); Ælian (i, 50); Oppian (Hal. i, 554); Pliny (ix, 23); Athenæus
(vii); Achilles Tatius (i.) One of Athenæus’s authorities, however,
questions the truth of it. (Deipn. l. c.)

According to Sprengel, the Asiatic ἐχίδνα is the _coluber Ægyptius_;
the ἔχις, probably the _C. ammodytes_; and the European ἐχίδνα, the _C.
berus_. (Comment. in Dioscor.)

It is clear, however, from Nicander’s description of the viper, that the
term ἔχις was applied to a considerable variety of venomous snakes. It
must not then be supposed to apply in all cases to the coluber ammodytes.
It is also certain, as will be seen under their proper heads, that other
serpents, to which specific names were given, such as the cerastes, the
hæmorrhus, and the asp, were merely varieties of the _vipera_.

The seps is not treated of by the Greek authorities on Toxicology,
except Nicander, but is briefly noticed by the Arabian under the name of
_famusus_. Avicenna states that the treatment of the viper applies to it.
(iv. 6, 3, 48.) From the description of it given by Nicander, it would
appear to have been a variety of the hæmorrhus. (See Theriac, 320, with
the Commentary of Eutecnius.)


SECT. XIII.—ON THE AMPHISBÆNA AND SCYTALA.

The same symptoms follow their bites, and the same remedies are
applicable to them; therefore it is unnecessary to treat of them
particularly.

       *       *       *       *       *

COMMENTARY. Nicander says that the amphisbæna is a small serpent with
two heads, and small eyes. The scytala, he says, is like the amphisbæna,
but thicker and larger towards the tail. Avicenna doubts whether the
amphisbæna moves both ways. He says it is a serpent of equal thickness at
both extremities, which probably gave rise to the supposition that it had
two heads. He calls it a snake of the fragile nature, which description
evidently points to the blind-worm. (See further, Matthiolus, Comment.
in Dioscor.) We suppose the altahban and alhuidia of Alsaharavius are
the amphisbæna and scytala. (Pract. xxx, 2, 19.) He recommends general
treatment, namely, the ligature, cupping, scarifications, with cold water
to drink.

Sprengel inclines to think that the scytala was the _anguis eryx_. He
makes the amphisbæna to be the _anguis fragilis_, L.; he questions,
however, the accuracy of the ancient accounts respecting its venomous
qualities. (Notæ in Dioscor.) But, indeed, Aëtius states distinctly that
these serpents are not venomous, and that their sting merely occasions
inflammation like that of wasps and bees. (l. c.) Nicander also merely
describes these serpents, and says nothing about their being venomous.


SECT. XIV.—ON THE DRYINUS. THE INTRODUCTION FROM GALEN.

The dryinus, that lives at the roots of oaks, is so pernicious and
destructive an animal, that if one tread on him he will excoriate one’s
foot, and great swelling will seize upon the whole limbs; and, what is
more wonderful, they say that if one attempt to dress the wound, one’s
hands will be excoriated; and that if any person attempts in defence to
kill the animal, he emits such a stench as overpowers all other smells.
When one has been stung by the dryinus, tumefaction of the part takes
place with redness, and blisters on the surrounding parts, along with a
discharge of a watery ichor. These symptoms are followed by cardialgia
and tormina. Birthwort given as a draught with wine is serviceable in
these cases, and the herb trefoil, and the root of asphodel, taken in
like manner, and the fruit of all kinds of oak triturated and taken in a
draught. In like manner the roots of the ilex pounded and applied to the
part are of use.

       *       *       *       *       *

COMMENTARY. Nicander says it is also called chelydros and hydros. He
makes a distinction between the chelydros and the chersydros, but
subsequent authorities confound them together. (See below.) He says it
inhabits lakes and marshy grounds, feeding upon locusts and frogs. Its
back is black, and its smell fetid. The symptoms occasioned by its sting
are livid swelling, delirium, cutaneous pustules, dimness of vision,
suppression of urine, coma, singultus, and vomiting of blood or bile.

Haly Abbas calls it adresa, and says that it emits a fetid smell, and
brings on inflammatory redness with an aqueous discharge from the wound.
(Theor. viii, 21.) Avicenna calls it _kedusu duras_. (iv, 6, 3.)
Isidorus says, “Chelydros serpens qui et chersydros dicitur quia et in
terris et in aquis moratur.” (Origines.)

Virgil translates Nicander’s account of this serpent into verses of
inimitable spirit and elegance. It will be remarked by the curious
reader that he mixes up together circumstances collected from Nicander’s
separate descriptions of the chelydros and dryinus. (Georg, iii, 425.)
Though critical emendation of the text of ancient authors be foreign
to the design of this work, we cannot omit the present opportunity of
stating that, from a comparison of the descriptions given by the Greek
and Latin poets, we are inclined to think that the 434th line of Virgil
should run thus:

    Sævit agris asperque siti atque exterritus œstro.

This is founded upon the 417th line of Nicander’s Theriacs.

It seems to be the chersydros which Dante alludes to in the following
verses:

    “Come le rane innanzi alla nemica
    Biscia per l’acqua si dileguan tutte,
    Finch’ alla terra ciascuna s’ abbica.”

                     _Inferno_, canto ix.

For an account of the hydrus, see the sixteenth section.

According to Sprengel, the dryinus is the _coluber lebetinus_. (Notæ in
Dios.)

Agricola finds fault with Lucan for distinguishing the chersydros from
the hydrus or natrix. He remarks that the boa is a species of hydrus. (De
Anim. sub.) They are now generally held to be different. See, however,
our commentary on the sixteenth section.


SECT. XV.—ON THE HÆMORRHUS, PRESTER, OR DIPSAS.

Those bitten by the hæmorrhus experience violent pains, and both
longitudinal and lateral contractions of the porous parts of the body,
occasioned by the persistence of the pains. From the bite there is a
copious discharge of blood, and if there happen to be a sore on any part
of the body it bursts out and discharges blood. The alvine evacuations
likewise are bloody, and the blood which is evacuated is thrombous.
When they cough they bring up blood from the lungs, and they die at
last vomiting blood irremediably. Those bitten by the dipsas experience
intolerable heat and intense thirst which is insatiable and unceasing,
so that they swallow copious draughts, and yet they feel as if they
had never drunk; and the whole system is affected, as in dropsy, owing
to constant ingestion of drink. Hence the animal has been called
prester, causon, and dipsas. By most of the ancients those bitten by
the hæmorrhus and dipsas were given over as incurable. But if we have
no particular remedies for this reptile we ought to make trial of the
general applications, and immediately have recourse to scarifications
and burning, and, if the part permit, to amputation of the extremities.
Then acrid cataplasms may be applied. All kinds of acrid food are also
useful, especially that from pickles, drinking undiluted wine, and using
baths. These things are to be applied perseveringly, and repeated at
short intervals, before the complaints make their attacks; for after they
make their appearance no advantage can be derived from medical aid. We
find these topical remedies described for their bites, namely, for those
of the dipsas, the powdered leaves of purslain with vinegar, polenta,
and bramble leaves powdered with honey, plantain, hyssop, white garlic,
leeks, rue, and nettle; and for those of the hæmorrhus the same things,
and, in addition, boiled vine leaves triturated with honey. By the mouth
the burnt head of the animal itself may be taken in a draught, or garlic
with oil of iris. They may likewise eat dried grapes.

       *       *       *       *       *

COMMENTARY. According to Nicander, the hæmorrhus is about a foot in
length, of a black or fiery colour, with two horns on its head, and eyes
like those of locusts. The symptoms brought on by its bite, as described
by Nicander, appear to have been very similar to those of the disease
called purpura hæmorrhagica, namely, a discharge of blood from the gums,
nose, ears, bladder, bowels, or any open sore. Ælian gives exactly the
same account of it. (H. A. xv, 13.)

It appears from Dioscorides that the dipsas was also sometimes called
prester and causon. (vi.) See also Ælian (H. A. vi, 51.) Lucian and
Isidorus, however, make a distinction between the dipsas and prester.
Lucian says that it resembles the viper _de dipsadibus_. In fact the
dipsas seems to have belonged to the viper kind. (See Bochart, Hieroz.
ii, 367.) Galen states that he was informed by the Marsi, who made
a living in Rome by dealing in serpents, that the dipsades were not
a peculiar species of serpents, but a variety of the viper found on
the sea-shores of Africa. (De Simpl. x.) Isidorus thus defines them:
“_Hæmorrhois_ aspis nuncupatur, eo quod sanguinem sudet qui ab eo morsus
fuerit: ita ut dissolutis venis, quicquid vitæ est per sanguinem evocat.”
“_Dipsas_ genus est aspidis quæ Latine _situla_ quia quem memorderit
siti perit.” (Orig. xii, 4.) The effects produced upon the system by the
sting of the dipsas seem to have been of a highly inflammatory nature.
According to Nicander, it kindles a flame in the heart, the lips become
parched, and the person is seized with an unquenchable thirst. These
symptoms are strongly portrayed by Lucan:

    “Ecce subit virus tacitum, carpitque medullas
    Ignis edax, calidâque accendit viscera tabe.
    Ebibit humorem circum vitalia fusum
    Pestis, et in sicco linguam torrere palato
    Cæpit....
    Ille vel in Tanaim missus, Rhodanumque, Padumque,
    Arderet, Nilumque bibens per rura vagantem.
    Accessit morti Libye, _factique_[1] minorem
    Famam Dipsas habet terris adjuta perastis.”

                                  _Pharsal._ ix, 754.

    [1] Sic lege non _factiq_.

The Arabians give a similar description of its effects. Haly Abbas
says, that it occasions great heat and burning. Dioscorides treats the
wounds of the dipsas and hæmorrhus upon general principles, namely, by
the external application of cauteries and cataplasms; and the internal
administration of wine and acrid food. Actuarius, in like manner,
recommends undiluted wine and acrid food, and also directs us to amputate
the part, or apply acrid cataplasms according to the degree of danger.
Most of the ancient authorities concur in recommending the theriac; for
an account of the modus operandi of which in this case, see Alexander
Aphrodisiensis (Prob. i, 152.)

We may mention that, after considering the descriptions given by
Nicander, his commentator Eutecnius, Galen, Actuarius, and Avicenna, we
are disposed to think that the text of our author at the beginning of
this section must be corrupt; but we have not ventured to deviate from
it, as we could not hit upon a conjectural emendation to satisfy us. None
of the others mention contractions of the interstices or porous parts of
the body, and all state that there is a discharge of blood from the pores
of the skin. Now it is not probable that our author should have omitted
a symptom so striking as this cutaneous hemorrhage, and substituted one
which the others take no notice of.

Sprengel makes the dipsas to be the _coluber prester_, and the hæmorrhus
the _C. cerastes_. That they were both vipers is quite obvious from the
ancient descriptions of them, and more especially from the account of
them given by Galen. (l. c.)


SECT. XVI.—ON THE HYDRUS, OR WATER SERPENT.

When a person has been bitten by a water serpent, the wound becomes
broad, large, and pale, and a black, copious, and fetid discharge, as
from a spreading ulcer, takes place, and the cure of the mischief is
accomplished only after a length of time, and with difficulty. Wherefore
powdered marjoram mixed with water is to be applied to their bites, or
oak ashes mixed with oil, or barley-flour with melted honey is given to
drink, and birthwort to the amount of two drachms in diluted wine, or
two cyathi of oxycrate; and afterwards the juice of horehound, or its
decoction with wine, or wild cresses, or the fruit of asphodel, or the
flour or the seed of hog’s fennel, with wine. A fresh honeycomb may also
be eaten with vinegar.

       *       *       *       *       *

COMMENTARY. This section is taken almost word for word from Dioscorides.
The chersydros, says Nicander, is like the asp, and its bite is followed
by malignant symptoms. The skin about the wound becomes parched and
putrid, along with heat and pains all over the body. Isidorus says of it:
“Hydros aquatilis serpens a quo icti obturgescunt.” (Orig. xii, 4.) See
also Pliny. (H. N. xxix, 22.) Haly Abbas says, it occasions lividity of
the part, from which a black fetid discharge takes place. (Theor. viii,
21.)

Bochart makes this to have been the serpent which so annoyed the
children of Israel in the wilderness. (Hier. ii, 421.)

According to Sprengel, it is the _coluber natrix_. (Notæ in Dioscor.)
Gesner and Dr. Milligan make it to have been the _coluber lutrix vel
chersea_, L. It is now generally held not to be venomous. We have alluded
in our commentary on the fourteenth section to the confusion of the
hydrus with the dryinus. Schneider has a learned annotation on this
subject in his ‘Curæ posteriores’ to Nicander’s Theriacs, (l. 432.)


SECT. XVII.—ON THE CENCHRINUS.

When a person is bitten by the cenchrinus, the bite is like that of the
echidna, mortification supervenes, and the flesh melts away, having been
previously swelled as in dropsy, and he becomes lethargic and comatose.
Erasistratus says that the liver, bladder, and colon are affected; for
upon dissection these parts were found corrupted. Wherefore they are
remedied by a cataplasm composed of the fruit of lettuce with linseed,
and by pounded savory, and by wild rue, and by wild thyme triturated with
asphodel; and two drachms of the root of centaury should be immediately
given in a draught with three cyathi of nine, or the root of birthwort in
like manner, and so also cresses and gentian.

       *       *       *       *       *

COMMENTARY. According to Nicander, the cenchrinus, called also the lion,
has a body of varied size, and marked with punctated squamæ.

Dioscorides and Actuarius give exactly the same account of this serpent
as our author. Haly Abbas in like manner describes it as occasioning
mortification and putridity of the part. (Theor. viii, 21.) Isidorus says
of it, “Cenchris serpens in flexuosis qui semper iter rectum efficit. De
quo Lucanus: Et semper recto lapsurus limite cenchris.”

Sprengel conjectures that it is a variety of the coluber berus, or viper,
which is highly probable. According to Belon, it is three palms long, of
the thickness of the little finger; of a cinereous colour, with black
spots. Aëtius makes it to be the same as the acontias, which there can be
no doubt was the same as the jaculus of Lucan. Yet Lucan treats of the
jaculus and cenchris separately. (Phars. ix.)


SECT. XVIII.—ON THE CERASTES AND ASP.

According to Galen, there are three kinds of asps: that called the
land asp, the chelidonian, and the third the ptyas, which is the most
pernicious of all; for, stretching its neck, and measuring a convenient
distance, with great sagacity, it disgorges the poison into the body.
This is said to be the kind of asp which Queen Cleopatra, when Augustus,
having vanquished Antony, wished to seize on her, took and applied to her
left breast, and being bitten by it she died very quickly. When a person
is bitten by the cerastes the part becomes tumefied, with hardness and
blisters, and from the bite there flows an ichor which is sometimes black
and sometimes pale, and like leeks; the whole system becomes of a dark
pale colour, with erection of the privy member, and mental alienation;
then dimness of sight comes on, and they die at last convulsed, as in
tetanus. When a person is bitten by an asp, the bite resembles the prick
of a needle, being very small in appearance, and without tumefaction,
and it discharges blood not copiously but in small quantity, and of a
black colour. Straightway dimness of the eyes seizes them, and various
pains all over the body, which are altogether slight, and not without
enjoyment, supervene; wherefore Nicander has properly said, “and without
suffering dies the man.” The colour is changed and becomes as green
as grass, there is a gnawing pain at the orifice of the stomach, the
forehead is constantly drawn upwards, the eyelids are moved insensibly
as in sleep, and with these symptoms death cuts off the man before
the third part of a day has passed over. In both these cases speedy
amputation of the extremities averts the evil. Wherefore the bitten
part is to be amputated without delay, if possible, or the flesh is to
be cut off immediately down to the bone, in order that the poison may
not pass through the parts which are bitten and the adjacent ones. Then
what remains is to be seared by cauteries. For the poison of these, like
that of the basilisk and bull’s blood, quickly coagulates the blood and
spirits in the arteries.

       *       *       *       *       *

COMMENTARY. According to Nicander, the most pestiferous asp is about an
ell in length, its colour squalid, its eyes of a drowsy appearance, and
when it bites a person it leaves a very small wound; neither swelling
nor inflammation is perceived, “and the man without pain sinks into a
profound sleep.” This is the serpent which Cleopatra despatched herself
with. See some curious remarks upon this event, and the nature of the
serpent in Galen (Ther. ad Pison.), from which our author borrows his
account of it.

Nicander says of the cerastes that it resembles the male viper, only
that the latter has no horns, whereas the former has either two or four.
Isidorus says of them, “_Aspis_ vocata quod morsu venena immittat et
aspergat: ἱὸς enim Græci venenum dicunt, et inde _aspis_ quod morsu
venenato interimat” (Orig. xii, iv); and of the cerastes, “_Cerastes_
serpens dictus eo quod in capite cornua habeat similia arietum: sunt
autem quadrigemina cornicula, quorum ostentatione, veluti escâ illiciens
sollicitata animalia perimit.” (Ibid.) Harris says, “The shephephon (Gen.
xlix. 17) is probably the cerastes, a serpent of the viper kind.” (Nat.
Hist. of the Bible.) Bochart, however, has proved that the shephephon
signifies both the cerastes and the hæmorrhus, which are very much
alike, being both vipers. (Hier. ii, 416.) Sprengel, in fact, makes the
hæmorrhus to be the same as the cerastes.

Our author’s treatment is principally taken from Dioscorides. Aëtius,
however, gives the fullest account of them. He says the sting of the
most fatal species of asp proves fatal in three hours; and that those
wounded by the cerastes generally live nine days. He represents the asp
as occasioning great coldness, torpor, and at last convulsions. Besides
the local remedies applicable in all such cases, he recommends in an
especial manner vinegar, which is to be administered in great quantities.
Celsus thus explains the way in which vinegar proves efficacious for
counteracting the effect of a frigorific poison: “Credo quoniam id
(acetum) quamvis refrigerandi vim habet, tamen habet etiam dissipandi.
Quo fit ut terra respersa eo spumat. Eadem ergo vi verisimile est
spissescentem quoque intus humorem hominis ab eo discuti, et sic dari
sanitatem.”

The author of the work ‘Euporistôn,’ usually published with those of
Dioscorides, recommends, in the case of a person stung by the asp,
constant shaking, beating, and movement of the whole body, with the
affusion of hot salt water. (Euporist. ii, 120.)

Pliny says the poison of an asp proves immediately fatal when introduced
into a fresh wound, more slowly when the sore is old, and that it is
perfectly innoxious when swallowed by the mouth. (N. H. xxix, 18.)

The account which Avicenna gives of these serpents is mostly taken from
Aëtius and our author.

Agricola describes the asp to be four feet long, and of the thickness
of a spear. The cerastes, he says, in other respects resembles a viper,
except that it has two or four substances on its head like horns.

Madden, a late traveller in the East, gives a different account of the
horned serpent (coluber cerastes); he says that of two which he purchased
from the Psylli one was a foot long, and the other a foot and a half. A
lancet smeared with the venom of one of them killed a dog in three hours.
The French naturalists who attended the expedition to Egypt found a
viper, called _hage_ by the inhabitants, which they held to be identical
with the asp of the ancients. We need have no hesitation then in deciding
that the coluber Ægyptiacus is the celebrated asp of antiquity. That
the cerastes was a variety of the asp seems highly probable from the
description which Nicander gives of both. (Theriac 177 and 259.) See also
Wilkinson’s ‘Thebes,’ p. 378. In fine, the asp and cerastes were merely
varieties of the common viper of Egypt.


SECT. XIX.—ON THE BASILISK.

This reptile seldom comes under the sight of men; but Erasistratus says,
when the basilisk bites one the wound becomes of a faint golden colour,
and he also says that three drachms of castor taken in a draught proves a
remedy in such cases, and in like manner the juice of poppy; but we have
had no trial of these things.

       *       *       *       *       *

COMMENTARY. The basilisk, according to Nicander, has a sharp body about
three palms in length, of a bright yellow colour, and is called the king
of reptiles, because all the others flee from his hiss. Pliny, Solinus,
and most of the ancient authorities seem to copy Nicander’s description
of the basilisk. The symptoms produced by his sting are said to be
inflammation of the whole body, lividity and putrefaction of the flesh.
(Theriac. l. c.) See also Galen (Ther. ad Pison.)

Avicenna states that the basilisk stupefies birds and other animals which
approach him. He relates the case of a soldier who transfixed a basilisk
with his spear, and the poison proved fatal both to him and his horse,
whose lip was accidentally wounded with the spear. Lucan relates the case
of a soldier in the army of Cato, who having wounded a basilisk with a
spear, and having felt his hand affected with the poison, saved his life
by immediately cutting it off with his sword. (Phars. ix, 830.) Similar
histories are given by Pliny, Dioscorides, Actuarius, and Isidorus.
Solinus affirms that it proves fatal to all beasts, birds, and vegetables.

For an explanation of the passages of scripture wherein mention is made
of the basilisk, see Bochart (Hier. ii, 339.)

Sprengel says: “Linnæus omnem fabulam (de Basilisco) ad Lacertæ genus,
capite cristato, _Iguanæ_ proximum, reduxit.” (Comment. in Dioscor.)
M. l’Abbé Bonneterre also affirms that the basilisk is not poisonous.
(Encyc. Méthod.) It may be doubted, however, if we be now acquainted with
the basilisk of the ancients. It would appear to us almost certain that
the ancient basilisk must have been either the _cobra di capello_, or one
of the serpents described by an intelligent traveller under the names
of _buskah_ and _el effah_ as being still found in Morocco. (Jackson’s
Account of Morocco, 109.) The former of these, indeed, judging of it from
the drawing which he gives must be a variety of the _cobra_ or _coluber
naja_, L. We may add that a very intelligent modern authority on the
toxicology of the ancients, Ardoyn, gives such a description of the
basilisk as applies very well to the _cobra_. The crown (corona) on the
head can refer to no other serpent than the hooded snake. (De venenis,
vi.) It is now well ascertained that the _cobra_ is indigenous in Africa.


SECT. XX.—ON THE SEA PASTINACA AND MURÆNA.

In the case of sea animals, such as the fire-flaire and murene, the
diagnosis is obvious, for these fishes are well known. Those who are
bitten by them are remedied by four drops of the juice of figs, or
a little more, with three or four small branches of wild thyme in a
draught, and those things used for echidna.

       *       *       *       *       *

COMMENTARY. Nicander says that the sting of the pastinaca occasions
putridity in the flesh of a man who is wounded by it, and that it proves
fatal to a tree in like manner. The same thing is asserted by Aëtius,
Oppian, Phile, and Ælian. Our author and Actuarius copy from Dioscorides.

Avicenna recommends an embrocation of hot vinegar, and ointments composed
of bay-leaves, oil of pellitory, and so forth; and in like manner
recommends various calefacient medicines internally.

The murene of the ancients was that elegant species of eel to which the
scientific name of _muræna helena_ is now applied. It is rarely found
on the British coasts but is common in the Mediterranean. The pastinaca
marina of the ancients, was the _raia pastinaca_, L., i. q., _trygon
pastinaca_, Cuvier, namely, the sting-ray or fire-flaire. Sprengel
affirms that its sting is not venomous, as the ancients represent; but
there can be no doubt that it is capable of producing inflammation. See
Yarrel (British Fishes, ii, 588.) We may mention in this place that the
account of the copulation between the viper and the murene which is given
by Nicander, Oppian and other ancient authors, is held to be fabulous
by Andreas, the physician, as quoted by the scholiast on Nicander. (Ad
Theriac, 822.)


SECT. XXI.—ON THE SEA-DRAGON.

Rub the wound inflicted by the sea-dragon with lead, or apply a cataplasm
of pounded wild thyme, or of boiled lentil, or of sulphur with vinegar,
or the dragon itself may be torn in pieces and applied. Wash the part
with human urine, and give potions of wormwood with diluted wine, or of
sage, or of fig branches steeped in sweet wine, or of the brains of the
fish itself.

       *       *       *       *       *

COMMENTARY. A great variety of remedies for the wound of the sea-dragon
are described by Nicander. For an account of the draco, see Dioscorides
(vi, 45); Aristotle (H. A. viii, 13); Ælian (H. A. xiv, 12); Nonnus
(276); Pliny (H. N. xxix, 20); Aëtius (xiii, 39); Phile (80); Avicenna
(iv, 6, 3.)

We need have no hesitation in referring the sea-dragon of the ancients to
the _trachinus draco_, L., Angl., the great weever or sting-ball. This is
agreed upon by all the best commentators, as Rondelet, Artedi, Coray, and
Sprengel. Fishermen are still very apprehensive of its sting. See Yarrel
(Brit. Fishes, i, 25.)


SECT. XXII.—ON THE SEA-SCORPION.

The wound of the sea-scorpion is cured by a surmullet torn in pieces and
applied, by sulphur vivum rubbed with vinegar, or by three bay-berries
pounded and drunk.

       *       *       *       *       *

COMMENTARY. See Dioscor. (vi, 45); Nonnus (277); Aëtius (xiii, 40);
Athenæus (353, ed. Casaubon.); Avicenna (iv, 6, 3, 23.)

Bochart says of the sea scorpion: “Is cum terrestri nihil habet commune
præter venenatos aculeos, non in caudâ sed in capite et toto corpore
sparsos.” (Hierob. ii, 635.)

According to Sprengel, it is either the _scorpæna scrofa_ or the _cottus
scorpius_ Bloch. (Comment. in Dios.) It is a fish still very much dreaded
on account of its sharp spines. See Yarrel (Br. Fishes, i, 76.)


SECT. XXIII.—THE PREPARATION OF THE BLOOD OF THE SEA-TORTOISE.

The blood of the sea-tortoise is to be prepared for keeping in this
way. Having stretched the tortoise with its belly upwards on a wooden
or earthen vessel, cut off its head quickly, and when its blood is
coagulated, divide it into many parts with a reed, put a sieve upon the
vessel in place of a lid and lay it up in the sun. When dried take it and
use for bites of vipers, as aforesaid; two drachms with one cyathus of
vinegar, on the second day four drachms with two cyathi of vinegar, and
on the third eight drachms with three cyathi of vinegar.

       *       *       *       *       *

COMMENTARY. This section is copied from Aëtius (xiii, 24.) In our
translation we have followed the text of Aëtius, that of our author being
manifestly corrupt.


SECT. XXIV.—ON PERSONS BITTEN BY CROCODILES.

For the bites of the crocodile apply levigated natron until the ulcer be
cleansed, then fill it with honey, butter, stag’s marrow, or the fat of
geese. But Galen says, that he has known persons bitten by crocodiles
manifestly relieved by the application of the fat of the crocodiles
themselves to the wounds.

       *       *       *       *       *

COMMENTARY. This case is more fully treated of by Aëtius (xiii, 6.) His
remedies are mostly of an acrid stimulant nature such as misy, pickle,
salts, myrrh, verdigris, &c. The application recommended by our author
upon the authority of Galen is ascribed by Aëtius to Apollonius.


SECT. XXV.—ON PERSONS BITTEN BY A MAN.

It will not be foreign to my subject along with venomous animals also to
treat of persons bitten by men, since the bites inflicted by men are much
more malignant than other ulcers, more especially if the person who bit
happens to be fasting, or had previously eaten some pulse, particularly
dried lentil. Wherefore, the general remedies for poisonous animals may
be applied externally to the bite with advantage at the commencement,
with the exception of such as are very acrid and caustic; in particular
having first rubbed the bite with oil, apply a cataplasm of the roots
of hog’s fennel with honey, or apply the flour of beans with oxycrate,
and vinegar and rose oil, sponging it frequently. And use the following
plaster: Of squama æris, of galbanum, of verdigris, of each, oz. j; of
wax, lb. j; of molybdæna, lb. ij; of oil, one sextarius. The molybdæna
being first boiled in the oil receives the verdigris and squama æris,
and when it thickens it receives the soluble substances. When the
inflammation subsides treat it as a common ulcer.

       *       *       *       *       *

COMMENTARY. Similar treatment is recommended by Aëtius (xiii, 1);
Apuleius (9, 2); Serenus (45); Pliny (H. N. xxviii, 4); Oribasius (de
Morb. Curat. iii, 71); Avicenna (iv, 6, 4); and Haly Abbas (Pract. iv,
28.)

It may be proper to mention in this place that instances have not
been wanting in modern times to confirm the accounts given by ancient
authorities, of fatal effects being occasioned by the bite of a man. See
Hildanus (Chirurg. i); Forestus (xxx, 12); Hoffman (Diss. de saliv. et
op. morb. 5); Zacutus Lusitanus (Prax. adm. iii, 84, 89.)


SECT. XXVI.—ON POISONS.

Having given a compendious account of venomous animals, we shall next
treat of deleterious substances, giving an exposition of the simple ones,
and detailing the symptoms of them with their general and particular
remedies. As to the compound ones we leave them to be treated of by any
person who chooses; for some have described the compositions of certain
deadly medicines which are more likely to prove injurious than beneficial
to the reader. For neither are the exact symptoms which occurred in
those who took them described, by which a suitable remedy might be found
out; for the symptoms varying according to the nature of the prevailing
ingredient, one might, from conjecture, vary the remedies accordingly.
Wherefore here again we must begin with the prophylactics.

       *       *       *       *       *

COMMENTARY. We now enter upon the consideration of the second and most
important division of toxicology; namely, alexipharmics, which treats of
poisonous substances taken inwardly. All the writers on theriacs treat
also of alexipharmics, and of these the most ancient, and one of the
most interesting, is the Colophonian poet Nicander. Of the subsequent
authors, Dioscorides and Aëtius among the Greeks, and Avicenna and
Alsaharavius among the Arabians, are most particularly deserving of
notice.


SECT. XXVII.—ON THE PRESERVATIVES FROM POISONS.

Of the doctrine of poisonous substances, the most difficult part is
the prophylactic; because those who administer poisons in a concealed
manner, prepare them so as to deceive the most skilful. Thus they take
away the bitterness of deleterious substances by mixing them with sweet
things, and the fetid smell by a mixture with aromatics. Sometimes
in diseases, while appearing to administer such things as wormwood,
southernwood, opoponax, and castor, for a beneficial purpose, they mix
poisons with them; or they give them in the food, namely, in the harder
and more complex articles, mixing the poisons with them. Wherefore a
person who entertains suspicions, ought to avoid all prepared dishes and
every intense quality, such as sweetness, saltness, and acidity; and in
particular to take plenty of water, for when the appetite is satiated,
the particular qualities are afterwards easily detected. There is
likewise another efficacious mode of prophylaxis: for they who suspect
anything of this kind should take such things as will blunt and take away
the effect of the poisons, as dried grapes with walnuts, rue, a lump
of salt, and citrons. Let them also take rape-seed to the amount of a
drachm in wine, or the leaves of calamint, or Lemnian earth, and twenty
leaves of rue, and they will not be hurt by any poison. And certain
antidotes taken with wine every day to the amount of an Egyptian bean
will protect completely, such as the one from skink, that from blood, and
the Mithridate, which king Mithridates took every day as a preservative
from deadly poison; and being captured by the Romans, he drank twice
of a deadly poison, and not being able to despatch himself thereby, he
killed himself with his sword. And since people are sometimes exposed to
deleterious things accidentally in desert places without design, if they
happen to take up their abode under certain trees, such as pines or firs,
they ought to be on their guard against deadly animals, which fall from
them and the roofs of houses, and keep the vessels in which their wine is
contained, and in which they boil victuals, well covered up, as has been
stated when treating of the preservatives from venomous animals.

       *       *       *       *       *

COMMENTARY. Nearly the whole contents of this section are taken from
Dioscorides. (Præf.)

The account of the treatment given by Aëtius is somewhat fuller than our
author’s, but not materially different.

Avicenna makes mention of the same medicines as Dioscorides, and says
nothing of any other remedies.

Of the substances mentioned by our author, and the others as
preservatives from poisons, some are demulcents, and may be supposed to
act by obtunding the acrimony of poisons, such as figs, walnuts, and
rape-seed; some are simple absorbents, such as Lemnian earth, which
probably resembled red ochre, and was also emetic: some are stimulants,
such as rue, calamint, and wine; and some are refrigerant acids, such as
citrons, which may be supposed to act as analeptics and restoratives.
Virgil mentions this property of the citron:

    “Media fert tristes succos tardumque saporem
    Felicis mali: quo non præsentius ullum,
    Pocula si quando sævæ infecere novercæ
    Miscueruntque herbas, et non innoxia verba,
    Auxilium venit, ac membris agit atra venena.”

                                    _Georg._ ii.

See in particular Simeon Seth (in voce Κιτρὰ); and Athen. (Deip. ii.)
Dr. Paris states that when a narcotic poison has been ejected from the
stomach, citrons or any fruit containing a vegetable acid will produce
the best effects. (See Pharmacologia i, 254.)


SECT. XXVIII.—THE GENERAL TREATMENT OF THOSE WHO HAVE TAKEN ANY SORT OF
DELETERIOUS SUBSTANCE.

If any persons have already taken some deadly poison with the intention
of despatching themselves, such as often happens in life, or from the
wicked design of others, if it be obvious to us what substance has
been taken, we can straightway apply the suitable remedy, as will be
described in the account of them. But if the medicine is unknown to
us, we must have recourse immediately to such things as are generally
applicable to those who have taken any poison whatever; for to wait until
the consequent symptoms have come on, is to render the case hopeless,
since owing to the remedies being too long of being applied such symptoms
can hardly be removed: wherefore, without delay, we must give warm oil
by itself or with water, and force them to vomit, or if oil is not at
hand, butter with hot water may be given, or a decoction of mallows, or
of linseed, or of spelt, or of fenugreek, or of nettle seed. For these
things will not only evacuate by vomiting, but will loosen the belly and
counteract the bad effects of the poisons, by blunting their acrimony;
and more especially oil will do this, as you may ascertain clearly from
the following consideration. For if you wish to produce ulceration
of the skin by means of cantharides, quicklime, or some such acrid
substance, and the body has been previously rubbed with oil, no ulcers
will take place, and neither also can you astringe the body if previously
rubbed with oil. Besides, vomiting is not only useful by evacuating the
offending matter, but by showing the poison which had been taken from its
smell, particles, or colour. For by its smell and bitterness poppy-juice
is known; by their colour, ceruse and gypsum; by their coagula, milk and
fresh blood; by their heavy smell and quality, the sea-hare and toad: so
that by these means we are enabled to have recourse to the remedies which
are suitable to each. With the oil may be mixed the decoction of mallows,
or the grease of geese, or broth prepared from fat flesh or fowls, or the
cinders of wood. Natron also triturated with hydromel, much old wine,
and those things which are prepared from fat or butter are efficacious.
Having evacuated the contents of the stomach by emetics, we must bring
away whatever had passed into the intestines by a stimulant clyster.
After these things, we are to give milk to drink, for whatever is noxious
and deleterious will be readily changed by it. We must also give those
medicines which are generally applicable to all such cases, among which
are the Lemnian vermilion, southernwood, agaric, hedge-mustard, the root
of eryngo, the seed of parsnip or of calamint, the Celtic nard, castor,
the inner part of green fennel-giant, the flowers of nerium (called also
rhododendron and rhododaphon), the juice of leeks, laserwort or the juice
thereof, sagapene, opoponax, the juice and root of hog’s fennel, the long
birthwort, the seed of wild rue, the leaves of that species of cestrum,
called betony; of each of these a drachm may be taken in wine. The
decoction of poley and liquid pitch in a linctus is also efficacious, and
the aforesaid antidotes are excellent remedies, especially the theriac
from vipers. But they have not the same power when taken after as before
the poisonous substances, for a dose which would have been sufficient, if
administered beforehand, to prevent any bad consequences, must be given
in a fourfold or fivefold quantity, in order to prove effectual when
administered afterwards, and that too not once, but twice a day. For such
is the opinion of the celebrated Galen.

       *       *       *       *       *

COMMENTARY. Except the last two sentences the whole of this section
is copied from Dioscorides. Celsus’ directions, so far as they go,
are excellent: “Commodissimum est tamen, ubi primum sensit aliquis,
protinus oleo multo epoto vomere: deinde, ubi præcordia exhausit, bibere
antidotum; si id non est, vel merum vinum.” The directions given by
Aëtius are to the same purpose as our author’s, but somewhat fuller. He
is particularly to be commended for the precision with which he lays
down the rules of treatment, when any organ happens to be affected in an
especial manner. Thus, if the poison attack the bladder, he directs us
to put the patient into a hip-bath of oil or water, in which fenugreek,
linseed, mallows, or some such emollient herbs have been, boiled and
to give him to drink the decoction of some vegetable diuretic, such as
parsley, fennel, or spikenard. If the bladder be corroded he directs
us to give the seed of cucumber in diluted sweet wine. In the same
manner when the intestines are corroded the same seed is to be given,
and all heating articles are to be abstained from. When the poison is
determined to the skin, he recommends the hip-bath of oil or water,
friction with warm oil, and the like, evidently with the intention
of evacuating it from the pores of the skin. Food of easy digestion,
soups with honey, tender fishes, and the like are to be given. When
the head is particularly affected he directs us to evacuate the bowels
with a clyster of linseed, marshmallows, and a decoction of the root of
the wild cucumber, after which sternutatories and odoriferous things
are to be applied to the nose. Like our author, he strongly commends
Lemnian earth with wine as an excellent and speedy emetic. This remedy
is also mentioned by Avicenna. Galen assures us that he found it an
excellent emetic in various cases of poisoning. (Simpl. ix.) It consists
principally of silica, alumina, and oxyde of iron.

Avicenna directs us to give immediately as an emetic, oil of sesame
or olive oil, impregnated if possible with the virtues of dill, and
afterwards to use demulcents, such as the decoction of linseed, melted
butter and milk. These emetics are to be followed by clysters, provided
the mischief has spread downwards. If the disorder continue, another
emetic is to be given, and draughts of milk repeated. When, after the
emetic, inflammation supervenes, he directs us to give snow-water, or
oil of roses, and to promote vomiting with them. When the poison is
ascertained to be of an inflammatory nature the parts affected are to be
cooled with camphor, rose-water, or that of coriander; or these things
are to be congealed in snow and applied over the vital organs. If the
poison is ascertained to be of a sharp penetrating nature, medicines
are to be given to blunt its acrimony, such as milk, almond oil, melted
butter, &c. Bloodletting, if indicated, is to be performed. When the
poison is known to be of a stupefying nature, garlic is to be given, or
the theriac and assafœtida in undiluted wine. When it is particularly
deleterious, the cure is to be effected by means of the mithridate,
theriac, musk, and other aromatics. He inculcates the necessity of
preventing sleep and of rousing by every possible means. The patient
is to be covered with aromatic cloths, the pit of his stomach is to
be rubbed, his face is to be fanned, his hair pulled, and in short,
everything is to be done to prevent him from sinking into a state of
stupor.

Haly Abbas recommends the same plan of treatment. When the poison is
discharged he recommends citrons, plums, and the like, as restoratives.
Rhases gives the following directions: First, he says, produce vomiting
with oil and water; then give food of a nauseating nature to continue
this operation; if the bowels are inflamed give snow-water and rose-oil,
and afterwards provoke vomiting once more: administer the theriac, rub
the hands and feet, and when the poison appears to have descended to the
intestines give clysters. (Contin. l. c.) Rhases and other of the Arabian
authorities recommend the bezoar stone as an antidote for poisons.


SECT. XXIX.—A CATALOGUE OF SIMPLE DELETERIOUS SUBSTANCES.

Of deleterious substances, the following animals are destructive:
cantharis, buprestis, salamander, pine-caterpillar, the sea-hare, the
toad, the mute marsh frog, and leeches when swallowed; and, of seeds, the
henbane, coriander, fleawort, hemlock, and gith; of juices, meconium,
opocarpasum, thapsia, elaterium, and mandragora; of roots, chamæleon,
wolfsbane, thapsia, ixia, hellebore, black agaric, ephemeron, which some
call colchicum, because it grows in Colchis; of trees and potherbs,
smilax, which some call thymium, but the Romans called taxus, the
strychnus furiosa, which is called dorycnium, the Sardoan herb, which is
a species of ranunculus, horned poppy, pharicum, toxicum, wild rue, and
mushrooms; of animal productions, fresh bull’s blood, coagulated milk,
Heraclean honey; of metals, gypsum, ceruse, lime, arsenic, sandarach,
litharge, adarce, lead, and that which is called mercury; and of domestic
articles, much wine taken at a draught after the bath, or must, or cold
water in like manner.

       *       *       *       *       *

COMMENTARY. Nicander, in his Alexipharmics, treats of the following
deleterious substances:—1, Aconitum, or wolfsbane; 2, Argenti spuma,
or litharge; 3, Buprestis; 4, Cantharides; 5, Ceruse, or whitelead; 6,
Conium, or hemlock; 7, Coriander; 8, Dorycnium (see below); 9, Ephemeron,
or meadow saffron; 10, Fungi, or poisonous mushrooms; 11, Hirudines, or
leeches; 12, Hyoscyamus, or henbane; 13, Ixias, probably a species of
chamæleon; 14, Coagulated milk; 15, The sea-hare; 16, Papaver, or poppy;
17, Pharicum, probably a composition from agaric (see Schneider’s note);
18, the red toad and marsh frog; 19, the salamander; 20, Bulls’ blood;
21, Taxus, or the yew-tree; 22, Toxicum, not ascertained. See Avicenna.

The lists of poisonous substances treated of by Dioscorides, Aëtius,
and Actuarius are nearly the same as our author’s. Those of Nonnus
and Scribonius Largus are less numerous. The Arabians treat of several
substances, the nature of which it is now difficult to determine. The
catalogues of Avicenna and Rhases are the fullest; those of Haly Abbas
and Alsaharavius scarcely contain so many articles; all of them, however,
contain several substances which are not treated of by the Greek writers
on toxicology. Among these we may just mention that they treat of the
gall of the viper, of the leopard, of an animal called leunza (leæna?),
of the shark, and also of the extremity of the stag’s tail, and bad
castor. The sweat of different animals is also included in their lists.


SECT. XXX.—ON CANTHARIDES.

The most grievous symptoms follow the administration of cantharides,
for almost from the mouth to the bladder the parts are tormented with
a gnawing pain. The taste resembles pitch or cedar rosin, and the
patients have inflammation of the right hypochondrium, with dysuria, and
frequently they pass blood by urine, and sometimes it is discharged by
the intestines, as in dysentery: they fall into deliquium animi, nausea,
and vertigo, and at last they become delirious. The proper remedies
are vomiting with water and oil, drinking milk, taking four drachms of
Cimolian earth with honied water, pine kernels, the seeds of cucumber,
fat beef soup, or soup of geese or of mutton; the flesh of fowls, lambs,
sheep, or pigs, being tender and fat, when boiled with linseed; much
must; dr. iv of the bark of rosemary; and after the food inject by
clyster the juice of rice, or of chondrus, or of spelt, or of ptisan,
or of mallows, or of linseed, or of marshmallows, or of fenugreek. And
sometimes having cleared out the intestine with honied water and nitre,
we may then inject these things, and afterwards allay the inflammation
with cataplasms of linseed and barley; for at first these things are
pernicious. Then we may have recourse to baths of sweet water, and give
the ointments of iris and of roses in a draught.

       *       *       *       *       *

COMMENTARY. The symptoms occasioned by taking cantharides, according
to Nicander, are erosion of the whole intestinal canal, ulceration of
the bladder, affection of the chest, and wild delirium. His remedies
are emetics, such as fat, the oil of iris with rue, or Samian aster,
laxatives, milk in clysters or taken by the mouth, and the decoction
of vine-shoots with honey. Dioscorides describes the symptoms in the
same terms as our author, and like him recommends emetics of oil and
emollient clysters, such as the decoction of linseed or of mallows. Like
our author, he disapproves of warm applications, such as cataplasms and
the hot bath at the commencement, because by their heat they promote the
distribution of the poison over the system; but after a time they are
useful, he says, by allaying the pains and promoting the discharge of
the poison by the cutaneous perspiration. His other remedies being the
same as our author’s, we need not enumerate them. Galen states that the
wings and feet of cantharides prove useful for removing the deleterious
effects occasioned by taking their bodies. His treatment otherwise, which
is borrowed from Asclepiades, is very similar to that of Dioscorides. He
in particular recommends the Lemnian earth, or terra sigillata, as an
emetic in this case. (De simpl. ix.) He also speaks favorably of milk.
(Ib. and de antidot. ii.) He approves very much of animal and vegetable
oils given in sweet wine or tepid water to produce vomiting. Galen
states decidedly that the viscus upon which the action of cantharides
is exerted is the bladder. (Ad Pison.) The treatment recommended by
Scribonius Largus is little different. Aëtius, Oribasius, and Actuarius
only copy from Dioscorides, without suggesting any improvement. Avicenna
and Rhases mention that cantharides occasion inflammation of the penis
and erections. They agree with the Greeks in recommending oily emetics,
clysters of the same, and, what we believe is an improvement which we
owe to the Arabians, injections of rose-oil into the bladder by means of
a waxen tube (flexible catheter). Rhases approves of bleeding, provided
it be long since the patient was bled, and violent pain be felt in the
region of the thighs, that is to say, if the urinary organs are much
affected. Haly Abbas mentions ardor urinæ, strangury, and bloody urine
among the symptoms, and recommends oil by the mouth as an emetic and
purgative, and by injection. Alsaharavius mentions swelling of the
penis, bloody urine, and suppression thereof, and remarks that the same
effects have been sometimes brought on by the external application of
cantharides, in which case he recommends the tepid bath and emollient
fomentations. His treatment is like that of his other countrymen; for
example, he joins them in approving of injecting rose-oil into the
bladder.

It would appear that cantharides were sometimes used by the ancients for
the purpose of committing suicide. According to Cicero, it was by this
means that C. Carbo destroyed himself. (Ad Familiar, ix, 21.)

Ambrose Paré, Matthiolus, and all the earlier modern writers
on toxicology, follow the treatment laid down by the ancients.
Notwithstanding the concurrent testimonies of all these authorities,
Professor Orfila, in the last edition of his ‘Toxicologie,’ and Dr.
Christison, in his late work on ‘Poisons,’ affirm “that oil is the
reverse of an antidote.” Yet, in a case lately published, the free
administration of olive-oil was followed by copious discharges, both
upwards and downwards, of cantharides mixed with the oil. (Edinb. Med.
and Surg. Journ. No. 104, p. 214.) And surely, if laxatives are to be
administered at all, oily ones are to be preferred, as producing least
irritation, and not being likely to be absorbed.

It can scarcely admit of dispute, that the _mylabris cichorei_ is the
same as the ancient cantharis. It is still used in Turkey and India for
the composition of blistering plasters, being possessed of much the same
properties as the Spanish fly.


SECT. XXXI.—ON THE BUPRESTIS.

Those who have drunk of the buprestis experience a taste resembling fetid
natron, which is followed by violent pain of the stomach and bowels;
there is swelling of the abdomen, resembling dropsy, and the skin of
the whole body is distended, the urine also being suppressed. They are
relieved by the same remedies as are given to those who have taken
cantharides; but they derive benefit in particular after evacuations by
vomiting and by the bowels, from taking dried figs, and drinking the
decoction of them with wine or milk, or a mixture of wine and honey,
and they may eat all kinds of pears, and take a woman’s milk. When the
violence of the disease has subsided they may eat with advantage Theban
palm-nuts boiled in wine.

       *       *       *       *       *

COMMENTARY. Isidorus says of the buprestis, “animal est in Italiâ parvum,
simillimum scarabæo longipedi.” (Orig. xii, 8.) See also Ælian (H. A. vi,
35); Pliny (H. N. xxx. 10.) The symptoms and treatment, as described by
the other authorities, are nearly the same as in our author’s description.

Among the remedies recommended by Nicander, the most efficacious are
milk and emetics of tepid oil. (Alex. 360.) The Arabians do not treat
of this article separately from cantharides, unless it be the stuphe of
Alsaharavius. (Pract. xxx, 2, 8.)

We can have no hesitation in holding that the buprestis of the ancients
was the _lytta vesicatoria_, or Spanish fly. See Sprengel (Comment. in
Dioscor.) and Schneider (ad Nicand.)


SECT. XXXII.—ON THE SALAMANDER.

When a person has taken of salamander, inflammation of the tongue
supervenes, with difficulty of speech, trembling, torpor, and ulceration.
Certain parts of the body all around become livid, so that often, if the
medicine remain, they mortify and drop off. In this case we should do the
same things as for cantharides; but more particularly we must administer
to them pine-rosin, or that of the pitch tree, or galbanum with honey,
or pine-kernels with a decoction of ground-pine, or nettle-leaves boiled
along with lilies in oil, the boiled eggs of land or sea tortoise, soup
of frogs, having the root of eryngo boiled with them.

       *       *       *       *       *

COMMENTARY. The principal symptoms, as detailed by Nicander, are
inflammation of the tongue, torpor, tremblings, aberration of mind,
vibices, &c. He treats it like narcotic poisons, with stimulants and
attenuants, such as pine-rosin, the leaves of ground-pine, nettle-seed
mixed with the flour of tares, &c. Dioscorides, Avicenna, and most of
the authorities direct us to treat this case of poisoning like that
of cantharides; Alsaharavius recommends emetics, draughts containing
pine-seed, honey, vinegar, wine, &c., with fat flesh. Oil and milk are
recommended by most of the authorities.

Avicenna says the salamander is a species of lizard. Aristotle mentions
the fabulous story of its being proof against fire as a circumstance
which was related. Pliny (H. N. x, 67), Ælian (H. A. ii, 31), and Phile
(c. 17) repeat it confidently. On the other hand, Dioscorides affirms
that the story is entirely without foundation (ii, 56.)

It is the _salamandra terrestris_. Sprengel says it emits a cold mucus,
which may extinguish a small lire. (Notæ in Dios. l. c.)


SECT. XXXIII.—ON THE PITYOCAMPA, OR PINE-CATERPILLAR.

When pine-caterpillar is drunk, there is straightway pain of the mouth
and palate, strong inflammation of the tongue, pain of the stomach and
intestines, with a prurient sensation of tension; and there is a fiery
heat of the whole body, and anxiety. Such cases are to be relieved in
like manner as those who have drunk cantharides; but in their case,
instead of plain oil we may substitute the ointment of apples.

       *       *       *       *       *

COMMENTARY. Our author, and indeed all the others, only copy from
Dioscorides.

Sprengel mentions several species of erucæ which infest pine-trees, such
as the leparis monacha, lasiocampa pini, &c. (Notæ in Dioscor.) Virey
remarks, that among the Romans there was an express law forbidding the
administration of the hairy caterpillar of the pine, as it produces the
most serious symptoms, and even loss of life, by its hairs. (Hist. des
Mœurs des Anim.)


SECT. XXXIV.—ON THE SEA-HARE.

When the sea-hare has been drunk an ill-savoured taste, like that of a
fetid fish, supervenes, and after a time the bowels are pained and the
urine becomes obstructed, or if any is discharged it is of a purple
colour. They loathe and detest all kinds of fishes, and have fetid
perspirations mixed with blood. We must give them therefore asses’ milk
or must frequently, or a decoction of the root and leaves of mallows,
or the root of hogs-fennel triturated with wine, or dr. j. of black
hellebore, or of the juice of scammony in honied water, and the warm
blood of a newly-killed goose, and river-crabs alone, if they can be
borne, may be given. It is a symptom of recovery when they can eat fish.

       *       *       *       *       *

COMMENTARY. Nicander’s description of the symptoms is like our author’s,
and his remedies are hellebore, and scammony, asses’ milk, &c. Haly Abbas
recommends only emetics at first, and afterwards milk. When there is
continued oppression of breathing he directs us to bleed and give the
syrup of poppies. (Pract. iv. 49.) Alsaharavius, like Nicander, depends
principally upon drastic purgatives, such as scammony and hellebore.
(See also Nonnus, 279.) Galen says it produces ulceration of the lungs.
(See Ther. ad Pison. and de Med. sec. gen. i.) For an account of the
lepus marinus, see Ælian (H. A. ii, 45; ix, 51; xvi, 19); Pliny (H. N.
ix, 48; xxxii, 1); Dioscorides (ii, 20; vi, 34,); Philostratus (vi, 32);
Phile (93). According to Schneider, it is called _chat marin_ in France.
Gorræus says it is a species of lizard, and resembles the land hare only
in colour. Sprengel inclines to think that it is the _aplysia depilans_.
See also Paris and Fonblanque (Méd. Jurisprud. ii, 141.) Rondelet refers
it to the class _mollusca_, and gives a drawing of it. (De Piscibus,
xvii.) Bellonius and Gesner give the same account of it, and all agree
respecting its poisonous qualities. They describe it as being a mass of
nearly unorganized flesh. Virey says it has long appendages like the ears
of the hare, but which are its eyes.


SECT. XXXV.—ON THE RED TOAD OR MARSH FROG.

When the red toad or marsh frog is taken, it brings on swelling of the
body, with intense paleness resembling the colour of the box-tree; and
dyspnœa supervenes with fœtor of the mouth, hiccough, and sometimes an
involuntary emission of semen. They are easily remedied, however, after
vomiting, by taking a large draught of undiluted wine, and two drachms
of the root of sweet cane, or the same dose of cyperus. We must also
compel them to exercise themselves strenuously in walking and running, on
account of the torpor which is upon them; and they ought to take the bath
every day.

       *       *       *       *       *

COMMENTARY. Nicander says the bufo apricans superinduces upon the body
difficulty of breathing, fetid breath, and colour like that of the
thapsus; he means probably jaundice. His remedies are, the flesh of frogs
boiled or roasted, pitch mixed with sweet wine and the spleen of a marsh
frog. Pliny says a decoction of marsh frogs in vinegar is an effectual
remedy in this case and against salamanders. (H.N. xxxii, 5.) Dioscorides
recommends emetics, wine, and active exercise. Avicenna, Rhases, and Haly
Abbas recommend nearly the same treatment. Haly approves of friction,
especially over the stomach. (Pract. iv. 49.) See a learned dissertation
on the Poisonous Ranæ in Schneider’s Notes on Nicander (Alexipharm.); see
also Gorræus’ Commentary on the same. Schneider inclines to think that it
must have been the _bufo cornutus._

Ælian states that when the blood of the phrynus is given with wine,
it proves a very fatal poison. (H. A. xvii, 12.) It would appear from
two passages in the Satires of Juvenal that in his time criminal acts
of poisoning were generally performed by means of this substance. (See
Sat. i, 510, and vi, 659.) Paris and Fonblanque, however, deny that any
species of toad is poisonous. See also Pennant, (B. Z. iii, 17.) He calls
the Rana rubeta the natter-jack.


SECT. XXXVI.—ON LEECHES.

If leeches have been swallowed with water, and have stuck to a part in
deglutition, you may ascertain that this has happened from the mouth of
the stomach being, as it were, sucked and bitten, which is a symptom of
the leeches having been swallowed. Sometimes florid blood is spit up by
hawking when the leeches have fixed to the windpipe. They may be rejected
by swallowing brine, or the leaves of beet with vinegar, or by drinking
snow with oxycrate. Let gargles of nitre (_soda_) with water be used,
and of copperas with vinegar. When they have stuck to the throat, put
the patient into a warm hip-bath and give him cold water to hold in his
mouth, and they will readily come to the cold. Some give bugs to those
who have swallowed leeches. I, says Galen, by using garlic in such cases,
have not stood in need of bugs.

       *       *       *       *       *

COMMENTARY. Nicander judiciously recommends when leeches have been
swallowed to drink vinegar, to take ice or snow, sea-water, fossil salt
(sal gemmæ?), or salt prepared from sea-water. Dioscorides treats the
case like our author. Celsus merely says, “acetum cum sale bibendum est.”
Bugs are recommended by Anatolius. (Geopon. xiii 17.)

Aaron, one of the authorities quoted by Rhases, directs us to lay the
patient in the sunshine and examine his throat carefully; and if the
leech can be detected to extract it with a forceps. If this cannot
be effected he recommends him to gargle the throat with some bitter
decoction or to swallow the same, if the leech has descended to the
stomach. He also directs him to hold snow in the mouth. (Contin. vii.)

Avicenna recommends nearly the same plan of treatment, and, like our
author, mentions the following device in order to get a leech extracted
that is fixed in the gullet. The patient is to go into a hot bath and
hold cold water in his mouth, which will have the effect of attracting
the leech towards it. (iii, 9, 5.)

When a leech has fastened in the throat of a beast of burden and cannot
be got at by the hand, Columella directs hot oil to be poured in by means
of a pipe, or if it has passed into the stomach, it is to be killed with
hot vinegar. (vi, 18.) The vapour from pounded bugs was also a popular
remedy in such cases. (Ibid. and Geopon. xiii, 17.)


SECT. XXXVII.—ON THE CHAMÆLEON.

When one has taken the black chamæleon intense gnawing and pain
supervene, and tremors with disturbance of the whole body; then
convulsions attack, with pituitous and frothy vomiting, and in some cases
hiccough with loss of speech, and distortion of the countenance. A fatty
decoction of wheat taken hot will be applicable in such cases, and a
sweet watery wine also hot, vomits, drinking of milk, emollient clysters,
and fomentations by cataplasms. To that kind which occasions suffocation
and lividity, a draught of wormwood or of natron with oxymel or of
radishes will be proper, and also fomentations to the hypochondrium.

       *       *       *       *       *

COMMENTARY. Dioscorides and Aëtius give a similar account of the
treatment and symptoms. On the chamæleon, see Apuleius (de Herb. 109.)
The black chamæleon treated of in this section is the _carthamus
corymbosus._ It is quite a different plant from the white chamæleon which
is treated of in the 46th section.


SECT. XXXVIII.—ON HENBANE.

Hyoscyamos when drunk or eaten brings on disorder of mind like that
of persons in intoxication; but is easily cured, being remedied by
copious draughts of honied water and milk, especially that of asses
or, if not, of that of goats or cows, and of the decoction of dried
figs. Pine kernels are also serviceable in such cases, and the seed of
cucumber taken with must, and salt wine with fresh axunge and must, and
nettle-seed in like manner, or natron with water will be proper, also
succory, mustard, cresses, radishes, onions, and garlic, each of these
being taken with wine. They must then be made to remain in a state of
rest in order that, like those who have drunk wine, they may digest what
they have taken.

       *       *       *       *       *

COMMENTARY. The description of the symptoms in Nicander’s Alexipharmics
is imperfect owing to an hiatus in the text. His remedies are milk,
fenugreek, nettle-seed, succory, cresses, mustard, the heads of garlic,
&c.

This section is taken from Dioscorides. Celsus recommends hot water and
milk, especially that of asses.

The description of the symptoms, as given by Aëtius, is somewhat fuller
than our author’s, but not otherwise different. He and Scribonius Largus
mention lividity of the members. Alsaharavius says, it induces sleep,
stupor, and coldness of the extremities. Avicenna and Haly Abbas
recommend the theriac and antidote of Mithridates. Rhases speaks highly
of milk. (Contin. ult.)

The general remedies which they all recommend are emetics, vinegar,
milk, sweet wine, and at last, vegetable stimulants, such as mustard and
onions, and the theriac.

See an account of the different varieties of henbane known to the
ancients in Dioscor. (iv, 64.); Galen (Med. Simpl. viii); Pliny (H. N.
xxv, 4); and in Schulze (Toxicol. vet. 20.) See also the Seventh Book of
this work.

The Arabians, in this place, treat of another narcotic to which they give
the name of _Derufitum_ or _Darfion._ See Avicenna (iv, 6, 1, 4); Rhases
(xxxix.)


SECT. XXXIX.—ON CORIANDER.

Coriander from its smell cannot be mistaken. When drunk it renders the
voice thick, and brings on madness like that from intoxication. Wherefore
those who have taken it talk obscenely, and the smell of the coriander
is perceptible from the whole body. They are relieved after the removal
of the poison by common oil or that of iris (as mentioned above), by
undiluted wine with wormwood and drank by itself; by eggs emptied into
one vessel and triturated with brine and swallowed; and brine also may be
drunk, and salt broth from a hen or a goose, and sweet wine taken with
lye.

       *       *       *       *       *

COMMENTARY. According to Nicander, the symptoms are violent delirium,
and great derangement of the mind, as in intoxication. His remedies are
principally emetics and wine, the intention of giving which is quite
obvious. Dioscorides gives nearly the same account of the symptoms and
treatment. Galen (de Simp. Med. viii) attacks Dioscorides in the most
unmeasured terms for saying that the action of coriander is frigorific,
while, on the contrary, he maintains that it is calefacient. Avicenna
combats the reasoning of Galen and agrees with Dioscorides; as do
Apuleius among the Latins, and Alsaharavius and Rhases among the
Arabians. Pseudo-Macer calls it a cold austere medicine.

With regard to the treatment, the Arabians recommend oily emetics, with
soda, pepper, salt, strong wine, &c. Avicenna (iii, 6, 2, 8); Rhases
(Cont. xxi); Alsaharavius (Pract. xxx. 2.)

Schulze is satisfied that the corion or coriandrum of the ancients was
the same as our coriander. He appears, however, to have rather overrated
its deleterious properties. It is only in particular states of the body
that it proves at all injurious. (Toxicol. vet. vii.) Sprengel also
is satisfied as to the identity of the ancient and modern coriander.
(Comment. in Dios.)


SECT. XL.—ON PSYLLIUM OR FLEAWORT.

Fleawort when drunk occasions coldness of the whole body and torpor,
with relaxation and lowness of spirits, which are relieved by the same
remedies as those given to persons who have drunk coriander.

       *       *       *       *       *

COMMENTARY. All the authorities agree in representing its effects as
being similar to those produced by coriander. They treat the case then
upon general principles with wine, pepper, and other such stimulants.

Schulze finds some difficulty in acknowledging that the _plantago
psyllium_, L. is the true psyllium of the ancients, and yet he admits
that no other plant has so good a claim to be identified with it. We see
no grounds for scepticism on this point.


SECT. XLI.—ON CONIUM OR HEMLOCK.

Hemlock, when drunk, brings on vertigo and dimness of vision, so that the
person can no longer see even to a small distance; there is hiccough,
disorder of the mind, and coldness of the extremities, and at last he
is suffocated in convulsions, the breath in the arteria aspera being
stopped. At first, therefore, as in other cases of poisoning, we must
bring it up by vomiting, and afterwards, by means of an injection,
evacuate whatever part had passed into the intestines; and then, as
our great remedy, we have recourse to undiluted wine, giving it at
intervals, during which we must administer the milk of cows or of asses,
or wormwood with pepper, wine, and castor; and rue and mint, with wine,
and a dram of cardamom or of storax; or of pepper, with nettle-seeds in
wine; or the tender leaves of bay tree; and in like manner laserwort, or
the juice thereof, with common wine or must; and sweet wine drunk alone
answers well.

       *       *       *       *       *

COMMENTARY. Theophrastus seems to have been acquainted with the sedative
properties of hemlock, for he recommends pepper and rosemary as antidotes
to it. (H. P. ix, 24); and Athen. (Deip. ii, 73.) The operation of
this poison in the case of Socrates is well described by Plato in his
‘Phædo.’ Socrates, after swallowing the poisoned cup, walked about for a
short time as he was directed by the executioner: when he felt a sense
of heaviness in his limbs he lay down on his back; his feet and legs
first lost their sensibility, and became stiff and cold; and this state
gradually extended upwards to the heart, when he died convulsed.

The symptoms, according to Nicander, are dimness of sight, vertigo, a
sense of suffocation, coldness of the extremities, impeded respiration,
and death. His remedies are emetics of oil, or undiluted wine, clysters
of the same, and undiluted wine taken by the mouth, with pepper, nettle,
assafœtida, and the like. Dioscorides, and all the other authorities,
recommend much the same treatment. Pliny and Aëtius mention lividity,
after death, as a symptom of poisoning by cicuta.

Theophrastus (H. P. vi, 2) and Pliny (H. N. xxv, 95) have described the
conium. Schulze is satisfied that it is the _conium maculatum_, L., and
in this opinion we fully agree with him. He adds, that the ancients have
made no mention of the cicuta virosa.

Dioscorides and most of the others enumerate convulsions among the
symptoms. It will be remarked, that in the abstract given above of
the symptoms of poisoning by hemlock in the case of Socrates, we have
stated that the great philosopher died convulsed. This we think the true
interpretation of the term used by Plato (ἐκινήθη), although it has not
been so understood by most of his interpreters. Dioscorides, in another
place, states somnolency, coma, stertor, lividity, torpor, coldness,
stupor, insensibility, and pruritus of the whole body, as the common
symptoms of poisoning by opium, mandragora, or conium.

Schulze ranks, among ancient mistakes, the assertion of Galen, that
narcotic substances may, in some instances, become digested and prove
nutritive. But Dr. Christison says, that both vegetable and animal
poisons may become digested, of which he gives an interesting example
with regard to opium (On Poisons, p. 52.)


SECT. XLII.—ON THE JUICE OF THE POPPY.

When one has drunk of the juice of the poppy drowsiness comes on, with
coldness and intense itching, so that often when the medicine takes
effect such an itching comes on that the person is roused from sleep
thereby. The smell of the medicine too is emitted from the whole body.
The remedies in such cases, after rejecting the substance taken by
vomiting with oil, and evacuating downwards by a stimulant clyster, are
oxymel drank with salts, or honey with warm rose-oil, and much undiluted
wine with wormwood and cinnamon, and warm vinegar by itself, and natron
with water, and marjoram with lye, the seed of rue and pepper given with
castor, and oxymel, savory, or the decoction of marjoram with wine. We
must also rouse by aromatics, put the person into a hot bath, and foment
on account of the pruritus which supervenes; and after the bath we may
use fat broths, with wine or must. Marrow also drunk with oil is useful.

       *       *       *       *       *

COMMENTARY. According to Nicander, the symptoms of poisoning by
poppy-juice are coldness of the extremities, eyes fixed, heaviness of the
eyelids, profuse and fetid perspiration, paleness, swelling of the lip,
relaxation of the under jaw, slow respiration, cold breath, and the usual
precursors of dissolution, namely, distortion of the nostrils, lividity
of the nails, and hollow eyes. His remedies are emetics, such as the oil
of iris or of roses, wine and honey; hot drink and rousing the patient by
cries, striking his body in different places, and wrapping it in cloths
smeared with oil and hot wine, and the hot bath as a restorative.

The symptoms mentioned by Dioscorides are lethargy, violent pruritus, and
the perspiration smelling of opium. His remedies are the same as those
of our author, namely, emetics at first, then clysters, and afterwards
wine and vinegar, with various stimulant and strong-scented things; such
as pepper, cinnamon, castor, marjoram, &c. The patient is to be roused
as directed by Nicander; and baths and fomentations are to be used to
relieve the pruritus.

Galen relates the case of a person reduced to the last stage of coldness,
whom he saved by administering freely a strong, light-coloured, and
fragrant wine. Yet, he remarks correctly, a small quantity of weak wine
operates unfavorably by promoting the distribution of the poison over the
system. He, in particular, recommends vomiting at first with wine and
oil, and afterwards strong clysters.

Aëtius mentions, among the symptoms, violent pruritus and convulsions.
None of the other Greek writers mention convulsions, but, among the
Arabians, Avicenna, Rhases, and Alsaharavius, have mentioned them. Modern
experience has determined that they are an occasional, but not a frequent
symptom produced by the immoderate administration of opium.

Scribonius Largus directs us, after repeated vomiting, to apply
embrocations of vinegar and roses to the head, to rub the feet, and to
put sinapisms to them and the thighs. Simeon Seth strongly recommends
vinegar.

Haly Abbas and Alsaharavius, and, in short, all the Arabians recommend
nearly the same treatment; namely, emetics of oil and water, or oil and
wine, hot clysters, acrid and strong-scented things, such as castor,
assafœtida, savin, &c., and the warm bath, friction, sternutatories, and
every means calculated to arouse, and to prevent sleep.

Serapion, Rhases, Avicenna, Haly Abbas, and Alsaharavius, agree in
stating that the smallest dose of opium which will prove destructive
to human life is two drachms. Modern authors are not agreed as to the
smallest quantity which may prove fatal, but surely, as Dr. Christison
remarks, Dr. Paris has fixed the minimum dose too low, when he affirms
that four grains may be sufficient to produce this effect. On the other
hand, we should think that a smaller dose than that mentioned by the
Arabians might be sufficient to destroy life. Perhaps the ancient opium
may have been weaker than that now in use.

It is worthy of remark, that most of the ancient authorities recommend
vinegar in cases of poisoning by opium, but we are inclined to think that
none of them administered it at the commencement, nor until the poison
had been removed from the bowels. This practice agrees very well with the
rule of treatment laid down by Orfila, Paris, and Christison, who state
that vinegar is prejudicial, if given at first, by favouring the solution
of the poison, but proves useful afterwards by acting as a restorative to
the system.

None of the ancient authorities recommend venesection.

In another work we have thus explained the ancient theory of the action
of opium upon the human frame. “In order to understand properly the ideas
entertained by the ancients respecting the _modus operandi_ of opium, it
will be necessary to say a few words in explanation of their opinions
upon certain points of physiology. Aristotle taught that the prime cause
of all the operations of life is mind, and that the prime instrument by
which it performs them is heat, which, therefore, he denominates the
_co-cause_ (συνάιτιον). He illustrates his meaning by comparing the mind
to the artificer, and heat to the wimble or saw by which he performs
his work. Having remarked, no doubt, that the heart is the warmest part
of the body, he appears to have considered it as the spring which turns
the whole machinery of the animal frame, the brain and nerves deriving
their origin and influence from it. (I need scarcely mention how well
these ideas accord with the ingenious hypothesis lately advanced by M.
Serres.) Many facts, indeed, seem to point out the supreme importance
of the heart. It is, as the ancients remarked, the _primum movens et
ultimum moriens_; and, along with its accessory organ, the lungs, it is
evidently the part which, in the higher classes of animals, renders them
independent of the many variations of heat and cold to which they are
subjected. It is this wonderful organ which, under the guidance of the
principle of life, preserves the heat of the body unaltered in all the
different gradations of temperature, from more than 100 degrees above
the boiling, to as many below the freezing point of the thermometer. It
seems, in fact, a real Prometheus that steals the fire from heaven. The
connexion between heat and the vital actions is very apparent also in
the inferior animals, who are not provided with such an apparatus for
preserving an equability of temperature. Thus the zoophyta, insecta, et
vermes, with the loss of heat, lose also sensibility and muscular energy,
which they recover again when their heat is restored. In this case it
is evident that heat is the cause (or at least the _co-cause_) of the
vital actions, and not the vital actions of heat. It has always appeared
to me a striking fact, illustrative of the great influence of heat over
the vital actions, that the strength of all animals is, bulk to bulk,
proportionate to the degree of their animal heat.

“This doctrine of the supreme authority of the heart, as being the focus
of heat, thus maintained by Aristotle, was eagerly defended by the
great Arabian commentator, Averrhoes, and by his countryman, Avenzoar,
who keenly attacked Galen for having questioned its truth, and taught,
as they represent, that the brain is the leading organ in the animal
frame. After having, however, carefully ransacked every part of Galen’s
works, in which I could suppose it likely to meet with any allusion to
this doctrine, I am led to believe that these Arabians, in the heat of
controversy, have misrepresented the real opinion of their master’s
rival. Galen appears decidedly to have maintained with Hippocrates—‘that
there is in the body no one beginning, but that all parts are alike,
beginning and end: for a circle has no beginning.’ Agreeably to this
idea, Galen remarks, that the brain cannot properly be said to derive
its powers from the heart, since an animal will run, breathe, and cry
after its heart has been taken out; nor can the heart be said properly to
derive its powers from the brain, since it will palpitate and contract,
after all communication with the brain is cut off, nay, after it has
been removed from the body. In so far, then, the functions of the brain
and the heart are independent of one another. But the brain is dependent
upon the heart and its appendages for vital heat, without which it would
be unable to continue its functions; and the heart, on the other hand,
is dependent upon the brain for imparting nervous influence to the
respiratory organs, without which it could not preserve its vital heat
unaltered. Hence the mutual connexion and sympathy of important organs—a
doctrine much insisted upon by ancient authors, and which bears some
resemblance to the theory lately advanced by Mr. Morgan and Dr. Addison.

“We shall now have no difficulty in understanding the ideas of the
ancients regarding the operation of opium. Galen and Avicenna believed
that the poison exerts its primary influence upon the heart, and impairs
its vital heat. Of course they considered its operation on the brain as
secondary. They called the action of narcotics frigorific or congealing,
no doubt because they remarked that it was attended with a diminution
of vital heat, and to this they attributed the loss of sensibility and
muscular energy. I leave it to the reader to judge whether this theory or
the modification of it lately proposed by Messrs. Morgan and Addison be
the more plausible.” (Edinburgh Medical and Surgical Journal, No. 103.)

But although the ancient physiologists maintained that the prime organs
of the animal frame suffer sympathetically in cases of poisoning, they
did not hold, it will be remarked, that all poisons exert their primary
action on the nervous system. This is the hypothesis lately advocated
by Messrs. Morgan and Addison, but which is, in fact, only a revival of
that maintained by Schulze in his ‘Toxicologia Veterum.’ He thus states
his theory of the action of poisons,—“Omnia symptomata et lethales
venenorum effectus hoc unum quam luculentissimè demonstrant, _ab omnibus
venenis nervos ipsos graviter affligi._ Nervea igitur vis seu vitalis, a
veneni stimulis commota, aut majori impetu agit, aut prævalente veneni
vehementia prorsus silet, nexusque omnes sensorii communis cum reliquis
nervis turbantur, vitâ animali aut graviter periclitante, aut prorsus
interiturâ.” (Toxic. Vet. vii.) Dr. Mead also, in his last edition of his
work on Poisons, advocates this hypothesis.

It appears to us, however, that this theory, although very simple and
plausible, is somewhat too exclusive. And that there are other modes by
which poisons operate than through the brain and nerves appears to be
demonstrated by the fact now clearly established, that poisons act upon
vegetables as well as upon animals. (V. Annales de Chimie, t. xxix.) Now
as vegetables are possessed of neither sensibility nor motion, it seems
preposterous to suppose that they have any nervous system.

Perhaps, then, we cannot do better than revert to the old doctrine
delivered by Alsaharavius. Sometimes, he says, poisons act upon the
heart, and thereby prove instantly fatal; sometimes upon the liver,
producing jaundice and phthisis; sometimes upon the brain, when they
occasion delirium; and sometimes their action is local, giving rise to
corruption and lividity of the part. (Pract. xxx. 2, 18.)

That the primary action of narcotics is upon the heart appears to us,
upon the whole, the most probable theory hitherto advanced upon the
subject.


SECT. XLIII—ON THE JUICE OF THE CARPESIA.

When the juice of carpesia is drunk it brings on heavy sleep and acute
suffocation. These are relieved by the same remedies as those given to
persons who have drunk hemlock.

       *       *       *       *       *

COMMENTARY. This section is taken, almost word for word, from
Dioscorides. Matthiolus confesses that he was quite unable to determine
what substance it was. (Comment. in Dioscor. vi, 13.) It is doubtful
whether the καρπήσιον of Galen and the κάρπασον of Dioscorides be the
same substance, and whether either be the same as the ὀποκάρπασον.
Sprengel can arrive at no certain conclusion respecting it. Valerius
Cordus supposed it to be the _piper longum._


SECT. XLIV.—ON MANDRAGORA OR MANDRAKE.

When mandragora has been drunk, stupor immediately comes on, with loss
of strength, and a strong inclination to sleep, so that the affection
differs in nothing from that which is called lethargy. Before any of
these symptoms come on, vomiting will be proper in this case; and
afterwards honied water, or natron and wormwood with must, or taken in
a dulcified wine, embrocations to the head with rose-oil and vinegar,
rousing by shaking the body, and by strong-smelling things, pepper,
mustard, castor, and rue pounded with vinegar, liquid pitch, and the
wicks of lamps lighted and extinguished, will be proper. When they are
difficult to rouse we may also apply sternutatories, and have recourse to
the general remedies in such cases.

       *       *       *       *       *

COMMENTARY. Our author, as usual, follows Dioscorides. Matthiolus,
by the way, in his commentary, questions the propriety of applying
rose-oil and vinegar to the head, as these things are of a cold nature,
whereas stimulants and calefacients are indicated. Perhaps these things,
when poured from a height upon the head, might prove restorative and
stimulant. The other Greek authorities however, as, for example, Aëtius
and Actuarius, approve of the practice. Alsaharavius recommends emetics,
and also directs us to pour vinegar and rose-oil on the head, and to take
vinegar in which hyssop and the like have been boiled.

Rhases recommends vomiting by means of water, honey, and fossil salt;
after which sweet wine is to be given, and vinegar and rose-oil poured
upon the head; castor, pepper, and rue are to be administered, along with
sternutatories. He mentions, however, that he knew an old medical man
who cured a young woman, who had fallen into a state of syncope, with
flushing of the face, after swallowing the apples of mandragora, by the
affusion of snow-water on her head. Avicenna properly directs everything
to be done to prevent sleep.

Schulze is satisfied that it is the _atropa mandragora_ of Linnæus.
There seems no doubt, however, that the mandragora of Theophrastus is
the _atropa belladonna_; while the mandragora mas of Dioscorides is
the _mandragora vernalis_, Bertol.; and the M. femina of the same, the
_mandragora autumnalis._

Theophrastus, Dioscorides, Galen, Athenæus, Aëtius, Suidas, Hesychius,
Apuleius, Pollux, and Frontinus, have made mention of the hypnotic
property of mandragora. It is singular that it should now have fallen
into neglect. It appears to have been used as a medicine in the days of
Shakespeare. Iago says:

          “Not poppy nor mandragora
    Nor all the drowsy syrups of the world,
    Shall ever medicine thee to that sweet sleep
    Which thou owed’st yesterday.”

                                        _Othello._

We will have occasion to treat of it in the Seventh Book.


SECT. XLV.—ON ACONITUM OR WOLFSBANE.

Wolfsbane immediately after being drunk occasions a sensation of
sweetness on the tongue, with a little astringency; vertigo supervenes,
more especially when the person attempts to rise up, and it brings on a
watering of the eyes; there is heaviness of the chest and abdomen, with
eructation of much flatus. In these cases the medicine must be brought up
by vomits, and the contents of the bowels evacuated by a clyster. We must
also give draughts from marjoram and rue, or from horehound with wine,
or from wormwood, or from rocket, or from southernwood, or mezereon, or
ground-pine. Opobalsam, too, taken to the amount of one drachm, with
wine, will likewise answer with them; also the rennet of a kid, or of a
hare, or of a fawn, with vinegar, and the dross of iron, or iron itself,
or gold, or silver, may be dissolved in wine, and the liquid taken,
and lye with wine, and the broth of a boiled cock, or the broth of fat
flesh taken with wine. The ground-pine, which is said to be a specific
in Heraclea of Pontus, where wolfsbane grows, is called holocleron, but
ionia in Athens, and sideritis in Eubœa.

       *       *       *       *       *

COMMENTARY. The symptoms, as described by Nicander, are astringency of
the lips, palate, and gums, gnawing pains at the stomach, singultus,
flatulence, running from the eyes, double vision, as from intoxication.
His remedies seem to have been principally emetics and calefacients. Thus
he recommends a handful of quicklime to be drunk with a hemina of wine,
also southernwood, spurge, ground-pine, marjoram, opobalsam, the metallic
preparations mentioned by our author, and the like. The accounts of the
treatment given by Dioscorides, Aëtius, and Actuarius agree exactly with
our author’s. Avicenna, Rhases, and Haly Abbas, in like manner, recommend
emetics, clysters, and calefacient medicines internally.

Diogenes Laertius states, upon the authority of Eumelus the historian,
that Aristotle the philosopher despatched himself with a draught of
aconite. (Vita Aristot.) Pliny relates that this poison proves fatal when
applied to the genital organs of women. (H. N. xxvii, 2.)

The ancients have described several varieties of aconite. See
Theophrastus (H. P. ix, 19); Pliny (H. N. xxv, 75); Schulze (Toxicol,
vet.); Schneider (in Nicand. Alexiphar.); and Sprengel (Rei. Herb.
Hist.) These modern authors in general are disposed to think that it was
the _iris tuberosa_. Sprengel, however, in the notes to his edition of
Dioscorides, is decided that the second species of Dioscorides (Mat. Med.
iv, 78) is the _aconitum napellus_; but respecting the first species,
he is in great doubts. All agree that the aconitum of Theophrastus is
different from the A. of Dioscorides and the other toxicologists. We
may be permitted to add, that the symptoms of poisoning by aconitum, as
given by Nicander, agree so well with those reported lately of cases of
poisoning by the _aconitum napellus_, that we cannot doubt their identity.


SECT. XLVI.—ON IXIA.

Ixia, which is also called ulophonon, when drunk has some resemblance
both in taste and smell to basil-royal. It brings on strong inflammation
of the tongue, and disorder of the mind; it suppresses all the
secretions, occasioning borborygmi and rumbling, with deliquium animi;
but there are no alvine evacuations. After the greater part of the
poison has been brought up by vomiting, or evacuated by the bowels, they
will experience relief from drinking the decoction of wormwood, with
much wine, vinegar, or oxymel, or the seed of wild rue, or the root of
laserwort, and in the like manner the decoction of tragoriganum with
some of the aforementioned, or with milk; or of turpentine, of nard, of
castor, of laserwort, of each an obolus in wine. The fruit also of the
walnut triturated with wine will be proper; or of rosin, of castor, and
of rue, of each dr. j; and in like manner of mezereon, dr. ij; of the
juice of thapsia, dr. ij, with honied water; and hot vinegar may be drunk
by itself.

       *       *       *       *       *

COMMENTARY. Nicander’s description of the symptoms is very similar to
that given by our author, and his treatment seems to have been conducted
upon the same principles; namely, by administering emetics and purgatives
at first, and, afterwards, discutient and detergent medicines, to
overcome the viscid nature of the poison. Our author’s plan of treatment
differs in no material respect from that recommended by Dioscorides,
Aëtius, Actuarius, Avicenna, and Alsaharavius. Avicenna described it by
the name of _aldabach_; Alsaharavius, by those of _alfos_, _aldolia_, i.
e. arbor risi.

Apuleius make ixias, ulophonon, chamæleon, ocymoides, and various cardui
synonymes (109.) The ixias, according to Gorræus, is a species of
chamæleon, but what species cannot be determined. (See, also, Schneider’s
note on Nicander.) Matthiolus calls it a glutinous substance, found in
the root of the chamæleon, or carline thistle. Schulze is decided that it
was a species of carlina (Toxicol. vet., 22.) See Harduin’s note on Pliny
(H. N. xxii, 21.) After mature consideration, we have no difficulty in
referring it to the _carlina acaulis_, or carline thistle.


SECT. XLVII.—ON EPHEMERON, OR MEADOW SAFFRON.

When one swallows ephemeron (which some call colchicum, because it grows
in Colchis, or bulbus silvestris), pruritus takes place over the whole
body, as if stung by nettle or squill; there is a gnawing pain within,
and great heat of the stomach, with considerable heaviness; but when the
affection gains strength, blood is discharged from the bowels, mixed
with the scrapings thereof. The same remedies are to be applied as to
those who have drunk salamander, in vomits and clysters. But before
the medicine gain ground we must give a decoction of oak-leaves, or of
acorns, or of the rind of pomegranate, or of wild thyme with milk, or the
juice of bloodwort, or of vine-tops, or of brambles, or of the medulla of
fennel-giant, or of myrtle berries, with wine; and when levigated myrtles
themselves are pounded and macerated in water, the liquor thereof may be
taken with advantage. And, in like manner, the middle pellicle of the
chesnuts, called Sardian, may be taken with the aforesaid juices, and
marjoram may be drunk with lye. Those affected are manifestly relieved by
drinking hot cow’s milk, and retaining it in the mouth, so that they who
have plenty of it do not stand in need of any other remedy.

       *       *       *       *       *

COMMENTARY. Our author’s detail of the symptoms is taken entirely from
Nicander, and his treatment also is mostly derived from the same source.
They seem to have depended principally upon vegetable astringents,
such as oak-bark, pomegranate-rind, and chesnuts, for checking the
hypercatharsis. Pliny, like our author, strongly commends milk (H.
N. xxvii, 33.) Dioscorides recommends emetics, clysters, vegetable
astringents, and demulcents. Alsaharavius says, that hermodactylus
occasions pruritus of the whole body, swelling of the palate, pains of
the stomach, and the like. He recommends emetics, clysters, cows’ milk,
and vegetable astringents, such as acorns with wine. This, it will
be remarked, is similar to the account which the Greeks give of the
symptoms and treatment of ephemeron, which is undoubtedly the _colchicum
autumnale_; and this circumstance tends strongly to prove the identity
of the ephemeron and the hermodactylus. We agree with Schulze, Prosper
Alpinus, and Humelbergius, that they were unquestionably the same plant,
notwithstanding that Sprengel, Matthiolus, and Dr. Murray are of a
different opinion. Dr. Paris considers that there is no doubt of their
identity. (See a learned dissertation on the Ephemeron in a note by
Schneider, on Nicander’s Alexipharmics.) We shall only further add, in
this place, that the learned Ardoyn, in his elaborate work on Poisons,
contends, that there is no doubt of the identity of the colchicum and the
hermodactylus. We, in fact, are surprised that this should have been ever
questioned.


SECT. XLVIII.—ON THE SMILAX OR YEW.

The tree called smilax is named thymium by some, and taxus by the Romans.
When drunk it brings on coldness of the whole body, suffocation, and
speedy death; the remedies for which are all those things which are given
to those who have drunk of hemlock.

       *       *       *       *       *

COMMENTARY. The description of the symptoms and the plan of treatment are
borrowed from Nicander, or, rather, copied direct from Dioscorides.

Different opinions have been entertained respecting the poisonous
nature of the yew. Haller, Bulliard, and others, deny that it is
poisonous; while Berkley, Ray, Matthiolus, and others, affirm that
it is. Orfila holds it to be a narcotic poison (chap. iv, cl. 4.) We
have known instances of its proving fatal to cattle. The newspapers
lately contained a melancholy case of a boy poisoned by yew-berries at
Winchester. Matthiolus is not pleased with Dioscorides for making it
to be a frigorific medicine; but Orfila, it appears, gives it the same
character; that is to say, he holds it to be narcotic. Virgil alludes to
its poisonous qualities:

    Sic tua Cyrnæas fugiant examina taxos.

See, also, Theophrastus (H. P. i, 5, and iii, 9); and Schulze (Tox. vet.
17).


SECT. XLIX.—ON THE STRYCHNOS FURIOSA, CALLED DORYCNIUM, BY SOME.

When one drinks of dorycnium, which some call strychnos furiosa, there
follows a sensation, as it were, of milk to the taste; constant hiccough,
watering of the tongue, and frequent ejection of blood; and there are
mucous discharges by the bowels, as in dysenterical cases. They are to
be remedied before any of these symptoms supervene, by those things
which are taken for ephemeron, I mean emetics and clysters, and whatever
else can evacuate the substance which had been taken. Honied water is
a particularly good remedy; or the milk of asses or of goats and sweet
wine, in a tepid state, may be drunk with a small quantity of anise.
Bitter almonds also are proper, the boiled breasts of fowls, all the
shell-fish eaten raw and boiled, crabs and crawfish, and the broth of
them when drunk.

       *       *       *       *       *

COMMENTARY. Our author’s detail of symptoms is taken mostly from
Nicander, or, perhaps, direct from Dioscorides. The poet’s plan of
treatment seems to have been much the same as that of Paulus. He omits,
indeed, to make mention of emetics and purgatives as being general
remedies in all cases of poisoning; but he recommends milk, must, and the
crustacea, such as the pinna, echinus, &c. The other authorities supply
nothing additional. Avicenna treats of it under the name of uva vulpis
stupefactiva mala; he copies from Dioscorides (iv, 6; i, 7.)

There is considerable difficulty about the nature of the dorycnium. Our
author, Aëtius and Apuleius, make it to be the same as the strychnos
furiosa, which is generally held to be either the solanum sodomeum, or
the atropa belladonna. On this subject, see Galen (de Med. sec. loc. x,
3); Pliny (H. N. xxi, 105); Apuleius (de Herb., 22). Schulze affirms,
that none of the ancient poisons is so little known as the dorycnium.
He is undecided as to its nature, except that it belonged to the
diadelphous or leguminous plants, and he is inclined to think that it was
an astragalus. (Toxicol. Veterum, 2.) Sprengel inclines either to the
convolvulus cneorus, L., or the con. dorycnium, L. But as far as we can
see, the most probable conjecture that can be made regarding it is, that
it was either the _solanum sodomeum_, or _atropa belladonna_.


SECT. L.—ON THE SARDONIAN HERB.

The herb called the Sardonian is a species of ranunculus, when drunk,
or eaten, it brings on disorder of the intellect, and convulsions with
contraction of the lips, so as to exhibit the appearance of laughter.
From this affection that ill-omened expression, the Sardonian laugh, took
its rise. In these cases, therefore, after vomiting, it will be proper
to give honied water and milk, with embrocations and lubrications of the
whole body, by calefacient remedies; and to have recourse to hot-baths of
hot oil and water, and to anoint properly and rub them after the baths;
and, upon the whole, to conduct the treatment as for convulsions.

       *       *       *       *       *

COMMENTARY. Dioscorides and our author are perfectly agreed as to the
symptoms and treatment. Aëtius recommends, likewise, castor with sweet
wine. Solinus, like our author, says that it brings on contractions
of the muscles, and the risus Sardonicus. Avicenna acknowledges his
ignorance of the nature and proper treatment of this herb, but supposes
that it belongs to the class of acute poisons. There seems, however,
no reason to doubt that it was a species of ranunculus. Schulze makes
it the _ranunculus sceleratus_, L., which bears the English name of
celery-leaved crowfoot; and we are clearly of the same opinion, although
Avicenna seems to make a distinction between the Sardonian herb and the
_kebekengi_, or apium risus, which is the βατράχιον of Dioscorides. See
Alsaharavius (Pract. xxx, i, 39.)


SECT. LI.—ON THE HORNED POPPY.

Seeing that the species of poppy called the horned, when eaten or drunk,
brings on the same symptoms as the juice of poppy, it is to be treated by
the same remedies.

       *       *       *       *       *

COMMENTARY. Miller says that the glaucium is called horned poppy because
it is a species of poppy having husks resembling horns. See some account
of it in Apuleius (53.) Schulze remarks that Dioscorides has described
several varieties of the poppy. 1, Papaver hortense; 2, P. opiiferum; 3,
P. agreste; 4, P. rhæas; 5, P. ceratites sive corniculatum; 6, Hypecoum.
The fifth of these, or horned poppy, is the glaucium luteum, Scop.
Dioscorides gives a distinct description, but treats of it as a medicine
rather than as a poison. (M. M. iv, 66.) None of the Arabians treat of it
separate from opium.


SECT. LII.—ON PHARICUM.

The substance called pharicum in taste completely resembles nard,
and when drunk it brings on paralysis, with disorder of the mind and
convulsion. After evacuation by vomiting, we must give the patient to
drink, along with wine, some wormwood, cinnamon, myrrh, or Celtic nard
(which some call saliunca), or of spikenard, dr. ij, or two oboli of
myrrh mixed with must or iris, and the flower of saffron with wine. The
head is to be shaven, and a cataplasm consisting of barley-flour, with
levigated rue and vinegar, is to be applied.

       *       *       *       *       *

COMMENTARY. Nicander, like our author, compares its taste to that of
spikenard, and says that it proves fatal in one day, inducing delirium.
He recommends the same internal medicines, and also makes mention of
applying a stimulant cataplasm to the head, evidently with a view of
relieving the phrenitis. The other authorities recommend similar
treatment.

There is great disagreement among the ancient writers on toxicology
respecting the nature of the pharicum. (See the notes of Gorræus and
Schneider on Nicander.) The former remarks that many suppose it a species
of nard. Dioscorides (Præf. vi) and Galen (Antidot. ii) make it to be
a herb. Scribonius Largus, and Hesychius consider it to have been a
compound medicine. After balancing all the statements Schneider comes
to the conclusion, that most probably it was a composition from agaric.
Schulze is wholly undecided as to its nature. (Toxic. Vet. 21.) Sprengel,
in like manner, can come to no certain conclusion respecting it. (Notæ in
Dioscor. l. c.)


SECT. LIII.—ON TOXICUM.

The toxicum seems to be so called because the barbarians anointed their
darts (τοξεύματα) with it. When a person has drunk of it, inflammation
of the lips and tongue comes on, also irrestrainable madness leading to
various fantasies, so that in the treatment of them they are difficult to
cure, and it is rare that any of those who have drunk of it can be saved.
However, they are to be forcibly bound with ligatures, and compelled to
drink sweet wine with rose-oil, and to vomit. Turnip seed, also, drunk
with wine will be proper for them, and the root of cinquefoil, the
blood of a he or she-goat when taken, oak bark, that of the beech or
ilex triturated with milk; also quinces when eaten, or triturated with
pennyroyal and drunk in water; and ammomum, and the fruit of balsam with
wine. But if any escape the danger they remain for a long time confined
to bed, and when they get out of it they spend the rest of their lives in
a state of timidity.

       *       *       *       *       *

COMMENTARY. The symptoms detailed by Nicander are much the same as those
enumerated by our author, namely, swelling of the mouth and throat, with
violent internal pains. His remedies likewise are much the same, namely,
forcing the patient, after he is well secured, to drink wine until he
vomit, and making him take bruised apples, rose-oil, oil of iris, &c.
He says, that certain savage nations upon the Euphrates poisoned their
arrows with it, which rendered their wounds immedicable, occasioning
lividity and putrefaction. Dioscorides, Aëtius, Actuarius, and, in short,
all the ancient authorities, copy his account.

It is very difficult to determine the nature of the toxicum. Theophrastus
describes a species of calamus by the name of toxicus. (H. P. iii,
12.) Avicenna, however, admits that he was wholly unacquainted with
its nature. (iv, 6; i, 29.) Some have supposed, with considerable
probability, that it was a preparation from the rhus toxicodendron.
Schulze is only decided that it was a vegetable poison. (Tox. Vet. 19.)
But it even seems doubtful whether it was a simple or compound medicine,
and whether of an animal or vegetable nature. (See Schneider’s note on
Nicander’s Alexiph. 248.) Sprengel inclines to the opinion that it was
collected from the venom of serpents. (Notæ in Dioscor.) All, however, is
mere conjecture on this subject.


SECT. LIV.—ON MUSHROOMS.

Of mushrooms, some prove deleterious from their general nature, and some
by the quantity taken. They all bring on suffocation resembling choking.
The general remedy which is to be instantly applied is to compel the
persons affected to vomit by means of oil. They are also wonderfully
relieved by drinking of the lye from vine-shoots, or from the wood of
the wild pear with oxycrate, salts, or natron. And wild pears or their
leaves, if boiled with mushrooms, take away their suffocative quality,
and if eaten they prove beneficial. Hen’s dung, drunk in oxycrate, proves
beneficial to them; likewise a drachm of birthwort, or of wormwood with
wine, and honey when licked or drunk with water; and baum with natron,
or the root and fruit of all-heal with wine, the burnt lees of wine with
water, and copperas with vinegar, radish, mustard, or cresses when eaten.
And since certain mushrooms having been tasted of by venomous animals
occasion not only suffocation but also ulceration of the intestines, we
must give in such cases plenty of wormwood, and the decoction of figs,
and of marjoram, and honied water. Emetics, the hot hip-bath, and raw
barley-flour when applied to the hypochondria, will also be proper.

       *       *       *       *       *

COMMENTARY. Nicander mentions suffocation as the common effect of taking
mushrooms. His remedies are radishes, rue, the flowers of copper,
natron, mustard, lixivial ashes, &c. Our author copies from Aëtius.
Simeon Seth recommends honey with tepid water, and a moderate quantity
of natron. Ruffus (ap. Oribas. Med. Collect, viii, 24) recommends
clysters of natron, wormwood, the juice of radish, and the decoction of
rue. Dioscorides recommends emetics of oil, natron, &c., and afterwards
vinegar and stimulant decoctions. Avicenna’s remedies are nearly the same
as those of our author. Alsaharavius directs us to give at first emetics,
and then calefacients, such as pepper, cumin, wine, and, if necessary,
the theriac. Haly Abbas, in like manner, recommends emetics, and then
wine with honey, the theriac, &c. The symptoms, he says, are cold sweats,
faintings, and embarrassment of breathing. All the ancient authors affirm
that mushrooms act upon the organs of respiration, and we remark that
a sense of suffocation is generally mentioned in the cases reported by
modern writers.

For a full report of fungi, or mushrooms, see Dioscor. (iv, 53);
Pliny (H. N. xxii, 46); Schulze (Tox. Vet. 14); Sprengel (Comment. in
Dioscor.); Schweighaeuser (in Athen. Deipnos. ii, 59); Schneider (ad
Nicand. Alex. 521). Diphilus, as quoted by Athenæus, states that all
mushrooms which are black, livid, and hard, or which grow hard after
being boiled, are of a deleterious nature. He recommends us to give
mulse, oxymel, natron, and vinegar, so as to produce vomiting.

Dioscorides gives the following characters of poisonous fungi: Such as
grow near rusty nails, or putrid rags of cloth, or near the lodging-place
of reptiles, or by trees which have bad fruits, are deleterious; such
have a glutinous coagulum (membrane adhering to the cap?) and when
gathered soon become putrid and melt away. (M. M. iv, 83). According to
Sprengel, these characters are not universally applicable (l. c.); but
considering the experience which the ancients had in the use of these
articles, they are no doubt generally so. The _amanita muscaria_, the
_agaricus necator_, and many other species, may be set down as belonging
to the ancient list of poisonous mushrooms.—Schulze, who appears to
have paid great attention to the subject, enumerates the poisonous
mushrooms of the ancients as follows:—1, Agaricus muscarius; 2, Agaricus
piperatus; 3, Agaricus emeticus; 4, Boletus versicolor; 5, Boletus
laricis. (Toxic. Vet. xiii, 5.)


SECT. LV.—ON BULLS’ BLOOD.

The blood of a newly-killed bull brings on dyspnœa and suffocation,
obstructing the passages about the tonsils and the parts concerned in
deglutition with violent spasms; the tongue, in such cases, is also
found red; the teeth are stained, and there are clots between them. In
this case we must avoid giving a vomit, because the grumous blood will
be more firmly fastened in the stomach by being raised upwards with the
contractions. We must give those things which are calculated to dissolve
the coagulated blood and loosen the belly; green figs, therefore, are
to be administered when filled with juice, along with oxycrate and
natron. All kinds of rennet are also proper with vinegar, and the root of
laserwort, with its juice in like manner; also cabbage seed, the lye of
figs, and the leaves of fleabane with pepper, and the juice of bramble
with vinegar. The bowels are also to be evacuated. Those who are going to
recover have fetid and bloody discharges by the anus. Cataplasms, made
of barley-flour with honey, are also to be applied to the regions of the
stomach and bowels.

       *       *       *       *       *

COMMENTARY. Bulls’ blood being exceedingly viscid and indigestible might
prove deleterious by becoming quickly coagulated in the stomach: we do
not find any mention of it, however, in modern works on toxicology.
Themistocles is said to have despatched himself with it. Nicander makes
no mention of emetics, and Dioscorides, like our author, condemns the
use of them. Nicander recommends almost the same identical remedies as
our author. It will be remarked that they are all of a penetrating,
attenuant, and solvent nature, such as wild figs, natron, laserwort, the
rennets of certain animals, &c. Galen mentions the pernicious effects
of coagulated blood in the stomach, and recommends hot vinegar for it.
(De Al. boni et mali succi.) Ruffus (ap. Oribas. Med. Collect. viii,
24) recommends clysters composed of natron, vinegar, the decoction of
cabbage, and of its seed, with vinegar.

The Arabians treat the case in a similar manner. Alsaharavius directs
us to give vinegar, natron, wine, and the like, also diuretics, but he
forbids the use of emetics.

Sprengel inclines to believe that bulls’ blood may prove deleterious,
if allowed to remain long in the stomach, by evolving azotic gas. He
therefore approves of the hot vinegar recommended by Galen. (Comment.
in Dios. 25.) Ardoyn states that a large quantity of bulls’ blood taken
into the stomach may produce suffocation by stopping the action of the
diaphragm. (De Venen. iv, 23.)


SECT. LVI.—ON COAGULATED MILK.

Those who take a large draught of milk containing rennet, experience a
great feeling of suffocation from its becoming coagulated. In treating
them, we may give as an antidote rennet with vinegar, compelling them
often to drink of it; also the dried leaves of calamint, and its juice
in like manner, or the roots of laserwort, or its juice with oxycrate,
thyme with wine, and the lye used by bonnet-makers; but nothing saltish
must be given, for thereby the milk becomes more firmly coagulated and is
converted into cheese. Neither must we make them vomit, for thereby the
coagula being lodged in the stomach will produce suffocation.

       *       *       *       *       *

COMMENTARY. Gorræus, in his notes on Nicander, remarks that milk only
proves prejudicial when taken in great quantity, immediately after
the rennet has been added to it, and before it has curdled. See also
Matthiolus and Ardoyn (de Venenis). Nicander recommends the same remedies
as our author, namely, such as are of a cutting and attenuant nature,
as rennet, vinegar, wine, lasewort, &c. Dioscorides forbids all saltish
things. Ruffus (ap. Oribas. Med. Col. viii, 24) recommends a clyster of
vinegar and natron, or asses’ milk with much salt. Celsus says, with his
accustomed brevity, “Si lac intus coit, aut passum, aut coagulum, aut
cum aceto laser.” See also Galen (l. c.) Haly Abbas, Rhases, Avicenna
and Alsaharavius also recommend rennet with pepper, assafœtida, vinegar,
&c. For bad milk which has spoiled on the stomach, all the Arabian
authorities concur in recommending first an emetic of hydromel, and
afterwards wine with pepper.

Sprengel accounts for the deleterious effects of curdled milk in the
same manner as he does for those of bulls’ blood, and remarks, that the
acid contained in the rennet of certain animals especially of hares, is
well calculated for dissolving and evacuating the coagulum (Comment. in
Dioscor. l. c.)

The Arabian authorities treat, among the deleterious substances, of flesh
and fish which have been cooked and hung up in a wet place until they
have become unwholesome. When eaten in this state, Rhases says they bring
on violent vomiting and purging, and may prove fatal unless the proper
remedies are applied. For these symptoms he recommends repeated emetics
and then purgatives; after which wine and pepper is to be given; and, in
the end, the remedies for poisonous mushrooms. (Ad Mansor. viii, 27, 28.)
See also Alsaharavius (Pract. xxx, 2, 15); Haly Abbas (Pract. iv.) Haly
Abbas recommends vomiting by means of tepid water, oxymel, and salt.

They treat, in like manner, of rancid fruits; which they state act
as poisons when eaten in large quantity. For the cure of these they
recommend emetics, the rob of bitter grapes, and medicines to whet the
appetite. Rhases (ad Mansor. viii, 30); Avicenna (iv. 6; i, 30.)

Avenzoar relates, at considerable length, the history of a case in which
delirium and other bad symptoms had been brought on and kept up by
drinking out of a cup which had been poisoned with some putrid meat. (i,
9, 9.)


SECT. LVII.—ON HERACLEAN HONEY.

Those who eat or drink the honey formed in Heraclea, of Pontus,
experience the same symptoms as they who have drunk of wolfsbane, and the
same remedies will be applicable. They are readily relieved by drinking
frequently of mulse, having the leaves of rue mixed with it.

       *       *       *       *       *

COMMENTARY. This section is taken from Dioscorides.

Avicenna makes mention of a poisonous kind of honey produced in Arabia,
for which he applies much the same remedies as those recommended by our
author. (iv, 6; i, 32.)

The effects of Pontic honey in occasioning madness is mentioned in the
‘Anabasis’ of Xenophon (iv, 8.) The same character of it is given by
Aristotle, Pliny, Diodorus Siculus, and Ælian. Tournefort confirms the
ancient accounts of its inebriating effects. See Sprengel (ad Dioscor.
ii, 103.)


SECT. LVIII.—ON GYPSUM.

Gypsum, when drunk, produces suffocation, by being converted into stone;
hence we must transfer the remedies applicable to those who have taken
mushrooms, giving them in this case, and substituting the decoction of
mallows for oil; for being of a fatty nature it lubricates the parts, and
prevents them from being injured by the stony hardness of the gypsum.
Oil, also, in honied water is proper; and the decoction of figs, and the
lye of figs, or of the ashes of vine-shoots with much wine, and marjoram,
or thyme with lye or vinegar. Clysters are also to be administered,
consisting of must and the decoction of mallows.

       *       *       *       *       *

COMMENTARY. Our author copies closely from Dioscorides.

Rhases and Avicenna treat this case upon much the same principles as
the Greeks, only they give scammony freely at first, and if dysentery
supervene they recommend the remedies suitable for it. Aëtius,
Dioscorides, and the other Greek authors, although they approve of
clysters, say nothing about drastic purgatives. Avicenna says, gypsum
in its action resembles ceruse, but is even more powerful than it in
inducing strangulation. Haly Abbas says, gypsum occasions colic and ileus
with dryness of the mouth, suffocation, difficulty of making urine, and
so forth. He directs clysters at first, and afterwards an electuary of
pepper and mustard to be given. Alsaharavius forbids emetics, recommends
water mixed with honey, and olive-oil for drink, also emollient clysters,
and sweet wine.

For an account of gypsum, see Pliny (H. N. xxxvi, 59) and Theophrastus
(de Lapidibus.) Isidorus gives the following description of it:—“Gypsi
plura genera: omnium autem optimum, lapis specularis: est enim signis
ædificiorum, et coronis gratissimus.” (Orig. xvi, 3.) The gypsum
speculare was evidently selenite, or crystallized sulphate of lime. See
Matthiolus (Com. in Dioscor.)

Dr. Kidd gives the following account of the varieties of the ancient
gypsum:—“It was, by the general description of it, an earthy compound of
lime; but the ancient naturalists seem to apply it to sulphate of lime,
the gypsum of the present day, and sometimes to a calcined carbonate of
lime, or quicklime, which they called calx.” (Mineral. b. i, p. 70).

Sir John Hill gives a full account of the ancient gypsums in his notes
on Theophrastus (de Lapidibus.) “Gypsum,” he says, “is nothing more
than a selenite less elegant than the rhomboidal or plated kinds.”
There can be no doubt that the γυψος διαφάνης of Philoponus (Com. in
Aristot. de Anima. ii) was pure selenite. It is singular that our recent
authorities on toxicology have not included gypsum in the list of
poisonous substances which they treat of, although there is good reason
to believe that the powder, if given in any great quantity, is highly
deleterious. We know for certain that gypsum, or stucco, is often used
for poisoning rats and mice. It is further deserving of remark that all
the earlier modern authorities on medicine, down at least to the middle
of the 16th century, treat of gypsum as an active poison. All the ancient
authorities, it will be seen, represent it in this light. Pliny makes
mention of a case of suicide committed by means of gypsum (H. N. xxxvi,
24.)


SECT. LIX.—ON CERUSE.

Ceruse, owing to its colour, cannot be mistaken, and when taken
voluntarily it whitens the palate, tongue, and the intervals between
the teeth. It also brings on hiccup and cough, dryness of the tongue,
and coldness of the extremities, with disorder of the intellect and
difficulty of moving. In this case it will be proper to give honied
water or the decoction of figs, or of mallows, or hot milk, or sesame
triturated with wine, or the lye of vine-shoots, or the oil of marjoram,
or of iris; also the bones of peaches, with a decoction of barley or
frankincense, or the gum of prunes, or the juice of the elm which
is contained in its follicles, along with tepid water; but let them
immediately vomit. The juice of thapsia will also be proper for them, or
three oboli of the juice of scammony, when drunk with honied water.

       *       *       *       *       *

COMMENTARY. Nicander compares the colour of ceruse to frothy milk. The
symptoms of poisoning by it are constriction of the palate and gums,
asperity of the tongue, singultus, a dry cough, nausea, heaviness of the
head, unnatural vision, and torpor. His remedies are emetics of oil, thin
milk, decoctions of mallows, sesame triturated with wine, prunes or elms,
which are to be given partly as emetics, and partly with the intention
of their being digested; for which purpose the patient is to be put
into the warm bath. See the Paraphrase of Eutecnius; also Dioscorides,
Aëtius, Avicenna, and Rhases, who recommend similar treatment. Aëtius,
like our author, directs us to give scammony, evidently to counteract its
astringency. Alsaharavius recommends emetics of the decoction of figs
with mead or common oil, the infusion of wormwood as a diuretic, scammony
with hydromel, and hot milk. Rhases recommends emetics of the decoctions
of figs and oil, with drastic purgatives and diuretics. (Ad Mansor.
viii, and Contin. xx, 2.) Avicenna’s principles of treatment are quite
similar, that is to say, he trusts to emetics, diuretics, and clysters,
and prevents the patient from sleeping. (iv, 6, 1.) Haly Abbas recommends
an emetic consisting of honey with hot water, vinegar and salt; he also
gives diuretics, such as the infusion of parsley, fennel, anise, and
southernwood. (Pract. iv.)

Dr. Alston says, “our white lead is certainly the ψιμύθιον of Dioscorides
and the cerussa of Pliny.” It was prepared by exposing the carbonate of
lead to the vapours of vinegar. See Milligan (Ad Cels. p. 112.)


SECT. LX.—ON LIME, SANDARACH, AND ARSENIC.

Lime, sandarach, and arsenic, when taken in a draught, bring on pains
of the stomach and bowels, with violent corrosion. Wherefore we must
administer all things of a diluent and solvent nature, such things as
will produce ready vomiting and lubricate the bowels, as the juice of the
marsh or common mallows, and a decoction of linseed, or of spelt, or of
rice, copious draughts of milk and honied water, broths which are fatty
and contain wholesome juices.

       *       *       *       *       *

COMMENTARY. Nicander has not treated of poisoning by these substances.
Dioscorides, Aëtius, and Actuarius give almost the same account of
the symptoms and treatment as our author. Their remedies are emetics,
lubricants, and laxatives. The Arabians copy their descriptions and
follow their treatment. Thus Alsaharavius directs these cases to be
treated by giving emetics of oily and fatty things, emollient clysters,
and unctuous articles, to prevent ulceration of the intestines. Avicenna
orders, in the first place, an emetic of warm water and oil, then
emollient decoctions, such as those of linseed and mallows, and fat
broths and milk. The cough is to be soothed by demulcents. (iv, 6, 1.)
Rhases states that quicklime and arsenic occasion putrefaction of the
intestines. (Cont. xxxvii. tr. 1.) Galen, however, has stated that
arsenic is not, properly speaking, a septic, but a strong caustic. (De
Simp. 1.)

However meagre this account of these important medicines may appear, it
will be seen, upon reference to the standard works on toxicology, that
the treatment at the present day scarcely differs, in any one point,
from the ancient mode of practice. Emetics, demulcents, consisting of
decoctions of emollient herbs, or copious draughts of milk, laxatives and
clysters, form the present practice.

The ancient arsenicum, or auripigmentum, was orpiment; the sandarach
was realgar, or the orange-red sulphuret. Our oxide of arsenic is a
factitious substance, prepared by sublimation from cobalt: it is much
more deleterious than auripigmentum or orpiment. Servitor and Avicenna
have described the factitious arsenic, or oxide of arsenic of the
moderns. The Arabian chemist Geber treats largely and ingeniously of
orpiment, which he holds to be closely allied to sulphur. He also speaks
of sublimed arsenic. (iii. 29.)


SECT. LXI.—ON LITHARGE.

Litharge, when drunk, brings on heaviness of the stomach and bowels,
with intense tormina; sometimes by its weight it wounds the intestines,
occasions retention of urine and swelling of the body, which becomes of
a leaden hue, and assumes an unseemly appearance. In such cases it will
be proper, after vomiting, to give the seed of the wild clary (horminum)
to drink with wine, three oboli of myrrh, wormwood, parsley-seed, pepper,
the flower of privet with wine, and the dried dung of wild pigeons, with
nard and wine.

       *       *       *       *       *

COMMENTARY. The symptoms which Nicander mentions as being superinduced
by litharge are borborygmi, pains resembling those of ileus, retention
of urine, and discoloration of the skin. His remedies are carminatives,
warm stimulants, and diuretics, such as myrrh, clary, St. John’s-wort,
hyssop, pepper, hedge mustard taken in wine, the green shoots of privet,
and the fruit of pomegranate. Scribonius Largus recommends emetics and
calefacient medicines, such as pepper, myrrh, parsley. The Arabians,
namely, Rhases, Avicenna, and Alsaharavius, concur in recommending
emetics, drastic purgatives, and calefacient medicines.

The ancient litharge was prepared like the modern. It is a semi-vitrified
peroxide of lead.


SECT. LXII.—ON LEAD.

When a person has drunk the shavings of lead or its soil, he experiences
the same symptoms as those from litharge, and is to be treated in the
same manner.

       *       *       *       *       *

COMMENTARY. We need scarcely say that litharge is now ascertained to be
a preparation of lead. (See the preceding section.) Most of the ancient
authorities state, like our author, that the symptoms and treatment of
poisoning by lead and litharge are exactly the same. It appears singular
that it should be asserted in some modern works on the materia medica
that the ancients were unacquainted with the deleterious properties of
lead. Galen even mentions that water conveyed in leaden pipes sometimes
proves deleterious by occasioning dysentery. (Med. sec. loc. vii.)
Aëtius makes the same observation. (xi, 45.) Palladius, the writer on
agriculture, speaks of it in the following terms: “Ultima ratio est,
plumbeis fistulis ducere, quæ aquas noxias reddunt; nam cerusa plumbo
creatur attrito, quæ corporibus nocet humanis.” (ix, 11.) Vitruvius also
mentions that water impregnated with lead is deleterious. (Arch. viii.)
Pliny notices the deleterious effects of the exhalations from lead mines.
(H. N. xxxiv, 50.)

The Greek writers on toxicology do not treat of copper as a poison; but
the Arabians have done so in brief terms, all agreeing in recommending
the same treatment as in cases of poisoning with arsenic. (See Avicenna,
Rhases, Haly Abbas, and Alsaharavius.) These authorities, likewise, lay
down in very succinct terms the treatment of poisoning by iron, which
they direct to be conducted upon general principles. They in particular
recommend laxative and demulcent medicines. (See Avicenna iv, 6, 18.)
As a slight novelty in their practice we may mention that he recommends
the affusion of vinegar with oil of roses, violets, &c., upon the head.
Averrhoes recommends from ⅓ to 1 dr. of balsam. (Coll. v.)


SECT. LXIII.—ON MERCURY.

Mercury, when swallowed, brings on the same symptoms as litharge, and
the same remedies are to be used in this case. A copious draught of milk
seems to be beneficial, and vomiting ought to be produced.

       *       *       *       *       *

COMMENTARY. Dioscorides, Galen, and Aëtius give the same imperfect
account of this important medicine and poison as our author gives, and
supply no additional information of any importance. The Arabians were
better acquainted with its properties, having ascertained that it might
be taken in its metallic state with impunity. Rhases says, “I do not
think that any great harm will result from drinking mercury when it is
pure, unless it be pains in the stomach and intestines. It afterwards
passes out in its natural state, especially if the person who swallowed
it moves about. I gave a draught of it to an ape, nor did I perceive
any inconvenience arise from it, except, as I have mentioned, that it
appeared to be pained in its belly, for it often bit it with its mouth,
and grasped it with its hands.” (Ad Mansor. viii, 42.)

Haly Abbas gives a similar account. Mercury, he says, in its natural
state, is not poisonous, and merely occasions some tormina in the belly;
but when killed (oxydised?) it is deleterious, and is to be remedied
by giving emetics of oil and dill, and afterwards oily clysters, &c.
(Pract. iv, 53.) See a similar account in Avicenna (iv, 6, 1, 2.) Mercury
that has been killed, or sublimed, that is to say attenuated, produces,
he says, grave symptoms, such as pain of the bowels, a bloody flux,
retention of urine, and so forth. He recommends, after vomiting, myrrh in
wine, with honied water, &c.

Serapion mentions that fumigations with mercury are very prejudicial
by superinducing nervous affections and paralysis. (De Simpl. 385.)
Alsaharavius is, we believe, the only ancient author who has mentioned
that rubbing the body with mercury occasions swelling of the mouth,
tongue, and throat, with erosion of those parts. He directs us to wash
or gargle with the decoction of dill, camomile, or mint. (Pract. xxx,
3.) Pliny mentions milk as a remedy against gypsum, ceruse, sulphur, and
mercury. (H. N. xxviii.)

Not having access to the unpublished MSS. of the ancient ‘Scriptores
Chemici,’ we cannot pretend to determine whether or not they had acquired
any considerable skill in analysing and detecting poisonous substances.
See an interesting account of these mss. in Fabricii ‘Bibliotheca
Græca,’ xiii, p. 747. Consult also Vossius ‘De Naturâ Artium,’ v. 9; Sir
William Drummond’s Papers in the ‘Classical Journal’ on the Literature
of the Ancient Egyptians; and Doutens ‘Dec. de Modern.’ p. 176. The only
original work on the chemistry of the ancients which we have read with
any attention is the ‘Chemia’ of Geber, which contains much curious
information regarding the metals, although nothing that suits our present
purpose.


SECT. LXIV.—ON WHITE HELLEBORE, THAPSIA, ELATERIUM, BLACK AGARIC, WILD
RUE, GITH, AND THE DOWN OF THE CACTOS.

We must be guarded in the administration of certain medicinal substances,
which often occasion as great danger as poisons themselves. Such are the
following, namely, white hellebore, thapsia, elaterium, and the black
agaric, for these bring on either suffocation or hypercatharsis, in which
cases we may cure the suffocation in the way described for mushrooms, and
such like substances, and stop the hypercatharsis by such things are as
calculated to suppress immoderate discharges. Likewise certain substances
which might seem not injurious to any considerable degree, will sometimes
occasion dangerous symptoms, and should not be neglected. Such are the
wild rue, gith, and the fresh poppy, which are the flowers of the thorn
called cactos. In such cases the administration of a vomit alone relieves
those who have taken them.

       *       *       *       *       *

COMMENTARY. This section is taken from Dioscorides. Of the pappus
Actuarius says, like our author, that it is the flower of the thorn
called cactos, and that vomiting relieves those who have taken it. (Meth.
Med. v, 12.) See Avicenna (iv, 6, 1); and Rhases (ad Mansor. viii, 49.)
Alsaharavius directs us in the case of hellebore to clear the stomach by
emetics, and to apply cooling plasters of citrons, apples, and roses. For
the wild rue he recommends emetics of oil, emollient clysters, and the
ashes of vine tops taken with water and vinegar.

In the Seventh Book we shall have occasion to state the opinions which
have been entertained respecting the helleborus albus of the ancients.
Schulze is very undecided. (Toxic. vet. iv.) The thapsia he makes to
be the same as the T. fœtida of Linnæus. Theophrastus has described
it (H. P. ix, 23). Pliny says it occasions swelling of the body, with
erysipelas. (N. H. xiii, 43.)

We shall treat of the elaterium also in the Seventh Book. Hippocrates
uses the word as a general term for all drastic purgatives, but by
Dioscorides, and the subsequent writers on the materia medica, it is
applied to the fæcula of the _momordica elaterium_.

The agaricus muscarius is a well-known poisonous mushroom. Schulze
properly remarks that its effects are narcotic; and Dr. Christison places
it in the class of narcotico-acrid poisons. See sec. liv.

Schulze is much inclined to believe that the πήγανον ἄγριον here treated
of is the _peganum harmala_ of Linnæus, a plant intermediate between the
ruta and melanthium. He is also disposed to think that the melanthium
of the ancients was the _nigella sativa_, L. We are inclined to adopt
this opinion from the text of Avicenna. (iv, 6, 1, 16.) Sprengel agrees
with Anguillara and Dalechampius in opinion that the cactos was the
_cynara cardunculus_, L., or cardoon artichoke, a variety of the C.
scolymus. (Comment. in Dioscor.) Schweighaeuser inclines to the opinion
of Villebrun, the French translator of Athenæus, who makes it to be the
C. sylvestris latifolia, which he says grows commonly in Sicily at the
present day. (In Deipnos. ii, 83.)

Under this head we may notice the treatment of poisoning by gum
euphorbium, and the spurges, of which no mention is made by the Greek
authorities on toxicology. For the Arabians, see Avicenna (iv, 6, 1, 4,
5); Rhases (Contin. xx, 2; ad Mansor. viii, 48); Alsaharavius (Pract.
xxx, 1, 19.) The symptoms as given by them all are, violent pain and heat
in the primæ viæ, with bloody discharges, and death, unless timely relief
be given. Their remedies are immediate vomiting with hot water and oil,
then administering demulcents, barley-water, and in the end, the theriac.
Galen and Haly Abbas, in their treatises on the Theriac, recommend it in
this case of poisoning.

The mezereon is not noticed by the Greeks or Romans either as a poison
nor as a medicinal substance. The Arabians treat of it under both these
heads. See Avicenna (iv, 6, 1); Rhases (ad Mansor. viii, 53.) The
symptoms as given by them are violent vomiting and purging, for which
they recommend sweet milk, butter, juleps, in the first place, and in
extreme cases the theriac and sealed earth. The Arabian authorities
confound their mezereon with the chamæleon of the Greeks, treated of in
the thirty-seventh section of this book. The _dende_ of Avicenna and
Serapion was the strychnos colubrinus, according to Sprengel. (R. H. H.
i, 250.)

Rhases classes the nux vomica along with the articles treated of in
this section. He recommends us in all these cases to give warm water to
promote the vomiting, and render it easier, and if violent convulsions
come on, he directs the patient to be put into a warm bath, and anointed
with hot oils. (Ad Mansor. viii, 49.) Serapion treats of it in his
Materia Medica (163.) The Arabians also treat of the methel-nut.

We are unable to determine satisfactorily the nature of the _condisi_,
which is treated of by the Arabians, under the present head. See Rhases
(ad Mansor. viii, 49); Avicenna (iv, 6, 1, 16.) Alsaharavius calls it
_cundes_. The symptoms, he says, are dryness of the nose, throat, and
palate, sneezing, muttering delirium, pain of the stomach, and, unless
speedy relief be brought, death. (Pract. xxx, 1, 24.) Ardoyn mentions
that some referred it to the struthium; but the above characters do not
at all apply to the soapwort (_saponaria officinalis_, L.), which is the
στρόυθιον of Theophrastus and Dioscorides. See further Sprengel (Comment.
in Dioscor. i, 192.)

The sow-bread (_cyclamen Europæum_) is also treated of by the Arabians
under this head. See Avicenna (iv, 6, 1, 16); Rhases (ad Mansor. viii,
59); Alsaharavius (Pract. xxx, 1, 24.) The symptoms, according to
Alsaharavius, are swelling of the throat, and strong pain of the bowels.
The sow-bread is treated of as an article of the Materia Medica by
Dioscorides (ii, 193.)

Dioscorides (M. M. iv, 82) does not reckon the oleander (_nerium
oleander_, L.) destructive to man, but the Arabians rank it among the
deleterious substances, of a heating and desiccant nature; and recommend
for it emetics, with the decoction of fenugreek, figs with honey, and the
like. See Avicenna (iv, 6, 18); Alsaharavius (Pract. xxx, 1, 27); Rhases
(ad Mansor. viii, 36.)

The anacardium, or Malacca bean, is treated of as a poison by Rhases
(Contin. xx, 2; ad Mansor. viii, 35); Avicenna (iv, 6, 1, 9);
Alsaharavius (Pract. xxx, 1, 42); Haly Abbas (Pract. iv, 50.) They all
describe it as an irritant poison, and recommend emetics of animal and
vegetable oils, with demulcents, to obviate the bad effects of it.

The apocynum, although not treated of by the ancient authorities on
toxicology, is described as a deleterious substance by Dioscorides (Mat.
Med. iv, 81); by Galen (De Simpl.); and by Pliny (H. N. xxv, 83.) It
appears to be the _periploca Græca_, L.

Dioscorides and Pliny likewise reckon saffron, or the _crocus sativus_, a
deleterious plant. Its deleterious action is very weak.

The atramentum sutorium, which was a solution of vitriol, was used as a
poison. See Cicero (ad Familiar. ix, 21.)


SECT. LXV.—ON DOMESTIC ARTICLES, SUCH AS WINE AND COLD WATER.

Cold water when drunk in a great quantity, and much undiluted sweet wine,
more especially after the bath, running, or violent exercises, bring on
suffocation and pains. In such cases, venesection quickly had recourse
to, and evacuation by clysters, remove the impending danger.

       *       *       *       *       *

COMMENTARY. Galen says, “Some by taking an immoderate draught of cold
water have been instantly seized with dyspnœa, convulsions, and tremors;
in a word, their whole nervous system has become affected.” (Meth. Med.
ix, 5.)

Dioscorides, Aëtius, and Actuarius concur in recommending the same mode
of treatment as our author. The Arabians, however, treat those who
have taken a draught of cold water unseasonably in a very different
manner from the Greeks. Thus Rhases and Avicenna recommend undiluted
wine internally, and the application of a plaster over the liver. The
difference between the practice of the Greeks and Arabians may be thus
accounted for. A large draught of cold drink may either threaten to
prove fatal at once by producing a violent impression upon the nerves
of the stomach, or it may superinduce symptoms resembling those of
gastritis. In the former case the practice of the Arabians may seem most
proper in order to support the heat and powers of the system, whereas
that of the Greeks will be indicated when inflammatory symptoms have
come on; and, indeed, even the Arabians bled under these circumstances.
(Avicenna, iv, 61, 31.) For an immoderate draught of pure wine which has
been taken unseasonably, the Arabian authorities concur with the Greek
in recommending immediate evacuation of the stomach and venesection,
to which they add cold water or whey, with troches of camphor. See in
particular Avicenna (iv, 6, 1, 31.)




APPENDIX TO BOOK V.


As no better opportunity is likely to occur, we shall in this place give
a short notice of two subjects connected with medical practice, which are
entirely omitted by our author.


ON FEIGNED DISEASES, AND THE DETECTION OF THEM.

Galen, we believe, is the only ancient author who has treated professedly
of the detection of simulated diseases. He begins his short treatise
on this head with remarking, that persons feign diseases from various
motives, and that it is expected the physicians should detect such
impostures. That, for example, inflammation, erysipelas, and œdema,
when produced artificially, ought to be distinguished from the same
diseases when they originate in constitutional causes. He adds, that
hæmoptysis, hæmatemesis, and bloody discharges from the bowels, are often
simulated. Hæmoptysis is simulated by opening a vein in the gums, and
sucking blood from it while one affects to cough. Others, he says, affect
dementia, fatuity, and insanity, all which cases the vulgar expect that
the physician should detect. Inward pain, such as that of colic, he had
often known to be simulated, and relates briefly an interesting case in
point. He remarks, that experience and natural sagacity will enable a man
to expose all impositions of this nature. He gives a very interesting
account of the manner in which he detected the nature of a swelling at
the knee, that had been produced intentionally by the juice of thapsia
(_thapsia garganica_, deadly carrot?) Feigned inward pains, he remarks,
may often be distinguished from the real by the aversion which the
_malingerer_ discovers to swallow medicines, which he would be anxious
to have given him if he were actually in acute pain; and adds, that the
state of the pulse, and the other symptoms of intestinal diseases, will
assist in making the detection. (Quomodo coarg. sint qui fing. se Ægrot.
t. iii, 388, ed. Basil.)


ON PROFESSIONAL IMPOSTORS.

Rhases has an interesting chapter on this head. The frauds of impostors,
he says, are more numerous than could be contained in his whole work.
Some of them, he adds, pretend to be able to cure epilepsy, and having
made a crucial incision in the back part of the head, they extract from
the wound something which they hold in their hands, and thus impose upon
people. Others, in like manner, cause it to be believed that they extract
a small lizard by the nostrils. Some of these characters, he says,
make it be believed that they remove films from the eye, by secretly
introducing a small membrane into the eye, and taking it out again.
Others manage to create a belief that they suck water from the ear with
a reed. Others also make it be believed that they extract worms from the
ears or teeth. Others practice a trick by which they obtain the credit of
extracting the ranula below the tongue. Why should I mention those, he
adds, who introduce pieces of bone into wounds and ulcers, and afterwards
extract them? He says, it is not uncommon for these impostors to sound
a man for the stone, pretend to find one, perform the operation, and
exhibit a calculus which they themselves had introduced secretly into the
incision. Others pretend to cure piles, make incisions about the anus,
and form ulcers there which did not exist before. Certain of them affect
by scarifications and other means to suck the vitreous humour from the
hip-joint, while they exhibit something of the kind which they themselves
have introduced. There are some who undertake to collect all the
infirmities of the body into one spot, and then extract them; for this
pretended object they raise an itching and violent heat in some place by
means of _alkekengi_ (winter cherry); and having accomplished this they
exact a fee for removing the uneasiness from the spot, which they do by
anointing it with oil. There are others who will make a man believe that
he has swallowed hairs, glass, or the like; and then tickling his throat
with a feather, and making him vomit, they exhibit the substance in
question as if it had been brought up. Thus, he adds, they often do much
mischief, and sometimes are guilty of culpable homicide. He concludes by
warning sensible people to be upon their guard against such wretches. (Ad
Mansor. vii. 27.)




BOOK VI.


SECT. I.—PREFACE TO THE SURGICAL PART.

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

       *       *       *       *       *

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


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

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

       *       *       *       *       *

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

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

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

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

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

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

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

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

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

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


SECT. III.—ON HYDROCEPHALUS.

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

       *       *       *       *       *

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

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

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

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

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

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

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

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

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

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

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

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


SECT. IV.—ON ARTERIOTOMY.

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

       *       *       *       *       *

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

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

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


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

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

       *       *       *       *       *

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

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

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

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

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

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

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

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

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

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


SECT. VI.—ON HYPOSPATHISMUS.

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

       *       *       *       *       *

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


SECT. VII.—ON PERISCYPHISMUS.

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

       *       *       *       *       *

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

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

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


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

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

       *       *       *       *       *

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

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

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

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

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

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

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

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

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

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

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

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

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

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


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

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

       *       *       *       *       *

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

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


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

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

       *       *       *       *       *

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

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

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


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

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

       *       *       *       *       *

COMMENTARY. This section requires no commentary.


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

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

       *       *       *       *       *

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

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

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

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

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

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


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

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

       *       *       *       *       *

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

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

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


SECT. XIV.—ON HYDATIDS.

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

       *       *       *       *       *

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

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

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

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


SECT. XV.—ON ADHESION OF THE EYELIDS.

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

       *       *       *       *       *

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

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

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

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

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

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


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

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

       *       *       *       *       *

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

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

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

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

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


SECT. XVII.—ON ACROCHORDON AND ENCANTHIS.

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

       *       *       *       *       *

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

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

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

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


SECT. XVIII.—ON PTERYGIA.

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

       *       *       *       *       *

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

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

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

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

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

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


SECT. XIX.—ON STAPHYLOMA.

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

       *       *       *       *       *

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

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

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

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

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

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

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

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


SECT. XX.—ON HYPOPYON OF THE EYE.

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

       *       *       *       *       *

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

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


SECT. XXI.—ON CATARACTS.

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

       *       *       *       *       *

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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


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

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

       *       *       *       *       *

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

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

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

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

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

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

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

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

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

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

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

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


SECT. XXIII.—ON IMPERFORATE MEATUS AUDITORIUS.

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

       *       *       *       *       *

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

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

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

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

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


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

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

       *       *       *       *       *

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

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

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

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

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

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


SECT. XXV.—ON POLYPUS.

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

       *       *       *       *       *

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

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

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

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

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

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

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

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

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

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

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


SECT. XXVI.—ON MAIMED PARTS.

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

       *       *       *       *       *

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

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

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

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


SECT. XXVII.—ON EPULIS AND PARULIS.

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

       *       *       *       *       *

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

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

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

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

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


SECT. XXVIII.—ON THE EXTRACTION OF TEETH.

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

       *       *       *       *       *

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

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

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

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

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

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


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

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

       *       *       *       *       *

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

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

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

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

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

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

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


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

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

       *       *       *       *       *

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

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

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

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

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

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


SECT. XXXI.—ON THE UVA.

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

       *       *       *       *       *

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

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

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

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

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

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


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

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

       *       *       *       *       *

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

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


SECT. XXXIII.—ON LARYNGOTOMY.

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

       *       *       *       *       *

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

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

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

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

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

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

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


SECT. XXXIV.—ON ABSCESS.

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

       *       *       *       *       *

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

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

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

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

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

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

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


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

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

       *       *       *       *       *

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

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

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

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

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


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

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

       *       *       *       *       *

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

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

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

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

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

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


SECT. XXXVII.—ON ANEURISM.

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

       *       *       *       *       *

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

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

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

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

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

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

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

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

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


SECT. XXXVIII.—ON BRONCHOCELE.

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

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

       *       *       *       *       *

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

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

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

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

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


SECT. XXXIX.—ON GANGLION.

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

       *       *       *       *       *

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

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

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


SECT. XL.—ON VENESECTION.

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

       *       *       *       *       *

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

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

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

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

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

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

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

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

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

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

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

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

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

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


SECT. XLI.—ON CUPPING.

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

       *       *       *       *       *

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

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

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

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

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

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

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

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

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

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


SECT. XLII.—ON BURNING THE ARMPIT.

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

       *       *       *       *       *

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


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

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

       *       *       *       *       *

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

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

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


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

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

       *       *       *       *       *

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

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

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

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

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

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

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


SECT. XLV.—ON CANCER.

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

       *       *       *       *       *

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

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

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

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

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

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

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

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

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

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


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

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

       *       *       *       *       *

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

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

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


SECT. XLVII.—ON BURNING OVER THE LIVER.

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

       *       *       *       *       *

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

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

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


SECT. XLVIII.—ON BURNING OVER THE SPLEEN.

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

       *       *       *       *       *

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

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

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

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


SECT. XLIX.—ON BURNING OVER THE STOMACH.

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

       *       *       *       *       *

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


SECT. L.—ON DROPSIES.

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

       *       *       *       *       *

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

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

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

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

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

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

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

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

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

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

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

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

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

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


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

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

       *       *       *       *       *

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

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

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


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

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

       *       *       *       *       *

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

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

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

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

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

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

                                         Οδυσ. φ.

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


SECT. LIII.—ON DEFICIENCY OF THE PREPUCE.

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

       *       *       *       *       *

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

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

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


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

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

       *       *       *       *       *

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

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

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


SECT. LV.—ON PHIMUS, OR PHIMOSIS.

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

       *       *       *       *       *

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

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


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

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

       *       *       *       *       *

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


SECT. LVII.—ON CIRCUMCISION.

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

       *       *       *       *       *

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

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.

       *       *       *       *       *

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.

       *       *       *       *       *

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.

       *       *       *       *       *

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.

       *       *       *       *       *

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.

       *       *       *       *       *

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.

       *       *       *       *       *

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.

       *       *       *       *       *

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.

       *       *       *       *       *

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.

       *       *       *       *       *

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.

       *       *       *       *       *

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.

       *       *       *       *       *

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.

       *       *       *       *       *

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.

       *       *       *       *       *

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.

       *       *       *       *       *

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.

       *       *       *       *       *

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.

       *       *       *       *       *

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.

       *       *       *       *       *

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.

       *       *       *       *       *

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.

       *       *       *       *       *

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.

       *       *       *       *       *

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.

       *       *       *       *       *

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.

       *       *       *       *       *

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.

       *       *       *       *       *

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.

       *       *       *       *       *

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.

       *       *       *       *       *

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.

       *       *       *       *       *

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.

       *       *       *       *       *

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.

       *       *       *       *       *

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.”

       *       *       *       *       *

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.

       *       *       *       *       *

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.

       *       *       *       *       *

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.

       *       *       *       *       *

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.

       *       *       *       *       *

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.

       *       *       *       *       *

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.

       *       *       *       *       *

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.

       *       *       *       *       *

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.

       *       *       *       *       *

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.

       *       *       *       *       *

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.”

       *       *       *       *       *

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.

       *       *       *       *       *

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.

       *       *       *       *       *

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.

       *       *       *       *       *

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.

       *       *       *       *       *

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.

       *       *       *       *       *

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.

       *       *       *       *       *

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.

       *       *       *       *       *

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.

       *       *       *       *       *

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.

       *       *       *       *       *

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.

       *       *       *       *       *

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.

       *       *       *       *       *

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.

       *       *       *       *       *

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.

       *       *       *       *       *

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.

       *       *       *       *       *

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.

       *       *       *       *       *

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.

       *       *       *       *       *

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.

       *       *       *       *       *

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.

       *       *       *       *       *

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.

       *       *       *       *       *

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.

       *       *       *       *       *

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.

       *       *       *       *       *

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.

       *       *       *       *       *

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.

       *       *       *       *       *

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.

       *       *       *       *       *

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.

       *       *       *       *       *

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.

       *       *       *       *       *

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.